Print Inspection: KIT002170

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen areas and memory care kitchenettes were reviewed on 01/14/25 from 10:15 am through 2:15 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Reach in coolers/freezers; * Walk in cooler fan cages; * Industrial can opener housing; * Industrial mixer and table; * Food delivery cart; * Stainless steel wall adjacent to and behind stove, fryer and grill top; * Interior of left oven; * Knobs, handles of appliances and equipment; * Caulking around the perimeter of handwashing sinks; * Interior of ice machine; * Unit reach in fridges and freezers; and * Unit microwaves. c. Container of raw chicken was noted in the deli reach-in cooler to be dated 01/04, this was to be used or discarded as of 01/10/25 per rule. It was noted 4 days past this requirement on survey. d. Multiple food items found stored open to potential contamination in walk-in freezer. e. Dry bulk food items were observed with scoops stored in the bins placing the food items at risk of contamination from the scoops. f. Facility found with unpasteurized shell eggs in walk in cooler. Staff 2 (Dining Services Director) confirmed residents were served cook to order eggs including runny (not fully cooked) yolks or whites if residents chose. Staff 2 indicated that facility usually purchased pasteurized shell eggs but their vendor was out. Staff 2 did not know facility would not be able to serve the above egg choices if shell eggs were not pasteurized and would need to serve fully cooked eggs (non runny yolks/whites) until pasteurized were obtained. Staff 2 immediately in serviced the staff to the requirement. g. Multiple single service disposable food service plates or food containers were noted to be stored open to potential contamination of food contact surfaces. h. Reach in cooler in Aspen unit was observed to be at 46 degrees Fahrenheit. Multiple condiments for residents as well as protein shakes for residents were stored in this fridge. Staff 3 (Memory care Administrator) was interviewed at 1:45 pm and asked to provide temperature monitoring records/procedures to ensure resident food was stored at or bellow 41 degrees as required. Staff 3 indicated the system they were using to monitor temperatures had stopped working in October and the facility was unaware this had occurred. Staff 3 acknowledged facility was unaware how long the refrigerator was not operating correctly. Staff 3 immediately turned down the thermostat of that refrigerator, discarded any open and/or potentially hazardous food items and implemented a hand written temperature monitoring log to ensure staff were monitoring food storage temperatures and alerting her and/or staff 2 and maintenance to any issues. i. Staff were observed washing lunch dishes. Staff did not perform hand hygiene prior to touching clean and sanitized dishes. Staff were observed to wash off dirty dishes and handle clean dishes without washing hands of sanitizing hands potentially contaminating clean dishes. Staff were also observed to rinse out sanitized cups with tap water and then put cups away for use therefor potentially contaminating the sanitized cups with tap water. At 1:45 pm, staff 3 was asked to provide a process/procedure for care staff to follow when cleaning and sanitizing dishware. Staff 3 acknowledged there was not a formal process in place. Staff 3 was informed of the above observations and acknowledged this was not a sanitary process in line with food code regulations for sanitation of dishes/equipment. j. Multiple staff drink cups were observed on the memory care unit kitchenettes. None of the employee drinks contained in the kitchen area were in line with food code requirements posing risk of potential contamination. Staff 2 toured with surveyor and acknowledged the above findings. At approximately 2:00 pm, surveyor reviewed above areas with staff 1 (Executive Director) and Staff 3 and they acknowledged the identified areas in need of correction.

Kitchen will be maintained in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. 1. a) Dining staff have assigned cleaning areas to complete daily, weekly and monthly. The dining services director/designee will ensure daily completion of tasks. b) Dates on foods raw or otherwise in deli and cooler will be checked daily and if 7 days or older will be discarded. c) All food items in walk in freezer will be stored in closed containers. d) Scoops for dry bulk food items will be stored in proper receptacles outside of food storage bin. e) Unpasteurized eggs will be served full cooked only. f) All single service disposable food service containers will be stored upside down to prevent contamination of food contact surfaces. 2. Weekly audits of all kitchen areas will be completed by the administrator or designee using the Oregon kitchen audit tool. Any areas not in compliance will be reviewed by the DSD and administrator. Corrective action will be taken to ensure continued compliance. 3. Weekly audits will be completed. Ice machine was completed by Roseburg Refrigeration - during the process instruction on how to maintain cleanliness was given to the DSD for routine maintenance purposes. 4. Administrator and Dining Service Director will be responsible to see that the correcitons are completed and are being monitored on an on going weekly basis. 1. g) Memory Care refrigerators will maintain a safe temperature at or below 41 degrees. Staff will be recording temperatures in a temp log once per 12 hour shift and notify MC administrator immediately if outside of food safe parameters. h) Staff will wash hand prior to touching and clean dishes. An in-service of this policy was completed, and policy posted near each dishwasher. Dishwashing to be audited by MC admin monthly. i) Cups used by staff in the kitchenettes will only have a handle, a lid, and a tight fitting straw to decrease risk of potential contamination. 2. Weekly audits of all kitchen areas will be completed by the administrator or designee using the Oregon kitchen audit tool. Any areas not in compliance will be reviewed by the DSD and administrator. Corrective action will be taken to ensure continued compliance. 3. Weekly audits will be completed. Ice machine was completed by Roseburg Refrigeration - during the process instruction on how to maintain cleanliness was given to the DSD for routine maintenance purposes. 4. Memory Care Administrator and Dining Service Director will be responsible to see that the correcitons are completed and are being monitored on an on going weekly basis.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

OAR 411-057-0140 Refer to C240.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: