Print Inspection: KIT002465

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, record review 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 seven cottage kitchen areas and main food storage areas (cooks shack, dry storage and freezer room) were reviewed on 02/12/25 at 10:15 am through 1:45pm 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 freezer door ice and water dispensers in 620,622, 608 and 604; * Kitchen floor in 608; * Microwaves in 608 and 604; * Ovens in 604 and 608; * Interior of cabinets and/or drawers in 608, * Interior of refrigerator in 604; b. The following areas were in need of repair: * Multiple cabinets or drawers in 611 and 608 with dings/chips/scratches/non smooth surfaces. Drawer in 608 broken. * Reach in refrigerator in 604 drawer broken. * Reach in refrigerator in house 612 at 50 degrees Fahrenheit, door not shutting/sealing appropriately; c. Staff 3 and Staff 4 observed to reheat alternate protein sources for meals and did not check temperatures of food items to ensure at appropriate/safe temperatures prior to serving residents. d. Multiple potentially hazardous foods (PHF) in all cottages were found open without open dates. Unlabeled and undated food items were found in multiple cottages. Staff food was found stored with resident foods in multiple cottages. e. Staff 3 and staff 4 were observed to not sanitize thermometers prior to use nor in between use for different food items. Staff 4 was observed to use a knife for cutting up resident food then wash and rinse and put back in sharps drawer without sanitizing equipment before storage. f. Cottage 608 had a resident requiring pureed foods. The pureed crab cake for this resident was not at the correct texture with visible varying particle sizes and not a smooth texture. The pureed food items were warmed in a microwave and the temperatures were not checked prior to plating. Surveyor checked the texture and it was grainy and not smooth with chunks. The temperature of the food product did not feel hot to the mouth and most likely was not at 135 degrees as required for service. Surveyor instructed staff of the need to reprocess the food item until smooth and consistent. Surveyor also notified staff 2(kitchen manager) who followed up with the cook to ensure correct consistency was served to the resident. g. Majority of cottages had dirty dishes in both sinks. Multiple staff were observed to wash hands over the dishes. Staff must have a designated empty and available sink for handwashing tasks. h. Multiple cottages had a bag of recyclable cans stored in the kitchen area and/or stored with food storage areas causing potential cross contamination concerns along with attractants for insects and pests. i. In cottage 608 plates for residents were plated and sat uncovered for 10-15 minutes prior to being served to residents. A resident’s meal was served to their room uncovered and unprotected. At approximately 1:15 pm surveyor reviewed items with Staff 2 (Kitchen manager/PIC) and they acknowledged the above areas. On 3/13/25 at 2:00 pm, surveyor reviewed above areas with Staff 1 (Administrator) who acknowledged the need for correction.

C240 A 1) All identified areas in Cottages 620, 622, 608, and 604, including reach-in freezer door ice/water dispensers, kitchen floors, microwaves, ovens, cabinets, drawers, and refrigerator interiors, have been thoroughly cleaned and sanitized. Food spills, splatters, dust, and debris have been removed to ensure all surfaces meet sanitation and hygiene standards. Cleaning supplies have been restocked in all cottages, and staff members have been assigned responsibility for detailed cleaning as part of their shift duties. 2) The importance of maintaining a sanitary kitchen environment will be reinforced at the March 12th all-staff in-service training, where proper cleaning protocols will be reviewed. A detailed cleaning schedule has been implemented in each house, and staff are now required to sign off on completed cleaning tasks. This schedule includes daily, weekly, and monthly deep-cleaning tasks to ensure continued compliance. Quality assurance inspections will be conducted on a weekly basis to verify that cleaning tasks are being completed as required. Any non-compliance will be addressed with immediate corrective action and retraining. 3) Cleaning schedules will include daily sanitation tasks performed by assigned staff, with weekly quality assurance inspections to confirm compliance. In addition, monthly deep-cleaning reviews will be conducted in all kitchen and storage areas to ensure all surfaces remain clean and sanitary. 4) The Kitchen Coordinator, Maintenance Director, Administrator, or a designated staff member will be responsible for ensuring compliance with cleaning protocols. These individuals will review sign-off sheets from daily cleaning schedules, conduct weekly sanitation inspections, and implement corrective actions as needed. B 1) All areas identified as needing repairs have been evaluated and addressed. The cabinets and drawers in Cottages 611 and 608 with dings, chips, scratches, or non-smooth surfaces have been repaired or replaced to ensure they meet sanitation standards. The broken drawer in Cottage 608 and the damaged refrigerator drawer in Cottage 604 have also been fixed. Additionally, the reach-in refrigerator in Cottage 612, which was not maintaining proper temperature and had a faulty seal, has been replaced with a new unit to ensure safe food storage at the required temperature of 40°F or below. 2) A preventative maintenance schedule has been implemented to identify and address repairs before they become compliance issues. Staff will be reminded at the March 12th all-staff meeting that all maintenance concerns must be immediately reported using the facility’s online maintenance software, UpKeep. Additionally, weekly quality assurance inspections will now include checks for damaged surfaces, drawers, and equipment functionality to ensure that all kitchen areas remain safe and in good repair. Any new issues identified will be reported immediately for maintenance intervention. 3) Quality assurance inspections will be conducted at least once a week in each house to proactively identify repair needs. Additionally, monthly inspections focused specifically on repairs will be conducted to ensure that all kitchen structures and appliances remain in compliance with safety and sanitation regulations. 4) The Kitchen Coordinator, Maintenance Director, Administrator, or a designated staff member will be responsible for overseeing kitchen repairs, ensuring they are identified, documented, and addressed promptly. They will monitor weekly quality assurance inspections and work with the maintenance team to confirm that all necessary repairs are completed as scheduled. C 1) Corrective action has been implemented to prevent this issue moving forward. All kitchen staff, including Staff 3 and Staff 4, have been retrained on the correct procedures for reheating food and checking temperatures to ensure compliance with FDA Food Code guidelines. Training included the proper use of food thermometers, ensuring that all reheated foods reach the minimum safe temperature of 165°F before serving. Additionally, supervisors have been instructed to observe meal service and verify that food temperatures are checked and documented before meals are plated. 2) This issue will be addressed at the mandatory all-staff training on March 12th, where staff will review the correct procedures for reheating food, using thermometers, and documenting food temperatures. Going forward, staff will be required to document food temperatures at each meal in a temperature log, which will be verified by supervisors during every meal service. To ensure accountability, a rotating meal observation schedule has been implemented to allow supervisors to actively monitor meal preparation and conduct in-the-moment corrections and training if necessary. 3) A rotating weekly meal observation schedule has been implemented, ensuring that at least one meal per week per house is actively observed to confirm that food temperatures are checked and recorded properly. Additionally, random spot checks will be conducted by supervisors to reinforce compliance. Any discrepancies will be immediately addressed through additional training or procedural adjustments as needed. 4) The Kitchen Coordinator, Administrator, or a designated staff member will be responsible for overseeing compliance with food temperature monitoring protocols. They will review weekly temperature logs, conduct meal service observations, and provide ongoing staff training to ensure adherence to food safety standards. D 1) All previously unlabeled and undated food items in every cottage have been identified and properly labeled with the date opened, use-by date, and item name. Food storage areas have been thoroughly inspected to remove any expired, improperly labeled, or undated items. Staff have been instructed on the immediate requirement to label all food items as soon as they are opened. Additionally, all staff food has been removed from resident food storage areas, and staff have been provided with a designated storage space for personal food items to prevent cross-contamination. 2) To ensure compliance, pre-printed labels with required fields (date opened, use-by date, item description) have been purchased and placed in each house for easy access. Staff will be required to immediately label food items upon opening. The March 12th all-staff training will include a review of proper labeling procedures, the importance of food safety, and separation of resident and staff food items. Additionally, quality assurance inspections will now occur more frequently, and supervisors will verify that all food is properly labeled and stored in designated areas during their routine inspections. 3) Weekly quality assurance inspections will be conducted in each house to confirm that all food items are properly labeled and stored according to regulations. These inspections will check for accurate date labeling, proper separation of resident and staff food, and adherence to food safety practices. 4) The Kitchen Coordinator, Administrator, or a designated staff member will be responsible for monitoring compliance with food labeling and storage procedures. They will verify that labels are used correctly, ensure staff food is stored separately, and enforce proper food safety practices during weekly quality assurance inspections. E 1) Immediate corrective actions have been taken to prevent future occurrences. Staff 3 and Staff 4, along with all kitchen staff, have been retrained on the proper sanitization of thermometers and knives before and between uses. This retraining included step-by-step demonstrations on approved cleaning solutions, proper washing and sanitizing procedures, and the risks of cross-contamination. 2) Proper sanitization procedures will be reinforced at the March 12th all-staff training, where staff will undergo additional instruction on FDA food safety guidelines for utensil sanitization. Supervisors will now conduct on-the-spot observations during food preparation to ensure thermometers and knives are properly sanitized. A rotating meal observation schedule has been established to monitor compliance during meal service. Visual reminders have been posted in kitchen areas, outlining the required steps for sanitizing utensils and thermometers before and between uses. Any staff observed not following correct procedures will receive immediate corrective coaching and additional training. 3) A weekly meal observation schedule will be implemented, ensuring that at least one meal per week per house is observed to confirm proper sanitization practices. Additionally, random spot checks will be conducted throughout food preparation times to ensure thermometers and knives are being sanitized between uses. Any non-compliance will result in immediate corrective action and retraining for involved staff. 4) The Kitchen Coordinator, Administrator, or a designated staff member will be responsible for monitoring compliance, ensuring proper meal observations, and overseeing staff adherence to sanitization protocols. They will review staff performance, conduct weekly inspections, and take corrective actions as necessary to ensure continued compliance. F 1) Immediate corrective action has been taken to ensure compliance with food texture and temperature requirements for residents requiring pureed diets. All cooks and kitchen staff have been retrained on proper food preparation techniques for texture-modified diets, with an emphasis on ensuring that pureed foods are smooth, free of chunks, and consistent in texture. Staff have been instructed to recheck all pureed food textures before plating and reheating, and thermometers will now be used to verify all pureed meals reach a minimum internal temperature of 135°F before serving. 2) Because food texture modification is a highly specialized skill, training will be conducted individually for each cook rather than as a broad all-staff training. Each cook will receive hands-on coaching from the Kitchen Coordinator to ensure they properly follow resident diet plans, food consistency expectations, and correct preparation techniques. Additionally, quality assurance inspections will now include recipe compliance checks and texture verification to confirm that all pureed meals meet the required consistency and temperature before being served. 3) Quality assurance inspections and meal observations will take place at least once per week in each house to ensure compliance with food texture and safety regulations. Supervisors will also conduct random, unannounced spot checks to further verify adherence to dietary consistency standards and proper temperature monitoring. 4) The Kitchen Coordinator, Administrator, or a designated staff member will oversee compliance with food texture and safety protocols. They will conduct meal observations, ensure cooks are properly trained on texture-modified diets, and monitor quality assurance checks to confirm ongoing adherence to resident dietary requirements. G 1) Immediate education and coaching have been provided to ensure that handwashing sinks remain empty and available at all times. Staff have been reminded that washing hands over dirty dishes is not acceptable and increases the risk of cross-contamination. All kitchen areas have been inspected, and handwashing sinks have been cleared of obstructions to ensure proper use. 2) Handwashing sinks in each house will now be clearly labeled to distinguish them from dishwashing sinks. This policy will be reinforced at the March 12th all-staff meeting, where staff will receive hands-on training on proper handwashing protocols, sink usage, and cross-contamination risks. Additionally, quality assurance inspections will be increased to allow for real-time corrective actions and on-the-spot coaching when necessary. Staff who fail to comply will be provided with immediate retraining. 3) Weekly quality assurance inspections will be conducted in all kitchen areas to confirm that handwashing sinks remain clear and designated solely for handwashing. Additionally, unannounced spot checks will be performed during meal preparation times to reinforce compliance and provide in-the-moment training if needed. 4) The Kitchen Coordinator, Administrator, or a designated staff member will oversee compliance by conducting weekly inspections, enforcing handwashing protocols, and addressing non-compliance issues as they arise. Staff who repeatedly violate the policy will be subject to additional training and corrective action. H 1) All improperly stored recyclables and resident soda cans have been removed from all kitchen areas and food storage spaces. Kitchen inspections were conducted to ensure that no resident recyclables remain in food preparation or storage areas. 2) New recycling bins with lids have been placed outside of food preparation areas to provide a designated space for recyclables while preventing contamination risks. Staff have been instructed that recyclables must never be stored in food preparation or storage areas. This policy will be reinforced at the March 12th all-staff training, where staff will receive guidance on proper waste and recycling management. Additional kitchen inspections will now be conducted on a more frequent basis to verify compliance. 3) Weekly quality assurance inspections will be conducted to confirm that recyclables are stored in designated areas and not in food preparation spaces. The recycling bins will also be monitored to ensure they are emptied regularly to prevent pest attraction and contamination risks. 4) The Kitchen Coordinator, Administrator, or a designated staff member will oversee compliance through routine inspections and staff monitoring. Any instances of non-compliance will be corrected immediately through coaching and retraining, and repeated violations will result in corrective action as needed. I 1) All staff involved in meal service and delivery have been educated on the requirement to cover plated meals at all times before they are served. Staff have been instructed to use plate covers or appropriate lids to ensure meals remain protected from contamination when they are not immediately consumed. Meal service procedures have been revised to require verification that all meals remain covered until they reach the resident. 2) Proper use of plate covers will be reviewed in mandatory training at the March 12th all-staff meeting. A rotating meal observation schedule has been implemented, where supervisors will oversee meal service daily and provide real-time coaching and correction if meals are left uncovered. Any uncovered meals identified during inspections or observations will be corrected immediately, and non-compliant staff will receive retraining as necessary. 3) A rotating meal observation schedule has been implemented, ensuring that each house is observed at least once per week to confirm that all plated meals are properly covered when left out or transported. In addition, random spot checks will be conducted daily during meal service to verify compliance. 4) The Kitchen Coordinator, Administrator, or a designated staff member will oversee meal covering compliance, ensure staff follow correct food handling procedures, and conduct routine monitoring of meal services..

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.

Please see Tag 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: