Print Inspection: KIT003264

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 house kitchens (Douglas and Ramp) on 03/13/25 from 10:40 am thru 2:00 pm revealed the following deficient practices. a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following: Douglas House: * Reach in refrigerators and freezers; * Drawers and cupboards; * Light fixtures above kitchen area; * Smoke detector and sprinklers above kitchen area; * Interior of oven; * Interior of microwave; and * Drawer under oven where pan lids were stored. Ramp House * Interior of oven; * Electric mounted can opener; * Interior of reach in refrigerators and freezers; * Thermometer used for temping food items; * Hot pads; * Interior of drawers; * Interior of cabinets/cupboards; * Cabinet under sink; * Baseboards near refrigerators; and * Left refrigerator seals with debris accumulation inside the cracks. b. The following areas needed repair: * Shelving in both dry storage areas with exposed wood; * Behind sink in Ramp house area with damaged caulking * Section under cabinets where mounted can opener with damage to backing coming off. * 3 of 4 reach in refrigerators not effectively holding temperatures. * Ceiling/attic space entry in dry good storage in Douglas house with hole allowing for potential pest entry. * Drawer directly under oven in Douglas not closing correctly. * Interior of some drawers and cabinets in both houses with worn/exposed porous wood sections yielding unsmooth surfaces. * Both refrigerators in the Ramp house had cracks or broken seals. * Right freezer in Douglas house with large section of unsmooth non cleanable area. * Left freezer in Ramp house with section of rusted area near the back of the freezer. c. Three of four reach in refrigerators were observed above 41 degrees Fahrenheit. The right fridge in Douglas was noted at 49 degrees at 11:12 am. The left fridge in Ramp house was noted at 49.1 degrees at 11:24am with yogurt stored in fridge noted at 46 degrees. The right fridge in Ramp house was noted at 44 degrees at 11:26am. All thermometers were located in the door of the reach in refrigerator where multiple food items were stored. The refrigerator temperature logs were reviewed for all refrigerators and documented majority of entries since January that were above 41 degrees. At 12:11pm the temperature of the fridge in Douglas house was rechecked and still read above 41 degrees. There was a pan of bbq chicken prepared on night shift for dinner that night. The temperature of that product was checked and read 54 degrees. At that time, Staff 2 (Person In Charge), was notified of the elevated temperatures and the need for intervention. Staff 2 verified the bbq chicken would be discarded as it had been out of acceptable refrigeration temperatures greater than 6 hours. Staff 2 also verified that all potentially hazardous food items would be discarded from that refrigerator. Staff 2 was not aware that the refrigerators were consistently not maintaining correct temperatures for cold food storage despite several staff entries into fridge temp logs of temperatures well above 41 degrees. d. Multiple food items were observed stored in both Ramp and Douglas house refrigerators that were not dated when opened as required. e. Multiple items were observed stored on the floor in Douglas house panty. Multiple canned good items were also noted in Douglas pantry that were damaged/Dented. Staff 2 was not aware canned goods that were dented could not be used in food service. f. Multiple pots/pans, cutting boards, dishes were noted in both houses that were heavily scratched, scored or damaged and in need of replacement. g. Staff in Douglas house were observed to reheat a resident’s alternative food choice in microwave for lunch. Staff did not check the temperature of the food product before going to serve to the resident. Surveyor intervened and asked them to check the temperature which was 160 degrees. Surveyor asked the staff what temperature reheated foods needed to be before serving to residents and they were not able to correctly identify the required 165 seconds. h. Food items for lunch were observed sitting on the counter or on the stove uncovered for both houses. Staff were not aware of the need to cover food items when not serving to ensure appropriate heat was retained. i. Staff in Douglas house did not sanitize the thermometer prior to checking food temperatures. j. Sanitation buckets in both Douglas and Ramp were observed higher than 600ppm for quaternary solutions. Staff did not have access to test strips and were using Bru tabs. Directions for bru tabs included 1-2 tabs per gallon of water. The bucket was ½ full (approx. ½ gallon) and staff used 2 tabs. Staff did not know the ppm (parts per million) required for effective sanitation. Staff 2 (PIC) did not know the correct ppm required for effective surface sanitation. k. Both Douglas and Ramp houses were utilizing residential style dishwashers for ware washing/sanitizing. Staff in both houses and PIC indicated use of “quick wash and heated dry” cycles for ware washing. Staff and PIC were not aware of internal wash or rinse temperatures of the machines. Facility did not have a system to test effectiveness of sanitizing for dishes. Surveyor asked for manufactures specifications which documented the ability to use a “sanitize cycle” for sanitation. Regular rinse water temperature of the machines were listed at 130 degrees. The sanitize cycle documented a final rinse temperatures of 155 degrees. Staff 2 verified no additional sanitize steps were done with dishes run thru the dishwasher. Staff 2 (PIC) was unaware of need for dishes to be sanitized. l. Whole shell eggs were noted to be stored above ready to eat foods in the refrigerator in Ramp house. m. Care staff were not wearing protective outer clothing or aprons during meal preparation, service or assistance potentially exposing food items to contaminants from person care tasks. n. At 1:00 pm, Staff 2 was interviewed. They were not able to demonstrate effective knowledge in final cook to temperatures for all meat/protein items. They were also not able to discus proper thawing practices, proper cooling time/temperature benchmarks and methods. The PIC did not demonstrate effective oversight for cold food storage with 3 of 4 refrigerators not storing food at appropriate temperatures. The facility did not have effective ware washing sanitation practices and oversight. Staff 2 (PIC) toured areas with surveyor and acknowledged areas in need of attention and correction. In an interview on at 1:45 pm, Staff 1 (Administrator) was informed of concerns found and acknowledged areas needing correction.

1. A) All areas of concern will be cleaned and sanitized appropriately as required. B) All items of concern listed will be repaired or replaced as required. C) Community will ensure all temperatures are taken appropriately and that all food items are stored and prepared at proper temperatures as required. D) All food items will be dated by Staff after opening as required. E) All food items will be stored correctly as required. F) All damaged items listed will be replaced as required. G) Community staff will ensure all temperatures are taken appropriately and that all food items items are reheated at proper temperatures as required. H) Community staff will ensure that all prepared food items are covered while serving to ensure proper temperature and protection from contaminates as required. I) Community staff will ensure thermometers are sanitized appropriately before taking the temperature of food items as required. J) Community staff will purchase testing supplies and ensure sanitation buckets are prepared appropriately before cleaning and sanitizing surfaces as required. K) Community staff will ensure all dishes are sanitized appropriately as required. L) Community staff will ensure all temperatures are taken appropriately and that all food items items and ready-to-eat food items are stored properly as required. M) Community staff will ensure that protective outerwear and aprons are worn while preparing and serving food to ensure proper protection from contaminates as required. N) PIC of Kitchen and Kitchen staff will be able to demonstrate effective knowledge regarding proper temperatures, proper thawing practices, food storage and handwashing practices as required. 2. A) We will correct our system for this concern by implementing a routine cleaning schedule focusing on these areas. B) We will correct our system for this concern by repairing or replacing items listed and implementing a routine inspection schedule for each area of concern. C) We will correct our system for this concern by reeducating our staff and updating our Kitchen Handbook to provide an addidtional resource for ensuring system corrections. D) We will correct our system for this concern by reeducating our staff and updating our Kitchen Handbook to provide an addidtional resource for ensuring system corrections. E) We will correct our system for this concern by reeducating our staff and updating our Kitchen Handbook to provide an additional resource for ensuring system correction. F) We will correct our system for this concern by replacing required items and implementing a routine inspection schedule for each area of concern. G) We will correct our system for this concern by reeducating our staff and updating our Kitchen Handbook to provide an additional resource for ensuring system correction. H) We will correct our system for this concern by purchasing additional kitchen supplies, reeducating our staff and updating our Kitchen Handbook to provide an additional resource for ensuring system correction. I) We will correct our system for this concern by purchasing additional kitchen supplies, reeducating our staff and updating our Kitchen Handbook to provide an additional resource for ensuring system correction. J) We will correct our system for this concern by purchasing additional kitchen supplies, reeducating our staff and updating our Kitchen Handbook to provide an additional resource for ensuring system correction. K) We will correct our system for this concern by ensuring the use of the "sanitize cyle" setting on all dishwashers, reeducating our staff and updating our Kitchen Handbook to provide an additional resource for ensuring system correction. L) We will correct our system for this concern by reeducating our Staff and updating our Kitchen Handbook to provide an additional resource for ensuring system correction. M) We will correct our system for this concern by purchasing additional kitchen supplies, reeducating our staff and updating our Kitchen Handbook to provide an additional resource for ensuring system correction. N) We will correct our system for this concern by providing additional educaction to our PIC throught the SafeServe training course, reeducating our staff and updating our Kitchen Handbook to provide an additional resource for ensuring system correction. 3. A) 3X per week. B) 1X per month. C) 3X per week. D) 3X per week. E) 3X per week. F) 1X per month. G) 3X per week. H) 3X per week. I) 3X per week. J) 3X per week. K) 3X per week. L) 3X per week. M) 3X per week. N) 1X per year. 4. A) Executive Director and or Designee. B) Executive Director and or Maintenance Director. C) Executive Director and or Designee. D) Executive Director and or Designee. E) Executive Director and or Designee. F) Executive Director and or Designee. G) Executive Director and or Designee. H) Executive Director and or Designee. I) Executive Director and or Designee. J) Executive Director and or Designee. K) Executive Director and or Designee. L) Executive Director and or Designee. M)Executive Director and or Designee. N)Executive Direcotr and or Designee.

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, record review 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 refer to C 240

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: