Print Inspection: KIT003368

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 was reviewed on 03/18/25 from 11:30 am through 2:00 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 freezer bottoms; *Walk in cooler metal racks; * Metal shelving storing spices; * Industrial can opener and housing; * Industrial mixer; * Walk in cooler fan cages and ceiling near fans; * Kitchen drains; * Blender base; * Right oven; * Floor under and behind ovens/range/grill; * Hood vents; * Juice machine; * Interior of drawers in the beverage area in dining room and * Light switches; b. The following areas were in need of repair: * Ceiling vent above reach in coolers/freezers with dust/dirt accumulation and large gaps; * Section of wall behind 3 compartment sink with damage * Several small sections of flooring seams missing/gaps in sealent creating non smooth/continuous flooring. * Chemical sanitizing dish machine wash cycle not reaching minimum temperature of 120 degrees as required. * Electrical outlet/switch for dish machine hood fan with missing bottom half posing a hazard. * Multiple cabinets/drawers in dining room beverage area with un smooth surfaces. Section of cabinet in kitchen area with piece of protective laminate missing exposing pourous wood. * Reach in freezer with large accumulation of ice/frost buildup and pealing/missing protective covering for racks yielding sections of rusted metal; c. Ice machine drain hose observed stored directly inside a dirty drain. The hose was touching the bottom of the drain and had a thick layer or biofilm. Staff were unaware that the drain hose could not be touching the bottom of the drain and that a air gap was needed as a back flow prevention. d. Utility cart noted to be damaged with burn rings from hot containers making cart unsmooth surface. e. Single use plates and bowls were found stored with food contact surfaces exposed to potential contamination. f. Utensils in the dining room were pre set without the food contact surfaces covered/protected from potential contamination. Staff pre set the next meals utensils directly after the meal. The dining room is open to residents, visitors, vendors and staff in between meals. h. Clean and sanitized utensils were found stored in the kitchen areas with the food contact surfaces pointing up and exposed to potential contamination. i. A white bucket was being used as a trash can and did not have a lid as required for when not in use. j. Red sanitizer bucket used for sanitizing surfaces appeared dirty and was not at the required parts per million (PPM) of sanitizer. Staff 2 (Cook/dedicated Person In Charge) was not able to identify the correct required sanitizer concentration (PPM). k. Copy of Oregon food sanitation rules kept on premises was from 2002. l. Facility did not have a food worker sick and exclusion policy as required. At approximately 2:00 pm, surveyor reviewed above areas with staff 1 (Administrator) and staff 3 (Assistant Administrator), who acknowledged the identified areas.

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 was reviewed on 07/25/25 from 11:30 am through 1:30 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 freezer bottom far left; * Blender base/buttons; * Juice machine; * Window screens * Windowsill * Ceiling vent above reach in coolers b. The following areas were in need of repair: * Section of wall behind 3 compartment sink with excessive water damage/hole * small sections of flooring seams missing/gaps in sealent creating non smooth/continuous flooring. c. Multiple pans of ready to eat foods (RTE) were observed stored in walk in uncovered and exposed to potential contamination. One pan of deserts for lunch meal was observed stored uncovered and exposed to potential contamination. The pan was next to open an window which was dirty. d. Kitchen employees were observed to handle RTE foods with potentially contaminated gloves. Staff were observed to leave service line multiple times and open Walk-in cooler door touching handle with gloved hands, handle containers of sauce, handles of skillet pans and wipe clothing all with same gloves that they handled ready to eat foods. Staff was observed to handle highly allergenic food product (Fried shrimp) with gloved hands and then handle other food products (sandwiches). Food code requires different utensils are used to serve different food products to protect from potential cross contamination. Food code requires single use gloves to be changed and hands cleaned when switching tasks. e. Single use plates and bowls were found stored with food contact surfaces exposed to potential contamination. f. Clean and sanitized utensils were found stored in the kitchen areas with the food contact surfaces pointing up and exposed to potential contamination. At approximately 1:00 pm, surveyor reviewed above areas with staff 1 (Administrator), Staff 2 (Maintenance) and staff 3 (Assistant Administrator), who acknowledged the identified areas.

Concerning spills, splatters and dust. Inside freezers,blender, juice mashine,window screens, window sills, and ceiling vent will added to kitchen cleaning chores, if not on list already. All chores will be delegated to each kitchen staff. These chores will be done one time weekly. Administrator will oversee these corrections. B. Sheetrock above dish sink and the floor seams will be repaired by maintenance team. Any repairs in the future will be repaired in a timely manner. Maintenance team will complete a 2x monthly walk through, looking for anything out of compliance. Administrator will oversee monitoring. C and D. A kitchen team training will be scheduled. The training will be including proper food storage, proper covering of foods and proper storage placement. Proper glove use will be included in training. Observation will be done weekly, at meal serving time. Corrections will be made immediately, if necessary. Administrator will oversee monitoring. E. Dishes exposed to potential contamination will be covered. Covers will be used at appropriate times by kitchen staff, including after last serve of the day. The closing cook will be sure covers are applied. correction will be evaluated daily. The Administrator will oversee monitoring. F. All utensils stored in countertop containers will be stored with all handles pointing up. This instruction will be included in the kitchen training.All kitchen staff will be aware of proper storage. Administrator will check often and monitor.

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 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on record review and interview, it was determined the facility failed to have developed policy and procedures to prevent and respond to potential communicable and food borne diseases. This includes protocols to prevent the development and transmission of communicable diseases including possible food borne outbreaks and gastrointestinal outbreaks including but not limited to Noro Virus. This also includes having a food worker sick policy for exclusion as outlined in Oregon Food Sanitation Rules. Findings include but are not limited to; On 03/18/25 during a kitchen survey, facility was asked to provide policy and procedures surrounding food worker illness and exclusion and Gastrointestinal illness outbreaks. Staff 3 (Assistant Administrator) was interviewed at 1:40 pm and stated they were unable to locate policy’s that address GI/Noro outbreaks/communicable disease response or food worker illness and exclusion. Staff 3 was provided information from food code that outlines the requirement. At approximately 2:00 pm Staff 1(Administrator) was notified via telephone of the need for these policies and procedures. No further information was provided to the surveyor.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on interview, observation and review of records, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

Sea Aire will be sure implemented corrections stay in place and stay in compliance. please see POC for C240.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: