Print Inspection: KIT003414

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 observations and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and in accordance with the Food Sanitation Rules, OAR 333-150-000. include, but are not limited to: Observation of the main kitchen, dining room kitchenette, and activities kitchenette on 03/20/25 at 10:40 am through 2:00 pm revealed the following deficiencies: 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: * Interior and exterior of Convection ovens; * 2 oscillating and 1 box fans; * Floors in corners/edges: * Floors under and behind equipment; * Ledges around baseboards throughout kitchen area; * Industrial can opener and housing’ * Industrial mixer; * Walls in dish machine/ware washing room/area; * Utility carts; * Metal racks in walk in cooler; * Cooling fan cages and ceilings in walk in cooler; * Exterior of ice machine; * White wood shelving throughout kitchen; * Removable hood vents; * Interior of steamer; * Exterior of white bulk food bins; * Open stainless steel shelving storing pots and pans; * Reach in refrigerator in Activity kitchenette; * Interior of cabinets in Activity kitchenette; * Ceiling vent in Activity kitchenette; * Over the stove hood/fan in Activity kitchenette; and * Blender base in dining room kitchenette;. b. The following areas were found in need of repair: * Multiple edges of shelving in cabinets in dining room kitchenette and activity room kitchenette with exposed porous wood. * Large gaps in the wall under dish machine where pipes exit. * Large cracks in floor of walk in cooler. * Large gap between flooring and cove base in main kitchen area from freezer floor sinking. Multiple stainless steel wall panels damaged from shift in floor. * Freezer with build up of frost/ice; * Multiple areas in main kitchen flooring where seems are pulling apart leaving gaps for debris build up. Floor under feet of convection stove damaged from heat of stove. * Section of wall under soap dispenser with damage to dry wall. c. Muliple staff in main kitchen handling food or clean equipment without facial hair restraints. d. Muliple food items in Activity kitcheneete refrigerator were found open without open dates. e. Staff drinks were observed stored in the Activity refrigerator where resident food was stored. A staff drink was observed stored in the dining room kitchenette that did not have a lid or straw as required per code. f. Staff in the main kitchen were noted to be eating in the kitchen at a rolling cart that was next to clean equipment and had single service meal items on the cart. At approximately 1:30pm, Staff 2 (Dietary Manager) was informed of this observation and acknowledged that was not an approved/dedicated area for staff to eat. g. Meal service was observed in the dinning room. Puree texture of bread items was observed to be very runny and did not hold any shape on a fork. The food item ran thru the tine of the fork. Staff were not aware this texture was too thin for puree. When surveyor pointed out the thin texture the staff indicated that they would put it in bowls. Surveyor intervened and insisted the too thin meal item not be served until thickened appropriately. Staff 2 visualized the food product and agreed it was not at the correct food consistency for puree and had kitchen staff correct the item before served to residents. h. During meal service, multiple residents at each table were served their meals at alternate times than other residents at the same table. This left some residents sitting and waiting for their food while other residents at the table were eating their food. This led to one confused resident attempting to reach over and take another resident’s plate. This caused the other resident to be upset and yell at the other resident. After meal service staff 1 was interviewed at approximately 1pm and they acknowledged that all residents at one table should be served together before moving to serve other residents from another table. Surveyor observed this practice not followed for multiple tables/residents during lunch meal. Surveyor toured the main kitchen areas with Dietary manager (staff 2) who acknowledged areas in need of correction. Surveyor toured the Activity kitchenette with staff 1 (Administrator) who acknowledged the identified areas. At approximately 1:30 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Administrator) and they acknowledged the areas in need of correction.

A: 1: All affected areas and equipment were immediately cleaned and sanitized by kitchen staff. 2: •Will implement a routine cleaning schedule covering all equipment and surfaces listed in the citation. • Equipment such as fans, mixers, and utility carts will be included in routine maintenance protocols. • Staff will receive training on food safety and sanitation procedures, with an emphasis on thorough cleaning under, behind, and above equipment. • The Activity and Dining Room kitchenettes were added to the facility-wide cleaning and inspection schedule. 3: Dietary Manager will review cleaning checklist for Responsible Staff Member(s) weekly x 4 and then monthly ongoing. 4: Dietary Manager is responsible to oversee the cleaning and maintenance of kitchen equipment. B. 1: Shelving will be repaired or replaced with sealed, non-porous materials to meet sanitary standards. Gaps in the wall under the dish machine will be sealed with appropriate wall patch and waterproof material. Damaged flooring, gap between flooring and cove base, and ice build-up in walk-in cooler will be repaired. Flooring under convection stove will be repaired or replaced. Wall under soap dispenser will be repaired. 2: Staff will be inserviced on notifying maintenance when repairs are needed. Maintenance will conduct routine kitchen inspections for repairs needed and review maintenance requests for kitchen repair needs and follow-up. 3: Kitchen audits will be conducted by the maintenance director or designee to include shelving, flooring, cabintetry, walls, and any other areas of disrepair monthly x 3 then quarterly x 3 to ensure compliance. 4: The Administrator will oversee the implementation of all corrective actions. Reports will be documented and reviewed during monthly safety meetings. Any new issues will trigger immediate investigation and timely follow-up. C-G: 1: Beard nets will be made readily available in the kitchen area. Signage reminding staff of PPE requirements will be posted near handwashing and entry points. All improperly labeled or undated food items or staff items were removed from the refrigerator immediately. Staff were directed to not consume food items in the kitchen and the cart and surrounding area were immediately sanitized. The pureed meal was withheld until the puréed food was modified to meet proper consistency standards. 2: Staff will be retrained on personal hygiene and grooming standards, including the mandatory use of facial hair restraints when handling food or clean equipment. Staff will receive refresher training on proper food storage and labeling procedures, including the importance of open dating to ensure food safety and prevent spoilage. Date label stickers and markers will be available in kitchenettes. Staff will be trained on the requirement that drink containers have a lid/straw. Signage placed at refrigerator indicating it is for resident food. Clear signage will be posted in the kitchen to remind staff that eating in food prep and storage areas is prohibited. All dietary staff will receive a refresher training on food texture standards. Visual guides will be posted in prep areas. 3: The Dietary Manager or Shift Supervisor will conduct daily checks ongoing to ensure all food handlers are in full compliance with PPE requirements and eating and drinking policies.The cook will perform consistency checks prior to each meal service for all texture-modified diets. Audits will be conducted weekly by the Dietary Manager to ensure compliance with food textures. *Any inconsistencies will be immediately corrected and reviewed in staff meetings. *Non-compliance will be documented and addressed immediately through verbal or written warnings, as appropriate. *The Activity Director or designee will check refrigerator and kitchenette areas for proper storage, labeling and staff consumption daily x 14, then weekly x 30 days to ensure compliance. *Results will be reviewed during monthly compliance meetings with the Dietary Manager. 4: Kitchen supervisors will be tasked with ensuring compliance with hair coverings, staff eating and drinking policies, and food textures each shift and reports of non-compliance made to the Dietary Manager. Activity Director or designee will be reponsible to ensure compliance with activities kitchenette food storage and labeling requirements. Administrator or designee is responsible to ensure compliance with dining room kitchenette food storage/labeling requirements and to ensure staff beverages have lids/straws. Findings will be reviewed monthly at Quality Assurance and Performance Improvement (QAPI) meetings to evaluate compliance and address repeat issues. H. 1: Dishwashing in the Activity kitchenette will be suspended, and all dishware will be cleaned in the main kitchen's approved commercial dishwasher. The residential dishwasher will be evaluated for replacement with a commercial-grade unit that meets state and local health code requirements for sanitization and capacity. 2: *Staff will be trained on equipment requirements for food service areas within the facility. *An internal review of all kitchen and kitchenette appliances will be conducted to ensure compliance with applicable regulations. 3: *The Facilities Director and Dietary Manager will coordinate to ensure any new appliances are installed and meet commercial specifications. *The Administrator will review compliance quarterly to verify all equipment in use across the facility meets regulatory standards.

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.

See plan of correction for 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: