Print Inspection: KIT004048

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 11/12/24 from 10:40 am through 2:00 pm and memory care unit during lunch service from 11:30 pm thru 12:00 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 coolers * Reach in deli cooler * Hand washing sink/facet * Walls surrounding hand washing sink * Wall above and next to spice shelves * Spice shelves * Metal can rack * Floors under, behind and between equipment * Industrial can opener * Interior and exterior of microwave * Exterior of bread drawer * Backdoor threshold * Counter next to microwave where blender and food processor are stored * Clean side of dish area with visible food debris and other contamination * Bulk white food bins * Industrial mixer * Blue lids for bulk foods * Stainless steel table where bulk bins stored * Reach in refrigerator in kitchenette * Dining room floors with food debris from breakfast meal observed during lunch meal * Kitchenette cabinets and drawers b. The following areas were in need of repair: * Caulking by dish machine area with black debris build up. * Tiles on base cove near back door and near steamer cracked/missing c. Multiple food items stored in reach in coolers and memory care unit refrigerator found not covered or sealed and exposed to potential contamination. d. Prepared/opened food items stored in reach in coolers found past seven days. Multiple potentially hazardous food items not dated when opened and/or prepared in reach in coolers and in unit kitchenette refrigerator. e. Multiple staff noted to be handling clean dishes and/or preparing/serving food/beverages without hair restraints as required. Staff member handling food/beverages/clean dishes with painted nails and did not have gloves on as required. A non-dietary or kitchen staff was observed to enter the kitchen and pass directly thru meal service area while plates were being served. This staff did not wash hands and did not don a hair restraint. This observed to occur three times during 10 min of meal service. Kitchen staff were asked and indicated it was maintenance staff cutting thru the kitchen to get to their office. Kitchen staff stated it occurred very frequently even during meal service times. Facility staff verified their door was not the only way to this staff’s workspace. This practice causes potential contamination during meal service and is not allowed per rule. f. Staff drinks were observed stored in food preparation areas and did not contain lids/straws/handles to minimize hand/lip contact as required. g. Bulk bin of flour observed stored open to potential contamination. A measuring cup was found stored inside the bin with a handle touching food product potentially contaminating the food. h. Surfaces sanitation bucket was tested and did not register any effective parts per million of sanitizing solution. Staff was not aware of when it was changed last. Multiple rags for sanitizing surfaces were noted stored outside of the red bucket in random areas in the kitchen including on visually soiled and dirty items. A large container of “clean” rags were stored underneath the dish machine. Staff 2 (Executive Chef) acknowledged they were clean and should not have been stored there. i. A pan with an open back of raw chicken was observed stored directly on top of a pan of ground beef. Staff 2 acknowledged the chicken should have been stored under the pan of ground beef in order to follow the correct storage hierarchy. j. Staff 2 was observed during lunch preparation to remove a raw chicken breast out of the reach in cooler with their bare hands and place on the flat top grill. Staff 2 then dipped their hands thru the 3 compartment sink set up (wash) (rinse) (sanitize) and then rinse off their hands in the hand wash sink. Food code requires a thorough and effective hand wash step after handling raw meats. The 3 compartment sink was directly adjacent to hand washing sink. Another instance Staff 2 was observed to wash their hands 5 seconds not the 20-30 seconds required for effective hand washing. k. There was a container of salt, a container of garlic and a container of parsley on a prep table near the flat top grill. Staff 2 was observed to reach in with hands for all three containers to season item cooking on the flat top grill. Staff 2’s hands were potentially contaminated therefor potentially contaminating the containers of seasonings. l. Facility did not have pasteurized whole shell eggs. Staff 2 confirmed they prepared residents egg of choice that included over medium, easy or poached with the yolks not fully cooked. Staff 2 was unaware of the need for pasteurized shell eggs. m. Facility did not have a current copy of the Oregon Food Sanitation rules on hand in the food establishment as required. n. A resident was assisted into the memory care dining room with their catheter bag on their lap. Resident handled the bag when handing in to staff to place on wheelchair in dining room clearly potentially contaminating their hands from the catheter bag. Staff did not offer or assist the resident in a hand hygiene step prior to serving them lunch. On 04/23/25 at 1:30 pm Staff 2 and Staff 1 (Executive director) were informed of the identified concerns and they acknowledged the areas in need of correction.

1)Food spills, splatters, dirt, trash debris, and black matter were cleaned from: -Reach-in coolers -Reach-in deli cooler -Handwashing sink/faucet -Walls surrounding handwashing sink and spice shelves -Spice shelves and metal can rack -Between and under equipment -Industrial can opener -Microwave (interior and exterior) -Bread drawer exterior -Backdoor threshold -Counter near microwave -Clean side of dish area -Bulk food bins and blue lids -Industrial mixer -Stainless steel table used for bulk bins -Reach in refrigerator in kitchenette -Dining room floors -Memory Care kitchenette cabinets and drawers •These areas have been added to a daily/weekly cleaning schedule. Staff Hygiene and Behavior -Staff were observed without hair restraints. This was addressed. All applicable staff now we retrained and wear hair nets and beard nets, in compliance with food safety rules. -A staff member with painted nails was handling food without gloves. This incident was addressed with staff member and retraining provided. -Improper handwashing and glove use by staff was addressed and retraining provided. -Staff 2’s contamination of seasoning containers led to disposal of those seasonings in containers. Retraining provided. -Staff drinks without proper lids/straws/handles were removed. retraining provided. Cross-Contamination and Storage -A pan of raw chicken stored above ground beef led to the disposal of ground beef. -Staff 2 handled raw chicken barehanded and improperly washed hands. This incident was addressed and staff were retrained on proper hand washing. -Unsealed and outdated food in coolers was discarded. -A bulk bin of flour left open was also discarded. -Staff member observed to not offer or assist a resident in a hand hygiene step prior to serving them lunch after they handled their catheter bag was addressed and staff provided retraining. Structural and Equipment Issues -Cracked/missing tiles and black debris in dish machine caulking were repaired or replaced. -Sanitation bucket with ineffective solution was discarded and replaced. -Soiled cleaning rags were removed and stored appropriately. -Unpasteurized shell eggs were replaced with pasteurized eggs. Documentation and Compliance -A current copy of the Oregon Food Sanitation Rules were printed and are now on-site. -Non-kitchen staff have been instructed to use alternate routes during food service to prevent contamination. 2) All dining and kitchen staff will receive retraining on: -Hair and beard restraint usage -Glove use -Proper hand hygiene -Food storage hierarchy -Food sanitation and contamination prevention -Chemical test procedures -Labeling, dating, and discarding food -Cleaning expectations -Task log completion and accountability All Memory Care staff will receive training on resident hand hygiene prior to serving residents food. 3) Executive Chef (EC) will conduct weekly inspections of all refrigerators, freezers, and cleaning/task logs to ensure full compliance. -EC will verify sanitation, labeling, and overall cleanliness per policy. -ED will also perform spot checks and maintain oversight of retraining documentation. -MC administrator will perform spot checks during meal services to ensure hand hygiene is provided to all resident prior to being served meals. 4) Executive Chef – Primary accountability for kitchen sanitation and food safety compliance. Environmental Services Director – Oversight of structural maintenance, cleaning compliance, and coordination with the EC Memory Care administrator-Primary Accountability for memory care staff training.

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.

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: