Print Inspection: KIT004995

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 a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the kitchen on 06/17/25 showed the following areas needed cleaning or repair: * Sections of flooring throughout the kitchen and dry storage had dark stains, black accumulation along the edges of baseboards and flooring, pieces of flooring were cracked and/or missing pieces and were pulling apart at seams. Patches to the flooring were pulling apart at edges and creating gaps in the floor; * Dry storage shelving had spills and debris on multiple shelves and debris was noted underneath the shelving units; * Refrigerator units were noted with spills and debris on the shelves and on bottoms of the units; * Spills and splatters were noted on the large three-door refrigerator doors and vents, and a broken handle was noted on the center unit refrigeration side; * Numerous lights in the kitchen had dead bugs, debris and/or dust gathered in the interiors; * Four cutting boards were extremely worn and frayed, two mixing spatulas were missing small pieces and cracked, and two blender pitchers were cracked and stained; * Debris, spills and discolored flooring was noted between and around equipment edges throughout the kitchen; * Splatters were noted on the ceiling near the steam table and stove area. Large amounts of dust and webs were gathered on vents at the front of the kitchen and hanging from a video camera from the ceiling; * Drains throughout the kitchen were darkly stained with black/brown accumulation and/or debris in the drain; * Multiple plastic edge coverings and plastic wall pieces were cracked and missing large pieces near the window and the handwashing sink; * Spills and splatters were noted on walls throughout the kitchen and along the fronts of both ovens; and * An air conditioning wall unit, above the window, had thick dark accumulation and dust on the inner vent slats. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (ED) and Staff 2 (Facility Services Director) on 06/17/25. They acknowledged the findings.

1. Damaged Flooring – Seams Pulling Apart and Gaps Forming • Corrective Action Taken: New flooring has been ordered. Kitchen flooring will be patched as an interim fix. • Systemic Change: Ongoing monitoring and preventative maintenance will be implemented to detect early signs of flooring damage and address them promptly. • Evaluation Frequency: Monthly inspections by Maintenance or Executive Director (ED). Weekly observations by Dining Services Manager (DSM). • Responsible Party: Maintenance Director, Dining Services Manager, and Executive Director. 2. Dry Storage Shelving – Debris on Shelves and Underneath • Corrective Action Taken: Shelving and surrounding area will be fully cleaned by Dining Department staff by 8/10/2025. • Systemic Change: Routine cleaning schedule reinforced and documented in daily cleaning logs. • Evaluation Frequency: Weekly checks by DSM. Monthly audits by DSM or ED. • Responsible Party: Dining Services Manager, with oversight by Executive Director. 3. Refrigerator Door and Handle – Spills and Spatter Present • Corrective Action Taken: Area has been cleaned. Door and handle will be replaced. • Systemic Change: Added to daily cleaning checklist. Shift lead cooks verify cleaning at close of each shift. • Evaluation Frequency: Daily checks by cooks. Weekly reviews by DSM. Monthly audits by DSM or ED. • Responsible Party: Cook staff, Dining Services Manager, Executive Director. 4. Ceiling Lights – Dust and Debris Present • Corrective Action Taken: Lights cleaned by Maintenance on 7/8/2025. • Systemic Change: Monthly maintenance schedule updated to include light cleaning in kitchen and food service areas. • Evaluation Frequency: o Monthly by Maintenance or ED. • Responsible Party: Maintenance Director and Executive Director. 5. Cutting Boards and Mixing Spatulas – Damaged/Frayed • Corrective Action Taken: Damaged items discarded on 6/17/2025. New equipment received on 6/30/2025. • Systemic Change: Weekly supply checks implemented. Replaced items logged with date. • Evaluation Frequency: Weekly by DSM. Monthly by ED. • Responsible Party: Dining Services Manager, Executive Director. 6. General Cleaning – Spills, Spatter, and Debris in Kitchen • Corrective Action Taken: Daily cleaning protocols are being enforced and documented. • Systemic Change: Cleaning checklists are posted and signed off daily by cook staff and reviewed weekly. • Evaluation Frequency: Daily cleaning by cooks. Weekly reviews by DSM. Monthly spot checks by DSM and ED. • Responsible Party: Cook staff, Dining Services Manager, Executive Director.

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 observation and interview, 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: