Print Inspection: KIT006629

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observations, interviews, and record review, it was determined the facility failed to follow texture components of diet orders for 1 of 1 randomly selected resident (# 1) needing puree diet textures. The incorrect diet texture placed the resident at risk for aspiration and/or choking. Findings include, but are not limited to: Resident 1 had a current physician order dated 06/17/25 noting the following diet order: “Regular diet: Pureed Texture, IDDSI [International Dysphagia Diet Standardization Initiative] Moderately Thick consistency.” On 09/05/25 at approximately 11:30 am Resident 1 was observed to be given her meal. Shortly after taking the first bite resident was observed to start coughing. Care staff did respond and go to resident asking if they were ok. The resident did nod indicating they were “OK”. Resident took another bite and began coughing again. Staff intervened and offered the resident a drink of their thickened liquid which appeared to subside the cough. After a few minutes passed the resident took another bite and again began coughing. The surveyor went over to view the resident’s meal and the meal texture did not look smooth as was expected with appropriate texture. Surveyor went to the North Unit and observed a plated meal designated as puree that had yet to be given/served to a resident. Upon investigation of the food products revealed several big chunks of whole unprocessed pieces of vegetables (carrots and green beans) or meat and the overall texture was not smooth as needed/necessary for appropriately pureed textures. Surveyor instructed Staff 4 (Cook) the items as plated could not be served. Staff 4 acknowledged the whole chunks were not appropriate for puree textures and they would serve any remaining residents needing puree something else. Staff 4 acknowledged that all puree items were mechanicalized together in batches and then individual resident servings taken out of the batches confirming the observed texture of the meal for resident 1 was not appropriate. At approximately 12:20 pm, surveyor presented the incorrectly pureed food items to Staff 1 (Administrator) who acknowledged the unsmooth and larger pieces in the pureed items that would not be appropriate for a resident needing pureed textures. Staff 1 acknowledged the presented texture would be a potential safety issue for residents needing puree diet. Surveyor informed Staff 1 of the observation of Resident 1 difficulty with lunch meal and the multiple coughing episodes. Staff 1 verbalized understanding and acknowledged the lunch meal presented appeared to not be the correct and safe texture for residents needing puree. At approximately 1:00 pm, Surveyor interviewed both cooks on duty (Staff 4 and 5). Both cooks acknowledged the larger pieces observed in lunch for puree was not appropriate or safe for residents needing puree texture. Surveyor asked staff to demonstrate appropriate pureed food items and neither cook understood the appropriate level of smooth texture needed for puree textures. After demonstration by surveyor Staff 4 and 5 were then able to understand and demonstrate the correct level of mechanicalizing of food items to produce a smooth/appropriate puree textures. On 9/08/25 surveyor returned to facility for lunch meal preparation and service and validated puree textures were correct. Resident 1 was observed during lunch meal and was not observed to cough throughout the lunch observation. On 09/08/25 at 12:28 Staff 2 (Dining Services Director) was interviewed and acknowledged the facility had not been pureeing items correctly.

1. Cooks to check textures prior to service to ensure smooth consistency needed for puree texture. All staff, including care staff received training on diet textures and what this should look like for puree textures. All new hires will receive the same training upon hire as part of new hire process from ED/Dietary Manager. Care staff to monitor during meals to ensure toleration of all textures of food being eaten. They will report any noted difficulties to manager on duty 2. Use different blending carafes to blend food to ensure appropriate texture is obtained 3. Evaluated daily 4. Dining Services manager, cooks and servers

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by:

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 main facility kitchen and the North and South unit kitchenettes on 09/05/25 from 10:40 am through 2:00 pm and again on 09/08/25 from 10:00 am through 2:00 pm revealed the following: 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: * Walls, and flooring behind/underneath of the dish machine; * Industrial mixer; * Industrial slicer; * Large can opener and housing; * Black tray holding clean dishes above service line; * Large can metal storage rack; * Speed rack in walk in cooler; * Metal rack in walk in freezer; * Interior of white bulk food storage container; * Top of dish machine; * Top of specialty coffee/cocoa machine; * Drain under dish machine; and * Juice machines in unit kitchenettes. b. The following areas needed repair: * Metal racks in walk in cooler had rust accumulation; c. Salad dressing containers in both units not dated with dates opened or use by dates. Salad dressing containers in deli cooler in main kitchen did not have open or use by dates. Multiple items noted in deli cooler without open dates. d. Multiple food items found past manufactures use by dates. Container of peperoni was observed well past use by date and visible signs of molding/spoilage were observed. e. Two large boxes of sprinkles found stored open to potential contamination. Ice cream bars in North unit freezer observed stored unwrapped/open to potential contamination. Containers of single use disposable utensils/service ware were stored open exposing items to potential contamination. f. Room trays for residents were observed on both units to be delivered/transported to the rooms without food or beverages covered/protected from potential contamination. g. A large soup kettle pot was observed stored in the walk-in cooler full of soup made the evening before. Staff were interviewed about proper cooling methods and time temperature guidelines to ensure safety. Staff were not able to discuss proper ways to cool items nor able to discuss temperature levels and time frames needed for safe storage. Staff verified the soup did not undergo any further steps to ensure safe storage. Staff 2 (Dietary Manager) was interviewed on 09/08/25 at 12:38 pm and acknowledged staff did not follow appropriate cooling steps and would discard the soup. h. The evening meal cook was not able to correctly state proper cook to temperatures for chicken/poultry. Menus were reviewed and multiple meals included chicken as a main entrée. i. Multiple bulk food items were found with scoops/utensils stored with hand contact areas touching food surfaces potentially contaminating the food product. j. White cutting boards were found heavily stained and scored and in need of replacement. Multiple fry pans observed with integrity issues. Multiple North unit resident reusable straws were found heavily stained and in need of replacement. k. Facility did not have the correct test strips to test/validate the surface sanitizer and three compartment sink sanitizer. Kitchen staff were not aware of the chemical used for sanitation and were not able to state the appropriate parts per million (PPM) needed for sanitation. Surveyor was able to validate sanitizer dispenser was dispensing correct concentration of sanitizer with surveyor provided strips. The incorrect chemical was posted on the dispenser. l. Kitchen staff did not have appropriate knowledge of puree diets to ensure diets were served as ordered. Puree food items for lunch on 09/05/25 were observed with visible chunks and/or large whole pieces of food mixed into the more mechanicalized pieces. There was no smooth blended texture observed to the food items. On 09/08/25 at 12:38 pm, Staff 2 was interviewed and acknowledged the facility was “doing puree wrong.” Staff 2 acknowledged they had not had any official training on puree textures. m. On both days of survey lunch meal was prepared and in ovens/warmers well before lunch service. On 09/05/25 lunch was in ovens/warmers at 10:40, at least one hour before service. On 09/08/25 lunch meal items were observed complete and in oven/warmers at 10:00am over 1 hr 30 minutes prior to meal service times. Staff 2 was interviewed regarding the possible reasons why meal items were cooked that far in advance of meal service times, and they indicated the staff have just done that since he started. Staff 2 was asked the barriers to preparing food closer to meal service times and he said there weren’t any. Staff 2 acknowledged cooking that far in advance with extended hot holding could continue to cook food and lead to potential food quality concerns/outcomes. On 09/08/25 at approximately 12:30 pm, Staff 2 was informed of above areas and acknowledged the needed correction. At 1:30 pm, the surveyor reviewed with Staff 1 (Administrator) the noted areas and they were acknowledged.

1-2a. Daily- clean speed rack, juice machines cleaned with each meal. Dry storage bins cleaned weekly 1-2b. Clean rust off metal racks in walk in and apply sealant 1-2c. Opened containers will have open dates 1-2d. Food deliveries will be checked for expiration dates and checked twice weekly 1-2e. Carton food items transferred to air tight containers. Freezers in units will be checked daily and opened food discarded. Utensils to be stored in airtight containers 1-2f. room trays will be covered with full tray covers that cover the entire tray during transport to rooms 1-2g.Soups stored in airtight containers, cooled with jamar cooling sticks in appropriate time frame 1-2h. education for cooks and temp charts posted for reference 1-2i.Using disposable scoops to throw away after each use to prevent contamination 1-2j. Replace cutting boards. Fry pans discarded. Using disposable straws for resident water bottles 1-2k. Correct test strips ordered and in community for use. Replace label for sanitizer. Inservice for PPM in sanitizer 1-2l.Puree textures will be checked for proper texture pror to service 1-2m. meals prepared and placed in holding no more than 30 minutes prior to meal service 3. All will be evaluated bi-weekly 4. Dining Services Manager/ED

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 main facility kitchen and the North and South unit kitchenettes on 12/04/25 from 9:40 am through 1:00 pm and revealed the following: 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: * Walls, and flooring behind/underneath of the dish machine; * Industrial and countertop mixer; * Large can opener; * Black trays holding clean dishes above service line; * Large can metal storage rack; * Stationary metal racks in walk in cooler; * Interior of white bulk food storage containers; * Top of dish machine; * Ceiling above the dish machine with splatter; * Metal racks in dry good storage; * Top of specialty coffee/cocoa machine; and * Juice machine in South unit kitchenette. b. The following areas needed repair: * Metal racks in walk in cooler had rust accumulation; * Metal racks in ware washing area storing clean dishes with visible corrosion/chemical build up creating unsmooth surfaces; * Drain under dish machine with protective coating removed; * Black utility cart was noted with large burn ring causing damage/pitting/scoring where food/dirt debris could accumulate. * Hot holding cart located in South unit observed with a damaged seal/gasket. * Area directly behind the handwashing sink and under soap/sanitizer dispenser had visible damage to the wood and the caulking. * The ceiling above the dish machine had two square hole in the tile. c. Items found in South Memory care unit reach in refrigerator observed without open dates. Milk container was found to past the manufactures use by date of 11/14/25. d. Multiple items found in walk in cooler that were past the manufactures use by dates or past 7 days from opened or prepared dates and should have been discarded. Food items were also observed opened without open dates. e. Staff food items were observed stored in the reach in deli cooler on the production/service line. Staff were not aware they could not store their food with resident food items. f. White cutting board/surface above deli cooler were found with deep scoring and in need of replacement. Multiple fry pans observed with integrity issues. g. Multiple dented cans were observed stored in dry goods. No clear system was in place to ensure damaged products were not used. h. Unpasteurized shell eggs were observed in the walk in cooler. Staff 2 (Dietary Services Director) indicated they did not serve any undercooked eggs. On the facility’s likes and dislikes board posted in the kitchen, it was documented that a resident desired their egg yolks runny. Facility did not have pasteurized eggs to serve residents who wished not fully cooked eggs. i. Upon entry into kitchen area at approximately 10:00am, entrée and starch items for lunch meal were placed into a warmer hot box cart by cook. Lunch service was not scheduled until 11:30 am, 1 hour and 30 minutes after the food items were done cooking and being held. This practice places food items at risk for palatability concerns from sitting for extended period of time. Staff 2 was interviewed and indicated they were attempting to have meal items completed no more than 30 minutes prior to service to minimize holding time as what is in line with standards of practice. j. Daily menus were observed posted in both the North and South unit that were from the wrong day (12/02/25). No weekly menu was posted in the South unit. On 12/04/25 at approximately 12:30pm, Surveyors reviewed the above areas with Staff 1 (Interim Executive Director) and Staff 2 who acknowledged the items still in need of correction.

1. Main kitchen and kitchenette walls and flooring, counter top mixers, can openers, black trays holding clean dishes, ceiling above dish machine, top of dish machine, top of beverage machines and the juice machines in kitchenettes were deep cleaned to remove accumulation of food, debris, dirt, dust, and black matter. Replaced metal racks in walk-in cooler and in ware washing area. Drain under dishmachine repaired Black utility carts replaced Hot holding cart gasket replaced on south side Repaired visable wood damage behind handwashing sink Repaired holes in ceiling above dish machine All staff have received re-education on using open dates and use by dates and all current food and beverages have been checked for expiration and use by dates. Staff received re-education regarding personal items not being stored on the production/service line and that they cannot store their food with resident food. White cutting board has been replaced. All canned goods were checked and all dented cans returned to Sysco. Kitchen staff have received re-education on not accepting dented/damaged goods from Sysco. Community only ordering pasturized eggs moving forward. All non-pasturized eggs have been removed from the community. Cooks have been re-educated on the expectation of having food ready closer to meals times. Daily menus are posted on the correct date. 2. Re-education with Culinary Director and Culinary team has been completed regarding sanitization, open and use by date expectations, expiration date expectations, no staff items in refrigerators or on prep line, no acceptance of dented cans from Sysco, food prepared and ready closer to food service times, importance of reporting maintenance needs to Culinary Director and inputting into TELs the same day discovered. Culinary director and Culinary Team have been given Kitchen Inspection checklist to conduct mock surveys and understand expectations and what to report. Updated and reimplemented the sanitization schedule and reeducated the Culinary team on daily expectations. 3. Culinary team to follow sanitization schedule daily. Maintenance items will be reviewed bi-weekly unless more urgent need arises. Culinary team will spot check kitchen and kitchenettes for open/use by dates, expirations dates, appropriate menu postings and no personal items are in these areas on a daily basis. Spot checks to ensure meals are ready close to meal service time bi-weekly. CBC Kitchen Inspection mock survey will be conducted quarterly. 4. Executive Director and Culinary 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 411-054-0105 (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.

See 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:

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 C160 and 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: 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, and C455.

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: