Print Inspection: KIT006720

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 memory care unit kitchenette on 09/11/25 from 10:00 am thru 2:00 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: * Juice machine in dining room * Wall behind trash can in dining room * Removable hood vents * Walk in cooler fan cage * Industrial can opener housing * Wall behind industrial mixer * Wall behind dishwasher b. The following areas needed repair: * Wall behind trash can in dining room damaged/scored * Bottom of side of cabinet in dining room * Hand washing station near steam table without sustainable hot water for effective hand washing * Left oven door not closing effectively for appropriate maintaining of cooking temperatures c. Main kitchen and kitchenette areas did not have thin diameter thermometer probe as required for accurate temperature checks for thin foods. d. Multiple cooking utensils and equipment with integrity concerns (dents, scrapes, heavy scoring, staining, melted spots, etc) and in need of replacement (pots, pans, spatulas, cutting boards, dome lids and bases, etc). Multiple white plates in memory care unit found with chips, cracks and scoring and in need of replacement. e. Food contact surfaces of single services and/or cooking equipment/utensils were observed stored unprotected from potential contamination. f. Multiple kitchen staff observed to reheat food items for residents in the microwave without demonstrating correct methods to ensure effective and even heating (i.e. stirring food item and allowing to sit/stand prior to checking temperature). g. Multiple dished plates of breakfast items were observed in the memory care kitchenette at 12:24 pm when food was delivered to memory care unit for lunch service. Upon investigation with staff, facility practice is to plate a meal and cover and store on the counter for any residents not in the dining room at the time of service in case they wish to eat at a later time. The main kitchen staff then removes/discards the meals at the next meal service. Meal items for breakfast trays temperatures were checked and found at 72 degrees Fahrenheit greater than 4 hrs post meal service. Staff were unaware of the appropriate cooling time/temperature requirements and the need to discard any cooling food after 2 hrs if not at 70 degrees or below. Staff was not aware food should not be allowed to cool on the countertop for extended time frames. h. A trash can was observed stored inside the dry storage/pantry area which is prohibited. Staff 2 was not aware trash receptacles could not be stored in food storage areas. i. Staff serving resident meals in memory care kitchenette was observed to not change gloves appropriately after potentially contaminating them during meal service when switching tasks, touching handles, and then resuming plating of food items. j. Cold food items (coleslaw and watermelon) were not transported on ice from main kitchen and were not held on ice during service and were noted to be at 49 degrees Fahrenheit prior to service. Cold food items should be at 41 degrees or below when served from tray line to maintain safety and palatable cold food temperatures. Staff 2 toured kitchen areas with surveyors and acknowledged the identified areas in need of correction. At approximately 1:45 pm, surveyors reviewed areas with Staff 1 (Administrator), Staff 3 (Memory Care Director) and Staff 4 (Wellness Nurse) who acknowledged the identified concerns.

A 1. All identified areas will be cleaned to OAR standard. 2. Cleaning schedule with check off list to address all areas in section A, this will be be communicated with kitchen staff. 3. Monitor weekly x4 weeks, then monthly X2 months 4. Admin/RCC B 1. All identified items will be repaired. Wall will be repainted and wall protection will be installed. Trim on cabinets will be replaced. Hand washing station's water temp will be corrected, sign removed and staff informed to use back sink. Repair left ovens door. 2. Items listed above will be on maintenance logs schedule to be repaired/replaced. 3. Add kitchen repairs to maintenance repair log for monthly compliance, monitored monthly 4. Admin C,D 1. Replaced utensils, thermometer and cutting board. 2. Included in kitchen repair log to maintenance 3. Monthly 4. Admin, Kitchen Lead E 1. Utensils will be covered 2. Covers purchased, reviewed with kitchen staff 3. Monthly as part of kitchen audit 4. Admin, Kitchen Lead, LN F,G,I,J 1. Food will be reheated properly, cooling time/temperature requirements will be followed, kitchen staff will prevent cross contamination during meal serving, Cold food items will be transported at right temperature with ice. 2. Kitchen staff to complete "Keeping food safe and nourishing older adults" on OCP. DON to post procedure above microwaves. 3. Weekly X4, then monthly X2 4. Admin/ Kitchen staff/ LN H 1. Trash bins will be in appropriate areas 2. Trash bin removed, signage to not place trash bin, staff educated at staff meeting 3. Weekly X4, Monthly X2 4. Admin/ Kitchen manager

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: The findings of the revisit #1 to the kitchen inspection of 09/11/25, conducted 12/30/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000 and OARs 411 Division 57 for Memory Care Communities.

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: Z 142: 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: Based on observations and interviews, it was determined the facility is in substantial compliance with rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.