Print Inspection: KIT006987

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, record review and interview, it was determined the facility failed to maintain the kitchenette in good repair and in a sanitary manner. The facility failed to ensure hot foods were held and served at appropriate temperatures in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main facility kitchen, memory care kitchenette and lunch meal service on 09/25/25 from 11:15 am thru 1:30 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: * Reach in refrigerator in unit kitchenette * Oven in unit kitchenette * Flooring in unit kitchenette b. The following areas needed repair: * Red temperature control cart used for hot holding and transportation to unit was noted with a damaged door seal creating a ½ - 1 inch gap in the door where hot air was felt exiting the unit. Multiple puncture areas in and around the cart were observed. Hot air was felt exiting the unit around these puncture points. The gauge to display the internal hot holding temperature was not operational to inform of what temperature the food was being held at. c. Reach in refrigerator in the unit kitchenette was observed and did not contain a thermometer to ensure resident food was stored at appropriate cold food storage temperatures. Staff in unit acknowledged there was a log posted on the refrigerator. Surveyor reviewed the log and it was blank. Memory care unit staff acknowledged she was not checking or logging the refrigerator temperatures and did not know who was supposed to. Staff 2 (Culinary Services Director) acknowledged that the care staff was supposed to be checking and logging the refrigerator temperatures in the unit kitchenette. d. A tray of plated cake desserts were observed transported from the main kitchen to the unit uncovered and not protected from potential contamination. f. Memory care lunch service was observed and began in the main kitchen at 11:15 am. Plates were dished up in the main kitchen and placed in the Red hot box cart. The cart was taken to the memory care unit at 11:44 am. At approximately 11:50 am, staff began checking the temperatures for the food items for service on that day. Three of the four hot items were noted less than the 135 degrees required for hot holding temperatures and included (turkey and vegetable gravy at 120 degrees, Mashed potatoes at 123 degrees and peas at 114 degrees). Meal service temperature logs from 09/19/25 thru the lunch meal of that day were reviewed and documented 66/78 hot menu items that were found at temperatures less than 135 degrees. Thirty-two hot food items were documented at 110 degrees or less, and seven hot food items were documented as served at temperatures less than 100 degrees. Care staff was interviewed and stated that they were ok to served the food items as long as they were 80 degrees or more. When asked what temperatures were she looking for to be considered hot enough they stated between 80-120 degrees. Staff was not able to discuss what the appropriate hot holding temperature was. Staff 2 was interviewed and acknowledged the facility’s standard of hot holding was 140 degrees. Staff 2 acknowledged the items in the cart observed at that meal were not at appropriate hot holding temperatures. Surveyor reviewed the food service temperature logs for the last week and acknowledged service temperatures served at 110 or less are not palatable and not appropriate. At 12:30 pm, Staff 1 (Campus Executive Director) was informed of the observed hot holding temperatures and acknowledged the concern identified. Staff 1 also acknowledged food service temperatures at 110 degrees and/or less would not be palatable. Staff 1 was asked to provide resident council minutes for the last three months to review. Staff 1 indicated that the facility was not conducting resident council for the memory care unit. Staff 1 acknowledged the requirement for residents to have input into menus and food service program. Staff 1 and Staff 2 acknowledged the other identified areas outlined above.

A deep cleaning of the kitchenette, refrigerator and floor has been completed in Memory Care. A check list has been created and implemented for cleaning of the kitchenette. This will be overseen by the Memory Care Director daily and Culinary Services Director weekly. A new seal has been ordered for the red temp controled cart. We will also be repairing the sides of the cart to seal up any puncture areas in the cart. This is being completed by the Regional Director of Operations. A new thermometer has been placed in the fridge, temp logs are being completed daily by caregivers. This is being overseen by the Memory Care Director Daily and Culinary Services Director weekly. A temp training will be completed with MC staff on holding temps and safe temps for food. This will be completed by the MC Director at all staff in October 15, 2025 Activities department will hold a monthly Resident Council meeting with the memory care residents. This meeting will include getting their input on menus and the food service. This will be completed by the MC Activities Director and overseen by the MC 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 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 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: