Print Inspection: KIT007920

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation and interview, it was determined the licensee failed to ensure adequate administrative oversight of facility operations regarding kitchen sanitation practices, which posed a risk to the safety of residents. Findings include, but are not limited to: During the annual kitchen inspection, conducted 11/17/25 through 11/20/25, administrative oversight to ensure adequate food sanitation practices in the facility kitchen was found to be ineffective based on the severity of the citation. 1. A situation was identified where there was a failure of the facility to comply with the Department’s rules that was likely to cause residents serious harm. An immediate plan of correction was requested on 11/17/25 at 12:00 pm in the following areas: OAR 411-054-0030 Resident Services, Meals, Food Sanitation Rule. The facility provided a plan of correction on 11/17/25 at 2:24 pm, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system(s) failure(s) associated with the licensing violation. 2. Refer to C240.

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 a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. The facility’s kitchen was observed in an unsanitary condition, with a person in charge without adequate knowledge or training, with multiple failed food safety practices which posed an immediate jeopardy situation that could threaten the health, safety, and/or welfare of residents. Findings include, but are not limited to: Observations of the ALF facility kitchen which prepares all of the facility’s meals and the lunch meal service were completed on 11/17/25 from 10:10 am through 2:30 pm, and the following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, and/or black matter was visible on or underneath the following: * Kitchen entrance threshold floor; * Stainless steel prep tables; * Stainless steel open shelving; * Interior and exterior of ice machine; * Ice machine scoop holder; * Juice machine area by nozzles; * Top of beverage dispensers; * Utility carts; * Hand washing sink; * Stainless steel shelving above hand washing sink; * Legs of prep tables; * Walls and floors throughout kitchen; * All kitchen drains; * Shelving under the steam table; * Interior and exterior of cabinets storing clean dishes; * Steam table wells; * Faucet and handles of prep sink; * Interior and exterior of temperature regulated/insulated carts; * Walk-in cooler floors under metal shelving and in thresholds; * Walk-in cooler metal racks; * Walls in walk-in cooler; * Interior of plastic bin storing fruit and vegetables; * Removable metal racks in walk-in cooler; * Fan cages of walk-in cooler and freezer; * Celling and sprinkler head in walk-in cooler; * Interior and exterior of microwave, convection ovens, and industrial steamer; * Removable hood vents; * Piping/electrical conduit by oven and wall; * Stove top burner plates; * Knobs and handles of stove and grill; * Industrial can opener and housing; * Industrial mixer; * Stainless steel table where mixer was located; * Interiors and exteriors of stainless steel drawers throughout kitchen; * Outsides, lids and handles of trash cans; * Windowsills and screens; * Vents and light fixtures; * White food bin exteriors; * Floors in dry storage; * Oven mitts; * Interior of clear plastic bin storing clean cooking utensils; * Knife holder attached to knives (knives and holder); * Sanitizer dispenser; and * Sides of steam line cabinets. b. The following areas were in need of repair: * A section of wall by the entry to the kitchen threshold was damaged near floor. * Caulking behind the three-compartment sink had black matter build-up and was in need of replacement. * Multiple areas in tile floor had missing grout; c. Scoops and spoons were observed in bulk food containers with handles touching food surfaces. d. Multiple kitchen staff were observed preparing food and/or handling clean dishes without appropriate facial hair restraints as required. Staff 2 (Dining Services Director) had visibly soiled and very dirty outer clothing. Staff 2 was observed to wipe his hands on his outer clothing multiple times during the review. e. Staff 2 was interviewed regarding how often sanitizer buckets were changed and he indicated every four hours, not every two hours or as needed per rule. f. The handwashing sink did not have paper towels to properly dry hands. Facility staff were not able to state when the dispenser had run out of towels. The hand washing sink also had visible debris inside the sink indicating was used for purposes other than hand washing. g. Multiple kitchen staff, including Staff 2, were not observed washing hands as required. This included times where hands were contaminated from touching clothing, other surfaces, and/or handles. h. Multiple food items were observed stored in dry storage, walk-in cooler and/or freezer that were not closed or covered and were exposed to potential contamination. i. A large container of used/dirty/rancid oil was observed stored uncovered under a shelf in the back food prep area. The facility did not have a system to correctly dispose of used cooking oil. Staff 2 indicated that bucket had been there for at least 2-3 months. j. A trash can without a liner and with visible food debris was observed stored in the dry food storage area. k. Staff 2 was preparing a ground beef product for lunch. The product was placed into the steam well without checking the temperature to ensure it had reached 155 degrees F for 15 seconds. Surveyors intervened and asked Staff 2 to check the temperature. It was found ranging between 140-145 degrees F. Staff 2 indicated they often put the products in about 10 degrees under to finish cooking in the steam wells. Surveyors indicated food for service must be fully cooked prior to placement in the steam wells and that food should not be “cooked” in the steam tables. Staff 2 also was not aware that ground beef could not be served at a medium doneness and must be fully cooked (155 degrees F or higher). l. Staff 2 was observed to check food temperatures with a thermometer that was not at a fully cooked temperature and did not sanitize thermometer prior to checking temperatures of fully cooked product, potentially contaminating the fully cooked product. Staff 2 was not observed to sanitize thermometer before, between products, or after use before storing probe in protective cover. m. Multiple kitchen towels were observed stored in various places throughout the kitchen, not in the sanitizer buckets as required. Several were visibly soiled and stiff. Staff 2 was observed to wipe his hands with a kitchen towel without observation of appropriate hand hygiene measures. n. Boxes of food product were observed stored on the floor of the walk-in freezer. In an interview, Staff 2 confirmed the facility had received stock more than 24 hours prior. o. Multiple cutting boards were found heavily scored or stained and in need of replacement. Multiple oven/hot mitts were found damaged with holes and rips. p. Staff 2 was not able to demonstrate knowledge in cleaning practices, effective hygiene practices, effective sanitation practices, correct cooking practices, proper cooling practices, appropriate cold and dry food storage practice, or proper reheating processes. In an interview on 11/17/25 at approximately 12:00 pm, Staff 1 (Executive Director) and Staff 3 (Associate Executive Director) was informed by the Surveyors of the significant sanitation and safety concerns, and that the kitchen would be shut down. The facility was instructed to submit an immediate plan of correction to address the unsanitary and unsafe conditions. Staff 1 had toured the kitchen area with the surveyors and had observed and acknowledged the areas identified and in need of immediate attention/correction. An immediate plan of correction to address the deficient kitchen sanitation practices was requested on 11/17/25 at 12:00 pm. The facility provided a plan of correction on 11/17/25 at 2:24 pm, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system(s) failure(s) associated with the licensing violation. On 11/20/25 at 10:15 am, the surveyors returned to inspect progress of addressing sanitation and poor repair concerns. Surveyors toured areas with Staff 4 (District Director of Operations), Staff 5 (Traveling Dining Services Specialist). Staff 4 and Staff 1 outlined the ongoing training plan for the Person-In Charge and the ongoing oversight of the food service operations. The facility also outlined the plan for a consultation from a Registered Dietitian at least quarterly for an extended amount of time to ensure on going compliance. Facility acknowledged lack of adequate staff for kitchen was a contributing factor to poor sanitation. At that time, it was determined the facility could safely resume food service operations.

Areas of the kitchen and dining room including but not limited to: Floors in the dinning room, chairs, kitchen enterance threshold, prep tables, shelving, ice machine, ice machine scoop holder, juice machine nozzles, beverage dispensers, utility carts, hand waskhing sink, prep tables, walls and floors, drains, steam table, cabnets that store clean dishes, steam table wells, facet hands, insultated cars, walking in cooler racks, walls of walk in cooler, food starage bins, fan cages, ceiling and sprinkeler in walk-in colloer, hood vents, stovetop burner plates, knobs and handles of stove and grill, industrial can opener, industrail mixer/stand, stainless steel drawers throughout the the kitchen windowsills and screens, floors in dry storage, oven mitts, knife holder and sanitizer dispenser. Have been cleaned and will continue to be maintained in good, clean working order. The section of the wall by the entery of the kitchen threshold will be repaired and replaced with a cleanable surface. Caulking behind three-compartment sink has been replaced. Scoops will be stored in designated holder, not in food product. Beard nets have been ordered and are availible to staff with facial hair. Aprons are availible to staff and will be changed when soiled. Hand hygiene training will be completed by all kitchen staff. Sanitizer buckets will be changed every two hours or as needed. Checking/changing paper towels for hand washing sink will be completed on task sheet daily. food items will be closed and/or covered to prevent potential contamination. Oil container has been removed and routine oil disposal oil disposal will be completed. Trash cans will not be stored in dry storage area. Training on reaching proper food temperature completed for all kitchen staff members. New theromometers ordered with disposable covers. Training on the use of these completed for all kitchen staff. All spills will be cleaned and towels will be removed from the floor promptly. Food product will not be stored on the floor. Cutting boards will be replaced. Utensils will be rolled in napkins prior to setting tables. A Registered Dietition will provide quarterly audits and partnership to ensure continued compliance. Staff training on policies and procedures of kitchen operations completed with staff. Weekly audits to be completed by administrator. Documentation of this will be kept in a binder in the kitchen. New task sheets for cleaning tasks presented during all staff meeting. Documentation of this will be kept in a binder in the kitchen. Weekly meetings to review kitchen status with Pro-temp and/or District Director of operations. Weekly audits to be completed by administrator. Documentation of this will be kept in a binder in the kitchen. New task sheets for cleaning tasks presented during all staff meeting. Documentation of this will be kept in a binder in the kitchen. Dinning Services Manger will complete cleaning audits 5 days a week. Manager on duty will complete on his days off. Brookdale Traveling Pro-temp will provide oversight and training for all kitchen staff including Dinning Services Manager. Weekly meetings to review kitchen status with Pro-temp and/or District Director of operations.

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 C 240

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: