Print Inspection: KIT008339

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 12/08/25 showed the following areas needed cleaning or repair. * Drips, splatters, and/or debris were observed inside cupboards, under shelves, on top of dry goods, inside drawers, on the ceiling, and on the walls throughout the kitchen and dry storage; * Multiple light covers in the kitchen had debris and dead insects inside; * Black discoloration and accumulation were noted along the floor edges, cabinets, baseboards, around the edges of equipment and at the door edges. Several sections of patched flooring around the center island were cracked or separating at the edges; * Chipped cupboards and shelves were noted throughout the kitchen with exposed particle board and/or missing paint; * Thick debris and sludge were located in the drain under the sink and a strong sour odor was present; * Lower-level metal shelves throughout the dry storage had debris, dust, drips, and/or spills; * Three cutting boards were significantly worn with discoloration and grooves; * Two knives in the butcher block had handles that were extremely worn, scratched and gouged; * Large amounts of debris were noted underneath the stove on an exposed shelf area. The ovens had one missing cover piece in place along the bottom and another one partially dangling as it impeded the opening and closing of the oven doors. Debris was noted in the bottom of the ovens; * Cobwebs, dust, and dead insects were noted in the windowsill, and the screen to the open window had a thick layer of dust and debris on it; * No alcohol wipes were available for cleaning of the probe thermometer; * Particle board/wood shelving in the custodian closet was warped, stained, and had chipped and peeling paint. A large piece of flooring was missing, with a chunk of loose laminate underneath buckets underneath the tankless water heater; * A large cut/split in the laminate flooring was located near the door closest to the dish area; * The microwave had splatters and spills on the interior. The interior door had a large area of missing paint and rust; * A large scrape with missing paint and drywall was noted along the wall in the attached break/storage room. Multiple drawers and cupboards had spills and/or debris next to clean dishes and utensils; and * The baseboard behind the stove was detached and hanging forward. The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Facilities Services Director) on 12/08/25. The staff acknowledged the findings.

1.A comprehensive deep cleaning of the kitchen, dry storage, custodial closet, and break/storage room was initiated, including all cupboards, drawers, shelves, ceilings, walls, floors, baseboards, windowsills, light covers, drains, equipment interiors/exteriors, and areas underneath appliances. All debris, grease, sludge, dust, cobwebs, and insects to be removed and surfaces sanitized using approved cleaning agents. The sink drain thoroughly cleaned and deodorized to eliminate sludge buildup and odor. Worn and damaged food-contact items were removed from service, including: Three significantly worn cutting boards Two knives with excessively damaged handles These items are to be replaced with new, food-safe equipment. Alcohol wipes were immediately stocked and made available for proper probe thermometer sanitation. Damaged and unsafe equipment to be addressed: Loose and missing oven cover pieces to be repaired or replaced to ensure safe operation. Remove debris from the ovens and exposed shelving beneath the stove. Microwave interior cleaned and sanitized; damaged/rusted interior surfaces scheduled for repair or replacement. Structural and surface repairs were initiated or scheduled, including: Repair or replacement of cracked, separating, missing, or damaged flooring. Repair of chipped cupboards, shelves, exposed particle board, and peeling paint. Reattachment of the detached baseboard behind the stove. Repair damaged drywall and scraped walls in the break/storage room. Replacement of warped and deteriorated particle board shelving in the custodial closet. All clean dishes and utensils were removed, rewashed, and properly stored after affected storage areas were cleaned. 2.A revised environmental cleaning and sanitation schedule was implemented, clearly outlining: Daily, weekly, and monthly cleaning tasks. Assigned responsibilities by position. A preventive maintenance program was reinforced to ensure routine inspection and timely repair of: Flooring Cabinets and shelving Walls, baseboards, and ceilings Kitchen equipment and fixtures A food safety equipment replacement protocol was established to ensure cutting boards, utensils, and knives are routinely inspected and replaced before becoming excessively worn. Staff were re-educated on: Proper cleaning of food-contact and non–food-contact surfaces Appropriate storage practices to prevent contamination Proper sanitation of thermometers and small equipment A supply monitoring system was implemented to ensure essential sanitation items (e.g., alcohol wipes, cleaning supplies) are consistently available. Windows, screens, and light covers were added to routine pest-prevention and cleaning checks. 3. Daily visual inspections of the kitchen and dry storage areas will be conducted by kitchen leadership. Weekly documented sanitation audits will be completed using a standardized checklist. Monthly environmental and maintenance inspections will be conducted to assess flooring, cabinetry, shelving, walls, equipment condition, and overall cleanliness. Any identified concerns will be corrected immediately and documented. 4.Maintenance Director Responsible for completing and monitoring all repairs, structural corrections, equipment maintenance, and preventive maintenance inspections. Executive Director Responsible for overall compliance oversight, ensuring corrective actions are completed, monitoring systems are followed, and ongoing sanitation and maintenance standards are upheld. The Maintenance Director and Executive Director will ensure that all corrective actions are completed, documented, and sustained to maintain a safe, sanitary, and compliant environment. Continuous monitoring will be conducted to prevent recurrence of these deficiencies.

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