Print Inspection: KIT008922

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, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observations made in the main kitchen storage and Memory care kitchenette storage and service areas on 01/14/26 from 11:10 am through 2:00 pm identified the following: 1. Campus Main Kitchen a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, white/grey billowy organic matter, and/or grease was visible on, underneath, or between the following: * Reach-in milk cooler interior door frame; * Reach-in milk cooler exterior door; * Walk-in cooler main flooring; * Walk-in cooler flooring under stationary racks; * Walk-in cooler stationary racks; * Walk-in cooler fan cages; and * Walk-in freezer floor under racks. b. Multiple items were observed stored in walk-in cooler and walk-in freezer that were uncovered/unprotected from potential contamination. Walk-in cooler fans and racks were observed with large amounts of white/grey billowy mold-like organic matter. c. Multiple packages of sliced deli meat were observed in walk-in cooler with date of 12/19 with the word “Frozen” next to the date. There were no other markings on the package to indicate when the item was pulled from the freezer or a use-by date to ensure it was within the appropriate safe use date. 2. Memory Care Kitchenette a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following: * Interior of cabinet under ice/water dispenser; * Interior of oven; and * Interior of grey bin holding clean dishes. b. The following areas were found in need of repair: * Cabinet under ice dispenser with water damage and exposed/porous wood. c. Several coffee mugs were noted/observed with heavy dark stains on the interior of the mugs. d. Mops and a broom were observed in the kitchenette stored next to packages of ready-to-eat foods and clean linens, creating a possible cross contamination risk for janitorial equipment to food/clean linens. e. A pot of soup was observed on the counter in a plugged-in soup kettle pot. The lid was observed off and the pot was not warm to the touch. Surveyor checked the temperature of the soup and it was noted to be at 115 degrees. Staff 3 (Memory Care Director) indicated memory care staff do not adjust the temperature knob on the kettle. Staff 3 acknowledged the soup was not being held at 135 degrees or above as required. Surveyor tasted the soup, and it was not hot and was not palatable. f. At 12:15 pm, a cart was observed in the kitchenette area holding cold food items (side salads and cottage cheese cups). Staff indicated dietary staff delivered the cart with those items at approximately 11:15 am. The cold food items were not held on ice. The temperature of a cottage cheese cup was checked, and the temperature was noted to be 51 degrees. The facility did not have a system to ensure cold items were held at 41 degrees or below. Surveyor tasted the cottage cheese, and it was not cold. The above items were reviewed with Staff 2 (Dining Services Manager), Staff 1 (Executive Director), and Staff 3 at 1:30pm. They acknowledged the identified areas in need of correction.

All identified kitchen areas, including coolers, freezers, racks, drains, vents, and equipment surfaces were deep cleaned and sanitized on or before January 30,2026. The Executive Chef or designee re-educated all culinary and service staff on required daily and weekly cleaning procedures on or before January 30,2026. The Executive Chef or designee will make daily, weekday observations of the kitchen for cleaning and sanitizing procedure completion. The Executive Chef or designee will conduct weekly audits of kitchen cleaning and sanitizing procedures for 12 weeks or until substantial compliance is achieved. All uncovered or unprotected items were immediately discarded. The Executive Chef or designee re-educated all culinary and service staff to proper storage and covering of foods on or before January 30,2026 The Executive Chef or designee will make daily, weekday observations of items stored in the walk-in cooler and freezer for proper covering. The Executive Chef or designee will conduct weekly audits of items stored in the walk-in cooler and freezer for proper covering for 12 weeks or until substantial compliance is achieved. All items without open and/or prepared dates were immediately discarded. The Executive Chef or designee re-educated all culinary and service staff to labeiling and dating of foods on or before January 30,2026. The Executive Chef or designee will make daily, weekday observations of items for proper labeling and dating. The Executive Chef or designee will conduct weekly audits of items for proper labeling and dating for 12 weeks or until substantial compliance is achieved. All items in need of repair were repaired or replaced on or before January 30,2026. All items observed to need removal in the kitchenette were immediately placed in an appropriate area. Administrator or designee will make daily, weekday observations of areas needing repair or replacement. Administrator or designee will make daily, weekday observations of kitchenette and items that may pose a cross contamination risk. The Administrator or designee will conduct weekly audits for proper repair and replacement for 12 weeks or until substantial compliance is achieved. All items outside of required temperature ranges were immediately discarded. The Executive Chef or designee re-educated all culinary and service staff on proper food holding tempuratures on or before January 30,2026. The Executive Chef or designee will make daily, weekday observations of proper food temperature. The Executive Chef or designee will conduct weekly audits of food holding temperature for 12 weeks or until substantial compliance is achieved.

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 Plan of correction for tag 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: