Print Inspection: KIT009092

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: On 01/27/26, the facility kitchen was observed to need cleaning, repair and/or changes in food storage in the following areas: 1. Areas in need of cleaning: • Bulk bins-food crumbs on lids; • Ice machine-dusty vents; • Dish machine-food debris; • Walls/ceiling/vents/shelving, ledges throughout kitchen-dusty; • Floor under dish machine-build-up; • Deli Cooler-food debris; • Stovetop-carbon build-up; and • Cupboard ledges on front of service line-food spills. 2. Areas in need of repair/maintenance: • Wall by dish machine-black and missing caulk; and • Cutting boards on steamtable and deli cooler-heavily scored, stained, and non-cleanable. 3. Food Storage: Surveyor found several food items in deli cooler and reach-in cooler that were either expired or without dates, and/or without coverings. The areas of concern were observed and/or discussed with Staff 1 (PIC) and discussed with Staff 3 (Regional Director) and Staff 4 (Dining Services Manager). Staff acknowledged the findings at 2:30 pm on 01/27/26.

1) All cited areas will be cleaned of dust, debris and crumbs. All build up will be remvoed from noted areas. Carbon build up will be removed from stove top and cupboard ledges will be cleaned. Wall by dish machine will be recaulked and cutting boards will be replaced. All items in deli cooler will be dated, covered, and removed by experation date. 2) Moving foreward all areas of concern will be auditied regualrly to prevent any further instances of violations. 3) Areas of concern will be audited monthly for complainace. 4)The Executive Chef will be responsible for monthly audits and of all areas of concern.

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 the following. These are repeat citations. On 03/31/26, the facility kitchen was observed to need cleaning and/or changes in food storage in the following areas: 1. Areas in need of cleaning: • Deli Cooler and Food Containers - food debris. 2. Food Storage: Surveyor found several food items in reach-in cooler that were either expired and/or without dates. The areas of concern were observed and discussed with Staff 1 (PIC) and with Staff 2 (Executive Director). Staff acknowledged the findings at approximately 2:30 pm on 03/31/26.

1) What actions will be taken to correct the rule violation for wach example/resident? *The Deli coolet will be/have been cleaned and sanatized. All food containers will be washed appropriatly and kept in cleanin working order free of debirs. *Cooks have been reeducated on proper food labeling and are checking dates on food in fridge daily. 2) How will the system be corrected so this violation will not happen again? Sous Chef and cooks will audit the food in the coolers daily to ensure nothing is out of date and that all items have been dated. 3)How often will the area needing correction be evaluated? Daily 4) Who will be responsible to see that the corrections are completed/monitored? Sous Chefs, cooks, Executive Chef.

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 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on interview, observation and review of records, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

1) What actions will be taken to correct the rule violation for wach example/resident? The executive chef will preform routine daily checks of all areas sited. 2) How will the system be corrected so this violation will not happen again? Ongoing daily audits have been implimented to ensure compliance in all sited areas. 3)How often will the area needing correction be evaluated? Daily 4) Who will be responsible to see that the corrections are completed/monitored? Executive Chef, ED

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. 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 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.

Reference 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 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: