Print Inspection: KIT009724

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, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the Kitchen survey, conducted 05/06/26, administrative oversight to ensure adequate Kitchen cleanliness rendered in the facility was found to be ineffective based on the number of visits. Refer to deficiencies in the report.

1. Please 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 ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 02/25/26, between 10:00 am and 1:15 pm, the facility kitchen was observed, and the following was identified. 1. Areas in need of cleaning in the main kitchen: *Oven/grill - spills, carbon buildup; *Small appliances - food splatter; *Juice Machine – buildup around spigot; *Shelving above steam table – dusty; *Can opener - white, grey matter buildup, metal shavings, worn blade; *Flooring throughout kitchen - slick, buildup around edges, under/around appliances/doors; *Dishwasher - food debris build-up on top; *Coolers/freezers/ovens - food debris on handles/fronts; and *Floor drains - unclean, discolored. 2. Areas in need of repair/maintenance in main kitchen: *Cutting boards on deli coolers/steamtable/prep areas- scored, stained, non-cleanable. 3. Sanitation/Infection Control/Food Preparation in main kitchen: Surveyor found several prepared food items undated and/or expired in reach-in and deli cooler. Staff 1 (PIC/Dining Services Director) confirmed that the PH test strips were incorrect and was unaware of the type of chemical in use for the sanitation buckets. Correct test strips were ordered. 4. Cross Contamination/Handwashing/Glove Use in main kitchen: Surveyor observed a cook touching serving utensils, the dirty handle on the cooler, the boiled eggs, the cut lettuce, and the cheese wearing the same gloves. The cook proceeded to prepare the chef salad and then removed the gloves and placed them on the cutting board at the steamtable. Surveyor observed a cook touch the raw meat patty and the cheese with bare hands, then sanitized hands and immediately touched the bun. Surveyor observed a cook eating at the service line. The cook discarded the dirty dishes in the dish room and returned to work without washing hands her hands. Surveyor found the exteriors and handles of multiple kitchen appliances/coolers soiled with food debris. 5. Areas in need of cleaning/repair in the memory care kitchenette: *Floor drain - stained, unclean. The areas of concern were observed and/or discussed with Staff 1 (PIC/Dining Services Director), Staff 2 (Executive Director) and Staff 3 (Associate Executive Director) at approximately 1:15 pm on 02/25/26. Staff acknowledged the findings.

1. All areas mentioned have been cleaned. Cutting boards that need to be replaced have been ordered. PH test strips have been delivered. 2. Cleaning logs will be checked when Dining Services Director (DSD) of Dining Room Supervisor (DRS) are present and checked weekly to ensure ongoing compliance. Education to be provided at dining staff meeting regarding labeling, dating, expired food. Education will be provided during meeting regarding contamination/handwashing/glove use to all dining staff. 3. Monday-Friday and when DSD or DRS are present. 4. Dining Services Director and Executive 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: Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include but are not limited to: On 05/06/26, between 12:30 pm and 1:00 pm, the facility kitchen was observed, and the following was identified. 1. Areas in need of cleaning in the main kitchen: *Oven/grill - carbon buildup; *Juice Machine – buildup around spigots; *Coolers – food spills, food debris on handles; *Shelving above steam table by thermometers – dusty; *Can opener - white, grey matter buildup, metal shavings; and *Floor drains - unclean, discolored, non-cleanable. 2. Areas in need of repair/maintenance in main kitchen: *Cutting boards on deli coolers/steamtable/prep areas- scored, stained, non-cleanable. 3. Sanitation/Infection Control/Food Preparation in main kitchen: Surveyor found several food items unsealed, undated and/or expired in reach-in and deli coolers. Expired foods were discarded. Surveyor observed improper thawing of food. Staff made corrections. 4. Cross Contamination/Handwashing/Glove Use in main kitchen: *Coolers/freezers/ovens - food debris on handles. 5. Areas in need of cleaning/repair in The Pines Kitchenette: *Cutting boards - heavily scored, stained, non-cleanable; and *Juice machine - buildup around spigots. The areas of concern were observed and/or discussed with Staff 1 (Executive Director) and Staff 2 (Associate Executive Director) at approximately 1:00 pm on 05/06/26. Staff acknowledged the findings.

1. All areas listed were cleaned. -Education provided on ensuring all food is labeled, dated and covered correctly and expiration dates are checked. -Education provided on handwashing and cross contamination. 2. Cleaning lists were updated and education was provided to all dining associates to follow cleaning lists. 3. Three times per week by Dining Services Director. 4. Dining Services Director and Executive Director.

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 observation and interview, it was determined the facility failed to ensure the kitchen inspection survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240.

Refer to 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 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.

Please refer to 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 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.