Print Inspection: KIT009891

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: Observations of the facility kitchen and food storage area were completed on 03/04/26 from 10:15 am through 1:30 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Hand washing sinks; * Interior of reach in freezer off service line; * Reach in freezer off service line seal; * Industrial steamer handle; * Behind and under oven/range/grill top; * Sides of frier/oven/grill; * Flat top grill grease trap; * Flat top grill; * Exterior of convection ovens; * Range top grates/spiders; * Removable catch trays under range top; * Flooring under large equipment; * Flooring under steam table; * Exterior and interior of plate warmer; * Stainless steal open shelving of steam table/service line; * Interior of deli cooler; * Industrial can opener and housing; * Industrial slicer; * Industrial mixer; * Interior of blender base; * Exterior of trash cans; * Interior lid of trashcan off service line; * Top of dishwasher; * Ceiling vent over food preparation area; * Threshold to entry to kitchen; * Carpet in entry way from dining room; * Ice dispenser; and * Walk-in cooler fan cover and ceiling; b. The following areas were in need of repair: * Caulking of hand washing sinks missing, or heavily stained/discolored and in need of replacement; * Multiple gaps identified where electrical conduit entered the wall or ceiling: * Multiple drainage hoses were observed stored deep inside floor drains causing potential for back flow issues if drains backed up and flooded; * Ice cream chest freezer fan observed with large dust accumulation; * Piping under three compartment sink with active leak with water accumulation on floor; * Heavy scale build-up found on exterior of industrial dish washer; and * Door seal on the bottom of the door to walk in cooler broken/cracked and in need of repair. c. Commercial mixer with food contact surface of bowl and paddle stored uncovered when not in use. Several large silver bowls used for food preparation stored open to potential contamination. Multiple containers storing cooking and food preparation utensils were stored with food contact surfaces open and exposed to potential contamination. d. Multiple cutting boards and cutting surfaces were found heavily stained and scored. e. Multiple opened food items stored greater than 24 hours were observed without open or prepared dates. Multiple food items were found past seven days from prepared dates and/or manufacturers’ use by dates and should have been discarded. f. Multiple food packages were found in the walk-in freezer and in dry storage area that were open or uncovered exposing the food products to potential contamination and food quality issues. g. Multiple canned food items were found dented and should have been removed from ready to use stock. h. Multiple staff drink cups/containers were observed to not be of the approved style lending potential contamination of lip contact surfaces. i. A container holding used/empty soda cans or bottles was observed stored in dry storage areas next to food and/or clean equipment. The container was not cleanable and did not have a cover to prevent or detract pests/insects. j. A scoop was observed stored in bulk food container with the handle of the scoop touching and potentially contaminating the food product. Staff 2 (Dining Services Director) toured areas with surveyor and acknowledged the findings. At approximately 1:30 pm, surveyor reviewed above areas Staff 1 (ED), who acknowledged the identified areas.

A. CORRECTION OF DEFICIENT PRACTICE The facility acknowledges the findings related to failure to maintain the kitchen in a clean, sanitary, and well-repaired condition in accordance with OAR 411-054-0030 and OAR 333-150-0000. Immediate corrective actions taken include: A full deep cleaning of the kitchen and all identified areas was completed, including but not limited to: 1. All cooking equipment (grills, ovens, fryers, mixers, slicers, can opener, blender base) 2. Refrigeration units (reach-in coolers/freezers, walk-in cooler/freezer, seals, fans) 3. Food contact surfaces and shelving 4. Floors, walls, ceiling vents, and hard-to-reach areas (under/behind equipment) 5. Trash receptacles and dishwashing area 6. All expired, undated, dented, or contaminated food items were discarded immediately. 7. All opened food items were properly labeled and dated per food safety guidelines. 8. All food and utensils were properly covered and stored to prevent contamination. 9. Cutting boards that were heavily scored or stained were removed and replaced. 10. staff drink containers were replaced with approved, closed-lid containers with straws and relocated to designated areas. Improper storage practices were corrected, including: 1. Removal of scoop handles from food contact surfaces 2. Removal of unclean soda container from dry storage 3. Proper separation of food and non-food items Maintenance repairs initiated/completed: 1. Plumbing leak under 3-compartment sink repaired 2. Walk-in cooler door seal replaced 3. Caulking at sinks repaired/replaced 4. Gaps around conduit sealed 5. Drain lines repositioned to prevent backflow risk 6. Deliming/scaling of dishwasher completed B. SYSTEMIC CHANGES TO PREVENT REOCCURRENCE The facility has implemented the following systemic changes: A daily, weekly, and monthly kitchen cleaning schedule has been developed and implemented, including: 1. Detailed cleaning checklists for all equipment and surfaces 2. Assigned staff responsibilities per shift A Food Safety and Sanitation Policy has been reinforced to include: 1. Proper labeling and dating of food (24-hour and 7-day rules) 2. Proper food storage and covering requirements 3. Handling of dented/damaged goods 4. Approved staff beverage policies A Preventative Maintenance Program has been implemented in collaboration with Maintenance Director to ensure: 1. Routine inspections of kitchen equipment and infrastructure 2. Timely repair of leaks, seals, and structural concerns A Kitchen Organization Standard has been implemented to ensure: 1. Separation of clean and soiled items 2. Proper utensil storage (handles protected) 3. Elimination of clutter and contamination risks C. STAFF TRAINING All Dining Services staff have been retrained on: 1. Oregon Food Sanitation Rules (OAR 333-150-0000) 2. Infection control and sanitation practices 3. Food labeling, storage, and dating requirements 4. Cleaning expectations and schedules 5. Training was conducted by the Dining Services Director and Executive Director. 6. All new hires will receive this training during orientation. D. MONITORING AND QUALITY ASSURANCE To ensure ongoing compliance: The Dining Services Director (DSD) or designee will: 1. Conduct daily kitchen sanitation inspections 2. Verify completion of cleaning logs each shift The Executive Director (ED) or designee will: 1. Complete weekly kitchen audits using a standardized audit tool The Maintenance Director will: 1. Conduct monthly inspections of kitchen equipment and facility condition The facility will implement a Quality Improvement (QI) audit: 1. Monthly review of sanitation, food storage, and maintenance compliance 2. Findings reviewed in leadership/QAPI meetings Any deficiencies identified will result in immediate corrective action and staff re-education 5. COMPLETION DATE All corrective actions and system changes will be completed by: ?? April 15, 2026 6. RESPONSIBLE PARTIES Executive Director – Oversight and compliance Dining Services Director – Daily operations and sanitation compliance Maintenance Director – Repairs and preventative maintenance RCC/Leadership Team – Ongoing monitoring and QI participation

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: