Print Inspection: KIT010016

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 the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen on 03/11/26, from 11:00 am through 12:40 pm, revealed the following deficient practices: 1. Main Kitchen: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following: * Folds of door seal gasket on small white refrigerator next to ware washing machine; * Trays under oven range; and * Bottom shelves of freezers in hallway closet. b. Items to be repaired or replaced: * Door seal gasket on small white refrigerator next to ware washing machine was torn; * Multiple large nonstick pans with majority of the nonstick surface worn away; * Multiple small wares with burn damage/uneven surfaces, rendering them unable to be cleaned and sanitized; and * Multiple small wares with worn wooden handles, rendering them unable to be cleaned and sanitized. 2. Procedures and Practices: c. Ground beef “chub” was thawing in the designated dish sink. d. No facial hair restraint in use. e. Multiple packaged food items in mini refrigerator without an open date. f. Prepared food item in mini refrigerator without a label or date. g. Handwashing sink hot water supply had been disconnected. h. Food preparation was occurring without a surface sanitation solution bucket set up. Surveyor addressed this with Staff 2 (Cook/Person in Charge) who then set up a surface sanitation solution bucket. Surface sanitation solution bucket was then later observed without a towel; towels were observed sitting on prep surfaces and being used multiple times without being returned to the sanitation bucket, potentially causing cross contamination. i. There were no testing strips available to test the parts per million (PPM) concentration of the surface sanitation solution being used, and therefore could not be validated that the solution being used was effectively sanitizing kitchen surfaces. j. Multiple packaged food items were in the standing reach-in cooler without an open date. k. Multiple prepared food items were in the standing reach-in cooler without an identifying label or production date. Kitchen staff disposed of these items. m. Kitchen staff were preparing “eggs to order” (over easy, sunny side up, etc.) without pasteurized eggs, resulting in undercooked eggs being served to residents. This surveyor instructed kitchen staff this practice could not continue until pasteurized eggs in shell were available for use. n. A digital probe thermometer was inserted into cooked food items without first sanitizing the probe. The thermometer was then put away without sanitizing. o. For dishes that did not fit in the mechanical warewashing machine that were being cleaned in the 3-compartment sink, there was not a final sanitizing step in the process. p. Corn tortillas were observed being served directly from the package without any fabrication/cooking/heating, resulting in the palatability of the food item being affected. q. Improper food thawing practices were observed. Staff had submerged frozen food in a water filled container that was sitting in a sink, but without a constant stream of cool water. r. An open can of soda (staff drink) without a lid/straw was observed above the area where food was being prepared. Staff 2 was unable to adequately articulate the following: s. Examples of situations that would result in cross-contamination occurring. t. The allowable timespan prepared food items could be in the culinary “danger zone.” u. The two-stage cooling process. v. The necessary cook-to temperature for reheating of food items. w. How to set up a station in the 3-compartment sink for sanitizing tools/pots/pans/hotel pans that don’t fit in the ware washing machine. x. Which chemical was being used for surface sanitation solution buckets. 2. Kitchenette in separate building: Procedure and Practices: a. Multiple food items were in the refrigerator without an open date (there was a sign posted on the refrigerator door instructing staff to label and date all refrigerated items). b. No testing strips were available for the ware washing machine, resulting in staff being unable to validate that the chemical PPM concentration was adequate for proper sanitizing. At approximately 12:45 pm, surveyor reviewed findings with Staff 1 (Business Manager) and Staff 2; Staff 1 and Staff 2 acknowledged the findings.

1.The facility immediately cleaned and sanitized all kitchen areas and equipment. Damaged items were removed and replaced. All unlabeled/undated food was discarded. Proper food handling practices were implemented, including correct thawing, labeling, sanitizer use, and thermometer sanitation. The handwashing sink was repaired. Staff drinks were removed from prep area. The facility discontinued the use of unpasteurized eggs for “eggs to order” and now only uses pasteurized or fully cooked eggs. A final sanitizing step using the three-compartment sink (wash, rinse, sanitize) was implemented for all dishes that do not fit in the commercial dishwasher. Sanitizer test strips were obtained and are now available and used in both the main kitchen and kitchenette areas. 2.A kitchen sanitation program was implemented including cleaning checklists, food labeling policies, and proper food handling procedures. Policies now require: • Use of pasteurized eggs or fully cooked eggs only • Proper three-compartment sink sanitizing procedures • Daily use of sanitizer test strips A kitchen binder has been implemented and staff were re-trained on all updated procedures. 3.Daily kitchen checks, weekly audits, and monthly reviews will be conducted. Monitoring includes: • Verification of egg compliance • Proper dishwashing and sanitizing procedures • Daily sanitizer test strip checks and documentation Any deficiencies will result in immediate corrective action and re-training. 4.Executive Director, Dietary Services Manager (DSM) Cook / Person in Charge

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: