Print Inspection: KIT010023

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 the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observations of the four house kitchens on 03/10/26 from 10:15 am through 2:30pm revealed the following deficiencies: 1. House 4 and main food preparation 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: * Stove top under back two burners; * Interior of microwave; * Interior of cabinets and drawers; and * Window screen. b. Multiple cabinet interior shelving edges were heavily worn, exposing porous wood surfaces yielding a non-cleanable surface. The back wall where pots and pans were stored was noted with heavy scoring/scratches that had exposed drywall, causing a non-smooth and non-cleanable surface. c. Clean and sanitized dishes were stored directly next to the dirty dish washing and/or hand washing sink, exposing clean dishes to potential splash contamination. d. An unlabeled/unidentified energy drink can was stored next to resident food products. e. Activities staff was observed to enter into the kitchen area during food/meal preparation without a hair restraint, and did not wash her hands. She then opened a cabinet and a drawer to retrieve a bowl and utensil for a resident. 2. House 3: 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: * Interior/exterior of cupboards/cabinets/drawers storing clean dishes and/or food; and * Interior of cabinet storing garbage can. b. Multiple cabinet interior shelving edges were heavily worn, exposing porous wood surfaces yielding a non-cleanable surface. c. A container of salsa was dated 03/03/26 without a use-by date. This was day seven and should have been discarded or a clear use-by date documented to ensure the product was safe for consumption. d. At 10:52 am, multiple containers of oatmeal were noted in the reach-in refrigerator with visible fresh condensation on the lids. Surveyor touched the outside of the container, and it was warm to the touch. The internal temperature of the food product was tested and read 97 degrees Fahrenheit. Staff were interviewed and indicated staff was finished serving by 8:40 am indicating that the food product was not at 70 degrees after 2 hrs. Staff were interviewed regarding cooling process and indicated they had not checked the temperature of the food product prior to putting it in the refrigerator. Staff indicated they had never checked the temperature when putting away food to ensure proper temperature thresholds were met during the proper cooling time frames. Staff indicated they feel the outside of the containers to ensure they are not too hot before putting in the fridge. Multiple containers of leftover food items were noted in the refrigerator also with noticeable condensation on the lids indicating they were not properly cooled down before lidded and placed in the refrigerator. e. There was no dedicated hand-washing sink. Dirty dishes were observed in both sides of the sink. f. Clean and sanitized dishes were observed stored directly next to the handwashing/dishwashing, sink exposing clean dishes to potential splash contamination. g. A small container of white powdery substance (sweetener) was observed uncovered and open to potential contamination h) Multiple containers of butter dated 03/06/26 were observed stored in a cabinet unrefrigerated. Some containers did not contain a date so it was unknown how long they were stored unrefrigerated. 3. House 2: 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: * Interior/exterior of cupboards/cabinets/drawers storing clean dishes and/or food; * Interior of cabinet storing trash can; and * Interior of ice machine with black and shiny biological matter build-up. b. Multiple cabinet interior shelving edges were heavily worn exposing porous wood surfaces yielding a non-cleanable surface. c. Multiple containers of leftover foods observed with large amounts of visible condensation on the lids indicating they were not properly cooled before covering and placing in the refrigerator. d. There was no dedicated hand-washing sink. Dirty dishes were observed in both sides of the sink. e. A container of butter dated 03/03/26 was observed stored in cabinet unrefrigerated. Some containers did not contain a date so it was unknown how long they were stored unrefrigerated. f. Handheld can opener observed to have heavy rust accumulation on the blade and needed replacement. 4. House 1: 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: * Interior/exterior of cupboards/cabinets/drawers storing clean dishes and/or food; * Interior of reach-in freezer pull out drawer seal; * Interior of microwave; and * Interior of cabinet storing trash can. b. Multiple cabinet interior shelving edges were heavily worn, exposing porous wood surfaces yielding a non-cleanable surface. c. Multiple food items stored past seven days and should have been discarded (washed lettuce, deli ham). Open cheese slices were removed from the manufacturer’s package and did not contain a use-by date for safety. A container of staff lunch was stored with resident food items causing a potential cross contamination concern. d. Multiple containers of left over foods observed with large amounts of visible condensation on the lids, indicating they were not properly cooled before covering and placing in the refrigerator. A container of oatmeal half full was noted to be warmer to touch and temperature was found at 79 degrees Fahrenheit at 11:18 am, more than three hours after service. e. A handheld can opener observed to have heavy rust accumulation on the blade and needed replacement. f. An undated container of butter was observed stored in a cabinet unrefrigerated. g. There was no dedicated hand-washing sink. Dirty dishes were observed in both sides of the sink. At approximately 1:45 pm, surveyor reviewed above items/areas with Staff 1 (ED), who acknowledged the need for correction.

Plan of correction for accumulation of food, spills, splatters, loose food and trash debris, dirt, dust- 1. Deep clean of all kitchens will be completed by 3/23/26. Weekly night shift duties list updated to include clean cupboards and drawers, clean microwave. Ice machine will be deep cleaned by 3/23/26 and there on monthly. 2. Updated cleaning duties sheets and maintenance routine schedules. 3. Resident Care Coordinators will do weekly walk throughs to ensure tasks are being completed. Administrator will sign off on monthly ice machine cleaning. 4. Administrator, maintenance director and resident care coordinators will be responsible for monitoring and corrections. Plan of correction for items that were found needing repair or replacement- 1. All areas cited for worn interior cabinet shelving will be covered in a rubber material to ensure they are cleanable and do not present safety or sanitation concerns. Rusty can openers in two houses. Back wall noted with scoring/scratches with exposed drywall has been repaired. 2. Kitchen Manager will check these weekly during walk throughs and report any concerns to maintenance. New can openers placed in two houses cited 3. Weekly 4. Kitchen Manager Plan of correction for staff related issues- 1. On 4/10/26 all staff will receive thorough training on food cooling procedures, open dates and when and how food is to be stored. Designated sinks posted with appropriate signage. Every kitchen will be rearranged to meet splatter criteria by 3/20/26. Spreadable butter replaced all regular butter on 3/18/26. 2. Kitchen Staff will do daily walk throughs while stocking to ensure all items above are maintaining compliance. Kitchen inspections will be completed bi-annually by administrator. 3. Daily and in depth bi-annually 4. Kitchen Staff and Administrator. Proper staff food storage; labeling of all food items with clear use-by dates to ensure safe consumption; adherence to proper food cooling and storage procedures; maintenance of a dedicated handwashing sink accessible at all times; prevention of splash contamination by ensuring clean dishes are properly protected; proper refrigeration of temperature-sensitive items lacking dates or exceeding the seven-day use period; and installation of appropriate signage to clearly designate handwashing sinks.

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: