Print Inspection: KIT011857

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: Observation of the facility kitchen and the dining room on 12/31/25, from 10:45 am through 12:15 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, pink slime (biofilm), and/or grease was visible on or underneath the following: * Pipes, walls, and flooring behind/underneath the commercial ware washing machine; * Top of dish machine; * Metal movable “speed” racks; * Light fixture housing in walk-in cooler; * Electrical conduit/piping to light fixture and above the door in the walk-in cooler; * Walk-in cooler condenser fan covers; * Juice machine (where spouts connect to machine) with splash accumulation; * Industrial can opener and housing; * Top of standing convection oven in rear prep area; * Heavy accumulation of ice on interior right wall of walk-in cooler; * Fire suppression sprinkler heads throughout the kitchen; * Interior of commercial ice machine; and * Ceiling vent covers throughout the kitchen. b. Items to be repaired/replaced: * All green racks (Metro racks) in the walk-in cooler observed to have significant areas of rust, rendering them incapable of being properly cleaned or sanitized; * Water observed leaking from a pipe under the commercial ware washing machine; * Ware washing machine was missing the cover for one of the temperature gauges; * Leak running down the right side wall of walk-in cooler, resulting in an accumulation of ice; * Fluorescent overhead lights in dry storage area; * All lights in overhead exhaust system (vent-a-hood); and * Open cabinet in dining room holding ware washing machine racks has missing laminate resulting in exposed particle board that is not able to be adequately cleaned and/or sanitized. c. Multiple food items in walk-in cooler without an open date. d. Multiple damaged canned goods in dry storage area intermingled with useable canned goods. e. Multiple damaged canned goods on storage rack adjacent to the front cooking line intermingled with useable canned goods. f. No clear system in place to prevent the intermingling of damaged canned goods with useable canned goods. g. Food item in walk-in cooler with a manufacturer’s expiration date of 11/22/25. h. Multiple uncovered food items plated for service observed in the walk-in, potentially resulting in cross contamination of the food items. i. Kitchen staff member washing and handling clean dishes was observed to not have facial hair effectively restrained. j. Oven racks being stored directly on the floor behind the convection oven. k. No testing strips available for staff to validate if the parts per million concentrations of the surface sanitation solution buckets were within the effective range for sanitizing food service/prep surfaces. At approximately 12:15 pm, the surveyor reviewed the findings with Staff 1 (Executive Director) and Staff 2 (Dining Services Manager). The deficiencies were acknowledged by Staff 1 and Staff 2.

A) 1. All noted areas with an accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, pink slime (biofilm) and/or grease have been cleaned thoroughly and appropriately. 2. A daily, weekly, monthly, and quarterly cleaning task list has been implemented for the dining team members to carry out to ensure cleanliness. 3. The Executive Director and Dining Services Director will conduct a walkthrough weekly as well as monthly as part of the community's CQI program to ensure complance in cleanliness of the kitchen and service areas. 4. The Executive Director is responsible to see that corrections are completed and monitored. B) 1. Items needing repair or replaced have been ordered and/or scheduled for repair. 2 The Executive Director and Dining Services Director will conduct an audit of the kitchen to include an environmental walkthrough to ensure that any items needing repair or replaced is documented with an action plan on a regularly scheduled basis. 3. This system will be evaluated once weekly and monthly as part of the CQI process. 4. The Executive Director is responsible to see that the corrections are completed and monitored. C) 1. All food items in the walk-in cooler have been audited to ensure that a open date is placed on to all open items. 2. The dining service team has been inserviced on the importance of labeling opened items with the open date for food safety precautions. 3. The Executive Director and Dining Services Director will do an audit walkthrough of the walk-in to ensure all opened items are open dated on a recurring basis. 3. This system will be evaluated once weekly and monthly as part of the CQI process. 4. The Executive Director is responsible to see that the corrections are completed and monitored. D) 1. The damaged canned goods in the dry storage area were removed and disposed of. 2. The dining services team has been inserviced on not having damaged canned goods intermingled with useable canned goods. 3. The Executive Director and Dining Services Director will evaluate this area on a monthly basis as part of the CQI process. 4. The Executive Director is responsible to see that corrections are completed and monitored. E) 1. The damaged canned goods on the storage rack adjacent to the front cooking line were removed and disposed of. 2. The dining services team has been inserviced on not having damaged canned goods intermingled with useable canned goods on the storage rack. 3. The Executive Director and Dining Services Director will evaluate this area on a monthly basis as part of the CQI process. 4. The Executive Director is responsible to see that corrections are completed and monitored. F) 1. A system has been put into place to prevent the intermingling of damaged canned goods with useable canned goods that has three layers of preventative measures. 2. Dining staff have been inserviced that the cook on shift receiving the food order is to check all canned goods upon delivery and return any damaged canned goods with the deliverer. The dining services director will then also audit inventory to ensure no damaged canned goods once the shipment has been completed. The Executive Director and Dining Services Director will conduct weekly walk throughs of the various storage areas to ensure the removal of any damaged canned goods not previously identified. 3. This system will be evaluated monthly as part of the CQI process. 4. The Executive Director is responsible to see that the corrections are completed and monitored. G) 1. The expired food item identified was immediately removed from the walk-in cooler. 2. Dining staff have been inserviced the importance of checking expiration dates when using and storing food products for food safety measures. 3. The Executive Director and Dining Services Director will conduct a weekly walkthrough to ensure no expired product is in the walk-in cooler. This system will also be reviewed monthly as part of the CQI process. 4. The Executive Director is responsible to see that the corrections are completed and monitored. H) 1. The uncovered food items were immediately removed from the walk-in and replaced with a covered option. 2. Dining staff have been inserviced on cross contamination of food products and the importance of ensuring food is not left uncovered in the walk-in. 3. The Executive Director and Dining Services Director will conduct a walkthrough weekly to ensure that all items in the cooler are always covered. 4. The Executive Director is responsible to see that the corrections are completed and monitored. I) 1. The kitchen staff member was instructed and provided the necessary equipment needed to have their facial hair effectively restrained. 2. Dining staff have been inserviced on proper sanitation procedures including the restraining of any visible hair. 3. The Dining Services Director will ensure that dining staff upon hire and recurring there after on a regularly scheduled basis are re-trained on the restraining of visible hair. 4. The Executive Director is responsible to see that the corrections are completed and monitored. J) 1. The oven racks identified behind the convection oven were removed and placed into a proper storage area. 2. The dining team have been inserviced on storing the oven racks in the designated area. 3. The Executive Director and Dining Services Director will conduct a weekly walkthough to ensure the oven racks are in their designated storage area. 4. The Executive Director is responsible to see that the corrections are completed and monitored. K) 1. Testing strips were immediately ordered and are currently on hand for staff to validate if the parts per million concentrations of the surface sanitation solution buckets are within the effective range for sanitizing food service/prep surfaces. 2. Dining staff were trained on proper test strip logging, procedure, and verification of effective ranges. 3. This Executive Director and Dining Services Director will conduct a weekly walkthrough to ensure sanitization buckets are being properly tested. This system will also be reviewed monthly as part of the CQI process. 4. The Executive Director is responsible to see that the corrections are completed and monitored.

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: