Print Inspection: KIT012012

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 05/19/26, between 10:30 am and 01:30 pm, the facility kitchen was observed, and the following was identified: 1. Areas in need of cleaning in Main Kitchen: *Hood vents, convection ovens, stovetop, grill, floor drains – carbon build-up and/or food spills in and around appliances; * Ice machine – white/black matter inside and dusty screen; * Refrigerator – dusty external vent; * Walk-in refrigerator – white matter on fan and shelves; and * Stainless frying pans – carbon build-up inside. 1a. Cleaning in Cottage B Kitchenette: * Refrigerator– food spills; and * Freezer – ice build-up. 1b. Cleaning in Cottage C Kitchenette: * Refrigerator –has food spills. 1c. Cleaning in Cottage D Kitchenette: * Refrigerator – has food spills; and * Freezer – has ice build-up. 2. Areas in need of repair/maintenance in Main Kitchen: * Steamer – leaking on the floor; * Handwashing sink – leaking faucet; inconsistent water temperatures; * Frying pans – Teflon surface that was scored; * Dish machine – missing data plate; * Cutting board on steamtable and in prep area – heavily scored, stained, non-cleanable; * Refrigerator – food stored in unsealed containers; * Pantry – dry goods not in rodent proof containers; * Exit door to outside from kitchen– has missing seal at bottom corner; and * Garbage – without lid. 2a. Repair/Maintenance in Cottage C: * Garbage – without lid. 3. Sanitation in Main Kitchen: * Chemical PH strips – test strips were expired; and * Leftovers – were returned to kitchen and placed into refrigerator after being in the cottage dining rooms. 3a. Sanitation Cottage B: * Hand Sinks – not dedicated. 3b. Sanitation Cottage C: * Hand Sinks – not dedicated; and * Refrigerator - above required temperature (discarded food). 3c. Sanitation in Cottage D: * Supplement – undated after thawing. The areas of concern were observed and/or discussed with Staff 2 (Wellness Coordinator/PIC) and Staff 4 (Cook) at approximately 01:30 pm on 05/19/26. Staff acknowledged the findings.

Areas in need of cleaning: Hood Vent: Professional cleaning schedue 6/8/26 and then every 6 months. Dietary Manager has on an every 2 week deep clean schedule that she is monitoring with dietary cleaning staff. Stove top: Dietary manager ordered alternate cleaning products to ensure proper cleaning. Completed 6/5/26. Staff to clean daily and Dietary Manger has on a weekly deep cleaning schedule that she is monitoring with dietary cleaning staff. Convection Oven: Cleaning completed on 6/4/26. Dietary Manager has on a weekly cleaning schedule that she is monitoring with dietary cleaning staff. Grill: Dietary manager ordered alternate cleaning products to ensure proper cleaning. Completed 6/5/26. Dietary Manager has on weekly cleaning schedule that she is monitoring with dietary cleaning staff. Floor Drains: Completed 6/5/26. Dietary Manager has on weekly cleaning schedule that she is monitoring with dietary cleaning staff. Carbon build up and/or food spills around appliances: Cleaning completed 6/5/26. On daily cleaning schedule with dietary staff and Dietary Manager has on weekly deep cleaning schedule that she is monitoring with dietary staff. Ice Machine: Applied Refridgeration deep cleaned and serviced on 5/21/26. They complted training with Dietary Manager on how to clean and care for ice-machine. On monthly deep cleaning schedule with Dietary Manager. Refrigerator - dustany external vent: Cleaned 5/21/26. On weekly cleaning schedule for dietary staff. Dietary Manager monitoring weekly. Walk-in refrigerator - white matter on fan and shelves: All shelving/fans cleaned as of 6/5/26. On cleaning schedule to be wiped down weekly and shelving to be taken out monthly to be pressure washed. On Dietary Manager has on weekly/monthly cleaning schedule that she is monitoring with dietary cleaning staff. Stainless Frying Pans - carbon build-up inside: New pans ordered 6/4/26. Dietary Manager will monitor monthly to ensure they are in proper condition and order new as needed. Teflon Fying Pans - surface that was scored: New pans ordered 6/4/26. Dietary Manager will monitor monthly to ensure they are in proper condition and order new as needed. Dish Machine - missing data plate: Ordered 5/30/26. Awaiting delivery. Second plate ordered in event it is needed. Dietary Manager has on mothly schedule to observe for placement. Handwashing sink - leaking faucet; inconsisten water tempatures: Plummer came 5/30/26 and ordered new parts. To be installed 6/9/26. Dietary Manager to monitor monthly for leaks and Maintenance Director to do monthly water temp monitoring. Steamer - leaking on the floor: Interstate Appliance scheduled for repair on 6/15/26. Dietary Manager will report any further issues immediately to Maintenace Supervisor for repair or to schedule repair. Cutting board on steamtable and in prep area - heavily scored, stained, non-cleanable: After investigation, found where to order new cutting board. Ordering from Curtis Restaurant Repair on 6/8/26. ED will look at quarterly with Dietary Manager to address any further concerns. Refrigerator - Food stored in unsealed containers: Dietary staff inserviced on proper storage on 5/21/26. Dietary Manager to do daily walk throughs on her work days to monitor for inproper storage and do on the spot training. Pantry - dry goods not in rodent proof containers: Items moved into proper containers on 5/21/26. Containers ordered 6/4/26 for the remainder of items that community did not have containers for. Dietary Manager to complete weekly audits for compliance and needed staff training. Exit door to outside from kitchen - missing seal at bottom of container: 6/4/26 seal was repaired by Maintenance Director. Dietary Manager will monitor monthly for proper repair. Gargabe: without lid: Lids now on all garbages. Manager check during daily rounding. Scheduled for all staff inservice on 6/18/26 to reinforce requirement for lids. Chemical PH strips - test strips were expired: Replace on5/21/26. Dietary Manager will monitor mothly to ensure within date. Leftovers were returned to kitchen and placed into refrigerator after being in the cottage dining rooms: All staff inserviced 5/20/26 to dispose of items. Items no longer being refrigerated. Daily continued monitoring from dietary staff for compliance. Cottage B, C,D: Hand sinks not dedicated: 6/4/26 all staff inserviced to utilize beverage tubs that beverages are delivered in vs. transfering beverages and ice to sink. Sinks are now dedicated solely to handwashing and dirty dishes. Managers to monitor daily during rounding to ensure compliance. Garbages - without lids: Lids now on all garbages. Managers to check during daily rounding. Scheduled for all staff inservice on 6/18/26 to reinforce requirement for lids. Refrigerators - food spills: All refrigerators clean as of 5/21/26. On night shift caregiver cleaning schedules. Maintenance to monitor weekly for compliance. Freezers - ice build up: All freezers defrosted 5/21/26. Maintenance Director to monitor weekly and defrost as needed. Fridge Cottage C - above required tempature. Fridge replaced 5/28/26. Daily temps taken. RCC's to review weekly for compliance. Cottage D supplement - undated after thawing. Med Tech's inserviced that supplements need to be dated upon opening on 5/21/26. LPN will re-inservice on 6/18/26 at Med Tech meeting. RCC will audit weekly for compliance.

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.