Print Inspection: KIT012413

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 food service areas in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main facility kitchen, memory care kitchenette and dinging area was completed 06/09/26, from 10:15 am through 1:45 pm, and the following was identified: 1. Main kitchen a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, and/or black matter was visible on or underneath the following: * Floors under equipment/counters in beverage service area; * Interior of beverage cooler in service area; * Drip tray of soda machine; * Interior of ice machine; * Floors under/near ice machine; * Flooring and walls under and around dish machine area; * Clean side of dish washing area; * Kitchen drains; * Floors under steam table; * Ceiling above steam table; * Ceiling and vent above clean section of dish pit; * Metal pole extending from service line to ceiling; * Interior of microwave; * Handheld mixer base; * Industrial mixer; * Flooring under and in between large equipment and behind oven/range/grill; * Handle of steamer; * Range top; * Interior of convection oven; *Interiors of conventional ovens; * Walk-in freezer floor; * Can rack in dry storage; * Movable metal speed rack outside walk-in cooler; * Metal racks in walk-in cooler; * Fan blades and cages in walk-in cooler; * Interior of plate warmer bases; * Cord for plate warmer; * Removable hood vents; * Stainless steel shelving above baking area; and * Floor grout lines in multiple heavy use areas. b. The following areas were in need of repair: * Seal for beverage cooler in service area torn/damaged; * Small gap in ceiling by sprinkler as you exited the door to independent dining room; * Larger gap around electrical conduit near the ceiling in the back prep area; * Multiple areas in the floor with grout missing or worn, collecting excess food debris; and * Multiple downspout drains reaching inside floor drains, not creating adequate air gaps during a backup/drain clogged event. c. Multiple food items found in reach-in cooler without proper labels and/or prepared/opened or use-by dates as required. Multiple food packages found open in walk-in freezer, exposing food products to potential contamination. Multiple items found open/uncovered and without proper labels/dates in deli cooler. d. A large bulk container of powdered sugar was observed with a scoop stored inside the product, with the handle touching the food product. e. Multiple kitchen staff observed making/serving/handling food or clean dishes/equipment without effective hair or beard/facial hair restraints. f. Multiple staff members were observed not to change gloves when potentially contaminated as required. One staff was observed to potentially contaminate his gloves when he left the service line, took dirty dishes to the dish area, handled the sprayer and dirty side of dish machine handle, then returned to serving food on the service line without changing his gloves. The staff then touched ready-to-eat food with the contaminated gloves. Surveyor intervened and had the facility discard the contaminated food. g. Multiple staff were observed not performing hand washing prior to donning gloves or when changing gloves, as required. One staff member was observed handling dirty dishes then starting to put away clean dishes without a hand hygiene step. h. A large quantity of dirty dishes was stacked/piled up directly next to the “clean” side of the dish machine area. Multiple racks of “clean” dishes were sitting on an area with visible food debris from the dirty side of the stacked dishes. There was no clear separation between clean and sanitized dishes and dirty dishes, causing cross contamination potential. i. Multiple dish washing racks were observed stored on the floor. j. The white service board on the deli cooler was observed heavily scored and stained. Multiple portable cutting boards were also found stained and/or heavily scored with deep grooves/pits and in need of repair or replacement. Sauté and saucepans were also observed damaged and/or protective coating worn or scraped off. k. A large quantity of delivered food was observed stored on the floor in the walk-in cooler, walk-in freezer, and dry storage area. The food was delivered the day before. Staff 2 (Executive Chef) was interviewed at approximately 12:45 pm, and acknowledged the items should have been put away the day of delivery. l. A box of fresh bell peppers was observed placed directly next to a large rack used for defrosting raw meats. There was a bag of raw chicken defrosting inches away from the fresh produce, with visible blood/juices dripping from the bag on to the pan nearly touching the box of produce. m. Plated food was placed on a delivery cart without lids or other coverings to protect from potential contamination during transport to the memory care area. 2. Memory Care Kitchenette a. A container of fruit preserves was dated with a use-by date of 02/12/26 and should have been discarded. b. Kitchenette did not have test strips to verify/ensure sanitation bucket was at the proper sanitation level. Surveyor used their strips and found the bucket to be higher than recommended concentrations. Care staff were unaware of what the proper concentration was supposed to be. c. Plated food items were observed uncovered in the meal transport cart. Staff were asked if meals were covered prior to delivery to resident rooms and care staff stated no, as they had nothing to cover the plates with. Meal trays were observed taken to resident rooms without being covered/protected from potential contamination. d. Multiple care staff were observed to provide meal assistance and deliver food items to residents without aprons or other protective barriers to prevent potential cross contamination from care giving tasks with meal service tasks. At 1:30 pm, identified areas were reviewed with Staff 1 (Executive Director) and Staff 2, who acknowledged the areas of concern.

1. All accumulation of food, spills, splatters, loose food and trash debris, dirt, dust, greast, and/or black matter has all been thoroughly cleaned, scrubbed, washed, and sanitized on and around every floor surface, countertops, dish washing station, walls, drains, steam tables, prep areas, ceilings, piles, mixers and all other equipment, range top, interior of ovens, walk-in freezer, walk-in cooler, dry storage, vents, hoods, shelves, racks, salad bar, soup bar, ice machine, and both beverage stations. Repairs have been completed for the following: seal for beverage cooler, both gaps in ceiling, downspout inside floor drain replaced, and grout on kitchen floor is being scheduled for repair/replacement as soon as possible. Food items have been covered and dated, and in-service conducted with all staff. Utensil removed from container and in-service conducted. Kitchen staff have hair restrained and in-service conducted. Staff in-serviced about contamination and importance of hand hygeine and changing out gloves. Aprons have been ordered as well. In-service for staff about keeping clean and dirty dishes separated to avoid cross-contamination. All cutting boards and the white service board have been replaced, all deliveries have been put away and staff in-serviced on the standard of putting items away immediately upon delivery. Staff in-serviced about the importance of keeping raw meat and other foods separate to avoid any cross-contamination. Staff in-serviced about discarding expired food in the fridge. Staff in-serviced about the use of sanitation bucket and sanitation strips and how to use them and read them properly. Plated food items and transport has also been in-serviced with staff. 2. All areas from ceiling to the floor, walls, floors, drains, vents, hoods, appliances, dish area, steam tables, dry storage, and walk-in freezer/cooler have been added to a daily and/or weekly cleaning schedule. Tasks are to be marked off upon completion and audited by Executive Chef. Task list will be adjusted accordingly if certain areas require more or less attention. Multiple in-services will be conducted with staff to go over cleaning expectations and task list, cross-contamination of raw food, proper food labeling and storage, and hand hygiene and clean gloves and aprons. Executive Chef will audit for expired dates/food, cleanliness, test strips, and covered food every other day to ensure compliance. Additional dome lids have been ordered to keep food covered during transport. 3. Surface cleaning, floors, walls, drains, dish area, range top, dry storage, salad bar, soup well, both beverage stations, and prep areas will be cleaned daily. Walk-in cooler/freezer, vents, hoods, shelves, racks, dry storage, and equipment will be cleaned weekly. However, all surfaces of kitchen will be monitored for cleanliness daily. Audits of Memory Care fridge will be audited daily, testing strips will be checked before each meal service. Care staff will each have their own apron that will be stored in the kitchen area to ensure availibility. 4. The Executive Chef and lead cook will be responsible for ensuring the kitchen maintains cleanliness and all repairs are done in a timely manner to stay in compliance. The Executive Chef and Memory Care Director will be responsible to ensure compliance in the Memory Care kitchen and food cart.

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 observations and interviews, 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.

1. PLEASE REFER TO C240 2. PLEASE REFER TO C240 3. PLEASE REFER TO C240 4. PLEASE REFER TO C240