Print Inspection: KIT012535

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: HOLI Senior Living 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 06/17/26, from 10:45 am through 12:00 pm, revealed the following: 1. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, rust, and/or grease was visible on or underneath the following: * All floors under/behind cooking equipment (significant build-up of food debris), ware washing machine and center prep island; * Floors and thresholds of walk-in cooler; * Top of ware washing machine; * Interior upper recesses of commercial ice machine-black debris; * Legs, casters and shelves of center island prep tables; * Underside of commercial mixer head * Safety cage on commercial mixer; * Table -legs and shelves- that commercial mixer is stored on * Bottom shelves of all reach in coolers and freezers; * Food delivery carts; * Hinges and insulation strips on all doors of all reach in coolers and freezers; * Vent cover located on wall next to kitchen entrance door; * Condenser fan cover in walk-in cooler; * Hand held “Salad Shooter” - significant black debris on cord; * Metro rack style cart (all racks, legs and casters) used to transport portable steam table; * Portable steam tables, all exterior surfaces, controls knob and water well; * Floor sink under commercial ice machine; * Floor sink under two-compartment sink in ware washing area; * Canned food dispenser/holder on cooking line next to reach in freezer; * Black industrial fan cover and interior; * Hood vent filters above cooking equipment; and * Industrial can opener mounting plate. 2. Items in need of repair or replacement: * Multiple sauté pans with heavily worn non-stick surface which could result in physical contamination of food items; * Both convection ovens (under range burners) on hot cooking line; * Various small wares; * Cutting boards with worn finishes, potentially uncleanable; * Oven mitts heavily soiled and or with scorch/burn marks; * Water leaking from ware washing machine; and * Significant rust on walk-in cooler storage racks, rendering them unable to be cleaned/sanitized. 3. Sanitation and food handling: * Improper glove use; * Lack of facial hair restraints on cooking staff; * Lack of hair restraints on serving staff; * Lack of hand washing between changing gloves; * Lack of handwashing after touching face/hair; * Surface sanitation solution buckets without wiping towel; * Damp towels observed on multiple food service areas/towels not returned to surface sanitation solution buckets after use; * Kitchen staff unable to articulate effective minimum temperature for reheating food items; * The person in charge unable to articulate the two-stage cooling process; * Ware washing machine racks stored directly on floor; *Person in charge preparing food without facial hair restraint; * Kitchen staff observed to handle clean dishes without first washing hands after handling dirty dishes; * Oven rack stored directly on floor; *Improper probe thermometer use-probe thermometer not sanitized before use, potentially contributing to cross contamination; * Kitchen staff unable to articulate effective parts per million (PPM) range for quaternary sanitizing solution; and * Food prep area with raw chicken and raw egg handling not cleaned in a timely manner. 4. Food storage: * Multiple opened packaged food items in walk-in cooler without open dates; * Multiple prepared food items in reach in cooler; * Multiple prepared food items in reach in freezer uncovered, potentially impacting quality/palatability; * Brown sugar on countertop with serving spoon scored inside of the container, potentially contaminating the product; * Food item in walk-in cooler was opened/transferred from original container over fifteen days ago, rendering it potentially hazardous; * Improper food storage hierarchy in reach in freezer; * Food item in freezer was not properly closed, potentially affecting quality of food item; * Damaged #10 can intermingled with useable canned goods; * Frozen red substance on bottom shelf of reach in freezer; and * In dry storage, multiple bulk food containers without securely fastened lids. 5. Other areas of concern: * One member of kitchen staff had an expired food handler’s card. * Lack of palatability/visual appeal of observed lunch items-all foods were shades of tan or grey/white. Observations of the ALF kitchenette on 06/17/26, from approximately 1:00 pm through 1:20 pm, revealed the following: 1. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, rust, and/or grease was visible on or underneath the following: * Interior of toaster and the shelf the toaster was stored on; * Cabinet shelves and doors/top of doors; and * Black debris on interior surfaces of commercial ice machine. 2. Sanitation and food handling: * Lack of handwashing between changing gloves; * Ice scoop placed directly in ice machine on top of ice, potentially causing cross contamination; and * Ant infestation in cabinet holding canned sodas. 3. Food storage: * Improperly closed cereal; * Improperly closed cereal with an open date of approximately two months ago, rendering the food item beyond its use by date; * Multiple packaged food items without an open date in standing reach in cooler in dining room (next to microwave); and * Opened packaged food item with an open date of 02/24/26, rendering the product past its safe use by date. 4. Other areas of concern: * Dirty dishes were stored in the dedicated hand-washing sink. At approximately 01:30 pm surveyor met with Staff 1 (Interim ED) and Staff 2 (Dining Services Director) to review deficiencies. The findings were acknowledged by Staff 1 and Staff 2.

All identified sanitation, food storage, equipment, and food handling deficiencies were immediately corrected. The main kitchen and ALF kitchenette received a comprehensive deep cleaning. Expired, improperly stored, unlabeled, and out-of-date food items were discarded. Equipment and utensils that were damaged or unable to be effectively cleaned were removed from service and replaced or scheduled for replacement. Staff received immediate re-education on proper hand hygiene, glove use, hair restraints, food storage hierarchy, labeling and dating of food, temperature control, sanitizing procedures, and safe food handling practices. The facility has implemented a comprehensive food safety and sanitation program that includes documented daily, weekly, and monthly cleaning schedules, standardized food labeling and dating procedures, preventive maintenance and routine equipment inspections, and ongoing food safety education with competency validation for all dietary staff. Routine sanitation audits and food safety observations have been incorporated into the Quality Assurance process to ensure continued compliance with Oregon Food Sanitation Rules and applicable OARs. The Dining Services Director will review sanitation practices, food storage, food handling, equipment condition, and cleaning logs daily. Weekly sanitation audits will be completed for 90 days, followed by monthly Quality Assurance audits thereafter. The Dining Services Director will be responsible for implementing and monitoring all corrective actions, including daily review of sanitation practices, food storage, equipment condition, and completion of cleaning logs. The Executive Director will provide secondary oversight by reviewing weekly audit results, participating in the Quality Assurance process, and ensuring ongoing compliance with Oregon Food Sanitation Rules and applicable OARs.

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on record review and interview, it was determined the facility failed to ensure 1 of 8 sampled staff who prepared food had active food handlers certificates. Findings include, but are not limited to: On 06/17/2026 employee records were requested and reviewed with Staff 1 (Interim Executive Director) to ensure staff had active food handler's cards on file. Staff 3 (Kitchen staff) did not have an active Oregon food handlers card. On 06/17/2026, Staff 1 acknowledged the need for all staff to have an active Oregon food handler card. Staff 3 is required to have an active food handler's card prior to returning to work. Refer to C240

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: Facility not in compliance with ALF/RCF rules. Refer to C240

All deficiencies identified under Tag C240 were corrected immediately. Corrective actions included the Memory Care kitchen and dining service operations to ensure compliance with Residential Care, Assisted Living, and Memory Care licensing requirements. Staff received education regarding food safety and sanitation expectations. Administrative oversight has been strengthened through routine monitoring of all dietary operations, including Memory Care. Food safety, sanitation, documentation, and regulatory compliance will be reviewed through ongoing Quality Assurance audits to ensure continued compliance with applicable Oregon Administrative Rules. The Dining Services Director will complete weekly compliance audits for 90 days. The Executive Director will review audit findings weekly and continue monthly oversight through the facility's Quality Assurance program thereafter. The Dining Services Director will monitor ongoing compliance with dietary operations and complete routine audits. The Executive Director will provide secondary oversight by reviewing audit findings, participating in the Quality Assurance process, and ensuring continued compliance with Residential Care, Assisted Living, and Memory Care licensing requirements.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 1 of 8 sampled staff (#3) who prepared food had active food handlers certificates. Findings include, but are not limited to: On 06/17/2026 employee records were requested and reviewed with Staff 1 (Interim ED) to ensure staff had active food handler's cards on file. Staff 3 (Kitchen staff) did not have an active Oregon food handlers card. On 06/17/2026, Staff 1 acknowledged the need for all staff to have an active Oregon food handler card. Staff 3 was required to have an active food handler's card prior to returning to work.

The employee identified without a current Oregon Food Handler Card was immediately removed from food preparation duties until a valid Food Handler Card was obtained and verified. A complete audit of dietary personnel records was completed to verify all staff performing food service possess current Oregon Food Handler Cards. The facility has implemented a Food Handler Card tracking system to monitor expiration dates. Verification of current certification will occur during the hiring process, orientation, and prior to expiration. Staff will receive advance notification of upcoming expiration dates, and employees will not be permitted to perform food service duties without a current Oregon Food Handler Card. The Dining Services Director will review Food Handler Card status monthly and during all new hire onboarding. Compliance will also be reviewed during routine personnel file audits and Quality Assurance meetings. The Dining Services Director will monitor Food Handler Card compliance, maintain certification records, and ensure staff remain eligible to perform food service duties. The Executive Director will provide secondary oversight by reviewing personnel audits, monitoring certification compliance, and ensuring ongoing adherence to Oregon requirements and facility policy.