Print Inspection: KIT013235

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 Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main kitchen and memory care unit occurred on 07/23/26, from 11:00 am through 1:15 pm, and revealed the following: 1. Main 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: * Underneath tables and chairs, with noted food debris from previous meal(s) and not cleaned between meal services; * Floors and walls near/under dish machine; * Floor drains; * Ceiling above steam line; * Ceiling vents; * Sprinklers; * Heat lamp above steam line; * Chains/hooks above steam line; * Light fixtures; * Movable metal rack; * Ceiling, area around cooling fans, and pipes in walk-in cooler; * Interior of ice machine along edges; * Interior of microwave; * Top of stainless steel shelving; * Open stainless steel shelving storing clean dishes; and * Plastic shelving in dish room. b. The following areas were in need of repair: * Multiple floor drains observed with drain downspouts reaching deep into the interior of the drain, not allowing for backflow prevention in the event of a drain overflow event. c. Container of Quat sanitizer strips noted damaged and unusable. Facility did not have any other strips available to ensure surface sanitation levels were at correct concentrations. d. Multiple wet cloths/rags used for surface sanitation were observed stored on kitchen countertops and other areas, not in sanitizing solution as needed. e. Multiple pans of recently cooked hamburger patties were observed on top of convection oven for extended time frame (approximately 11:00 am to 12:27 pm) before being put away, conflicting with effective cooling practices. f. Cook was observed to reheat a previously cooked and cooled hamburger patty on the grill for lunch service, without checking the temperature of the food product with a thermometer to ensure proper reheat temperatures were reached. g. A box of ready-to-eat dried cranberries was observed stored uncovered and open to potential contamination in the dry storage area. h. Cold food items were noted stored on the counter for lunch service and were not properly emersed in ice to ensure they were kept at 41 degrees F or below during service. i. Care staff assisting residents in the dining room, as well as serving plates/drinks and coming in and out of the kitchen, did not have on aprons to create a clean barrier from their potentially contaminated clothing. 2. Memory Care Unit a. The microwave was observed with heavy amounts of dried food splatter and debris. The microwave was also noted with multiple areas that were rusted, with the protective coating peeled off, creating a non-smooth, non-cleanable surface. b. Care providing staff were observed to assist with meal activities and assistance without aprons or other protective barriers to prevent potential cross contamination from prior care giving tasks. c. Meal trays were delivered to the memory care unit from the main kitchen at 11:20 am and were set in the dining room. The carts were open and not insulated. The trays were covered with dome lids. Staff 2 confirmed there was not a heated pellet under the plates to keep food hot. Staff 2 indicated the facility had an insulated cart but that it was too small to hold plated trays and they used for desserts. Staff 2 indicated the facility did not have a system in place to monitor meal service temperatures to ensure temperature palatability. The plated meals sat for greater than 30 minutes before being served at 11:53 am. The temperature of the plated food was checked and found to be at 102 degrees. Staff 2 acknowledged the meal was not a palatable hot temperature. On 07/23/26 from approximately 11:00 am through 12:45pm, Staff 2 (Interim Dining Services Director), toured kitchen with surveyor and acknowledged the areas identified. At approximately 1:00 pm, the surveyor and Staff 1 (Business Office Manager) reviewed areas of concern. Staff 1 acknowledged the above areas that needed to be addressed.

MAIN KITCHEN: 1. We have hired a Dinning Services Director to oversee all aspects realted to dining services. a. In regards to cleaning - We have immediately addressed the areas of noted concern during the visit and are getting the areas cleaned. b. In regards to the drain down spouts reaching deep into the interior of the drain - Those have been shortened. c. In regards to Quat sanitizer strips - new ones have been ordered. d. In regards to multiple wet cloths left on counter tops not in sanitizer solution - Education was provided as to why they should be stored in the santizer solution vs. on the counter tops. e. In regards to pans of hamburger patties left out on the counter and not following effective cooling practices - A kitchen all staff and education was provided on this (8.11.26). Food safety Fundamentals (REL-SRC-0-FSF) 1 HOUR class was also assigned in relias related to food handling and will be completed by (8.15.26) f. In regards to the cook reheating a hambuger patty and not temping - education was provided to all cooks at the kitchen all staff. The class Food safety Fundamentals (REL-SRC-0-FSF) 1 HOUR was assigned to them in Relias and will be completed by (8.15.26) g. In regards to a box of ready to eat dried cranberries. This was thrown away. Education was provided about the potenial for contamination related to dry good at the kitchen all staff (8.11.26) h. In regards to cold food items noted to be on the counter and not stored properly for service - Education was provided immediately and all kitehcn staff will also be completing Food safety Fundamentals (REL-SRC-0-FSF) 1 HOUR by (8.15.26) 2. a. Kitchen cleaning logs were revamped and broken down into daily, weekly and monthly tasks along with maintenace specific tasks. b. Since the drains have been made shorter this is handled. c. This has been added as a task to the monthly check list to check expiration date and for any damage to the strips. d. Additional buckets for sanatizer solution/cloths have been strategically placed around the kitchen. e. Education providded to cooks staff about proper food cooling practices. f. Edcuation provided to cooks about proper re heating practices. g. Education provdied to ALL kitchen staff on proper stoage and additional plastic containers have been purchased to put these types of things in. h. Education provided to ALL ktichen staff related to keeping cold food cold druing meal services. Trays are being used. 3. All areas will be monitored on a daily basis by the Administrator at this time until we have a trained Dining Services Manager on staff. At that time it will be re-evlauted and moved to daily, weekly or monthly depending. 4. The Administrator will be in charge of all monitoring along with the Maintance Director for maintence specific tasks. Once we have a Dietary Manager full trained, he will be repsonsible for continued monitoring along with the Administrator and Maintence Director (for maintenance specific tasks). MEMORY CARE UNIT: 1. a. Microwave - a new microwave was immediately replaced. b. Aprons not being worn - Training will be held on (8.11.26) with MC staff as to why aprons needs to be worn including infection control. c. Food delivered to the MC not being at temp- NEW warmer for food transportation will be ordered 2. a. Microwave - Checking the microwave for rusting, peeling etc will be added to a maintenance specific log for them to monitor for these things. b. Aprons - We have ordered aprons for all MC staff to wear druing meal service. c. Food being delivered to MC not being at temp - a long with the new food transportation warmer that is to be ordered, we will also create a temp log for all food to be temped in the memory care just prior to service to ensure that the food is still at the correct temperature. 3. a. Microwave - this will be done weekly by maintenance. b. Aprons - Periodic checks to ensure that MC staff assisting with meals are wearing them. c. Food not at temp - Temp log kept at each meal. 4. Maintenace will be in charge of the microwave. Memory care RCC will ensure that ALL MC staff have aprons available for meal service. The Med Aide on Duty will ensure that everyone is wearing them at each meal. MC RCC will esnure that temp logs are avilable and the med aide on duty will ensure that the temps are getting filled out. If food isn't temping correctly, the kitchen is notified so they can get properly temped food to the MC. The facility Administrator and/or Dining Services Director will oversee and quality check all areas to ensure that these systems are remaining in place.

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:

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.

see C 240

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: