Print Inspection: KIT013268

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: Observation of the main kitchen on 07/23/26, from 9:50 am through approximately 11:00 am, revealed the following: 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: * Flooring and walls?throughout the kitchen; * Inside walk-in refrigerator and freezer floors, walls, and doors; * Walk-in refrigerator fans; * Metal racks inside walk-in refrigerator; * Floor drain near handwashing sink; * Flat top, oven, stove, fryer, and toaster; * Hood vents; * Below steam table counter cabinets; and * Stainless shelving near coffee machine and handwashing sink. b. Inside the walk-in refrigerator, a tray of baked potatoes was not dated, was uncovered, and was open to the air. c. A large open bag of oats in the dry storage was open to the air and undated. d. A large unopened bag of oats and bread racks were being stored on the floor of the dry storage. On 07/23/26 at approximately 10:45 am, the areas in need of cleaning and repair were discussed with Staff 1 (Regional Vice President) and Staff 2 (Executive Chef). They acknowledged the findings.

1. Actions taken to correct each cited example - The Executive Chef and dietary team removed food spills, splatters, loose food, trash debris, dirt, dust, black matter, and grease from kitchen floors and walls; walk-in refrigerator/freezer floors, walls, doors, fans, and racks; the floor drain near the handwashing sink; flat top, oven, stove, fryer, toaster, hood vents; below steam-table cabinets; and stainless-steel shelving near the coffee machine and handwashing sink. The cited areas and equipment were cleaned and sanitized. - The uncovered, undated baked potatoes and the open, undated oats were discarded. Prepared foods were checked for covering, labeling, and date marking. Open dry goods were sealed in food-grade containers or securely resealed and labeled with the open date. - The unopened oats and bread racks were moved to approved shelving at least six inches above the floor. Refrigerator, freezer, and dry-storage areas were checked for the same practice. - The Environmental Services Director inspected the cited physical areas and entered repair needs into the work-order system for completion by 09/21/26. 2. System changes to prevent recurrence - A master sanitation schedule now lists daily, weekly, and monthly tasks, assigned staff, completion time, and supervisor verification for each cited area and piece of equipment. - Opening and closing checklists require review of floors, walls, drains, equipment, walk-ins, shelving, cabinets, food covering, date marking, dry-goods sealing, and storage at least six inches above the floor. The Executive Chef reviews the logs each shift and corrects missed tasks before the next meal-service period. - Dietary staff will be retrained by 09/21/26 on OAR 411-054-0030 and applicable OAR 333-150-0000 requirements for cleaning, sanitizing, covering, labeling, date marking, dry storage, and documentation. New dietary employees receive this training before working independently. - Repair needs are tracked by work order. Audit results, corrective actions, training records, and repair follow-up are reviewed through QAPI. Repeat concerns result in coaching, retraining, or corrective action under facility policy. 3. Frequency of evaluation - The Executive Chef or designee completes documented opening and closing inspections each day. - The Executive Director or designee completes a formal audit weekly for 45 days. After substantial compliance is met and maintained, audits move to every other week for 45 days. Substantial compliance means a score of at least 95%, no uncorrected immediate food-safety concern, and no repeat cited practice. - A score below 95% or repeat finding returns monitoring to weekly audits and triggers immediate correction and retraining. Results are reviewed at weekly QAPI meetings during monitoring and monthly after sustained compliance. Monitoring continues until substantial compliance is met and maintained. 4. Responsible persons - Executive Chef: daily sanitation, staff assignments and training, food-storage practices, log review, and immediate correction. - Executive Director: completion of the POC, formal audits, training verification, QAPI review, and follow-up when standards are not met. - Environmental Services Director: inspection, work orders, repair completion, and documentation. Regional Vice President or designee: oversight review of audit trends and QAPI progress.

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: