Print Inspection: KIT013700

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 interviews, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the kitchen from 08/14/26 through 08/17/26 revealed the following concerns: 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 throughout the kitchen; * Door thresholds/doorways; * Flooring in corners, edges, and between and under equipment; * Wall behind and beside the ice machine; * Walls beside and behind major equipment; * Drains throughout kitchen; * Industrial can opener and housing: * Industrial mixer and table; * Deli refrigerator door; * Interior of deli refrigerator; * Blender exterior; * Walls behind trash can; * Walls at kitchen entry; * Stainless steel shelving throughout kitchen; * Exterior of ovens (handles/knobs); * Interior of ovens; * Sides of major equipment; * Stove top; * Exterior and lids of white bins storing bulk foods; * Metal speed/baking racks in main kitchen and in walk-in cooler; * Interior of microwave; * Fan cages in walk-in cooler; * Milk crates stored in walk-in cooler; and * Stationary metal racks in walk-in cooler. b. The following area was found in need of repair: * A large hole in the ceiling of the dry storage exposing piping. c. The white surface/cutting board on steam table was heavily stained and scored. Multiple portable cutting boards were also heavily scored/stained. d. Multiple items observed in the deli cooler were not dated when opened/prepared. Multiple items in cold storage older than seven days or past the manufacturer’s use-by/expiration date and needed to be discarded. e. A container of cottage cheese had visible contamination of another food item, indicating a used/dirty utensil was used and potentially contaminated the food product. Staff 2 (Dining Services Manager) acknowledged that practice was not acceptable and the food items needed to be thrown away. f. Multiple food items were stored open/uncovered and exposed to potential contamination. g. Food contact surfaces of equipment were stored uncovered or unprotected from potential contamination. h. The cook was observed handling ready-to-eat food items with gloves that were contaminated from touching handles of drawers when serving on the service line. i. Staff were observed washing their hands in a hand wash sink without a splash guard. There were multiple trays of poured drinks placed next to the sink, causing a contamination risk. j. Room trays were observed being delivered to rooms with beverages that were not covered/protected from contamination during transport. The surveyor reviewed the above areas with Staff 2 (Dining Services Manager), and they acknowledged the identified areas. At approximately 1:30 pm Staff 1 (Administrator) was informed of the sanitation concerns identified and the facility was asked to put in place a plan for immediate cleaning of the kitchen. On 08/17/26 at 9:40 am, the surveyor returned to the facility and noted significant improvement in the kitchen cleanliness. The surveyor reviewed with Staff 1 and Staff 2 the identified areas needing corrective action. They both acknowledged the concerns.

PROVIDER’S PLAN OF CORRECTION Survey Tag: C240 Rule: Kitchen Maintenance and Sanitation / OAR 333-150 000 The facility recognizes the findings identified under Tag C240 and has implemented the following Plan of Correction to address the identified concerns, maintain the kitchen in good repair and sanitary condition, and prevent recurrence. A. Kitchen Cleaning and Sanitation Immediately following the survey findings, the Dining Services Manager (DSM), Executive Director (ED), and kitchen staff completed a comprehensive cleaning of the kitchen. A focused “cleaning party” was held to address the areas identified during the survey, including flooring, corners, edges, areas underneath and between equipment, walls, doorways and thresholds, drains, food preparation equipment, refrigerators, ovens, stove tops, shelving, storage bins, speed racks, walk-in cooler surfaces, fan cages, trash areas, and other areas identified during the survey. The facility reviewed and revised its kitchen cleaning procedures and implemented detailed daily, weekly, and monthly cleaning schedules. The cleaning schedules identify specific areas and equipment to be cleaned and maintained. Kitchen staff are responsible for completing assigned cleaning tasks and documenting completion on the designated cleaning logs. Daily cleaning tasks include, but are not limited to: • Sweeping and mopping floors throughout the kitchen. • Cleaning and sanitizing food preparation surfaces and sinks. • Cleaning the mixer, mixer stand, blender, microwave, stove top, steam wells, warmer, steamer, ovens, reach-in refrigerators, dish machine, shelving, carts, and other food service equipment. • Cleaning walls and surfaces in identified work areas. • Cleaning and organizing dry storage, prep, dish, cook line, service, and walk-in/freezer areas. • Cleaning refrigerator doors and interiors as scheduled. • Cleaning food storage shelves and ensuring appropriate organization. • Auditing food items for dates, product quality, package integrity, and proper storage. • Cleaning handwashing sinks and service areas. • Removing trash and debris and cleaning surrounding areas. • Cleaning the exterior of beverage, coffee, juice, and ice equipment. Weekly cleaning tasks include, but are not limited to: • Cleaning and polishing food preparation surfaces, shelving, sinks, storage areas, and equipment. • Cleaning walls, drains, trash receptacles, food storage bins, recycling containers, speed racks, and overhead storage areas. • Degreasing and cleaning stove top burners. • Cleaning hood vents. • Cleaning and polishing dishwashing and food service equipment. • Cleaning and organizing the walk-in/freezer area. Monthly and scheduled deep-cleaning tasks include, but are not limited to: • Cleaning dry storage racks and crates. • Cleaning walk-in cooler fan vents and racks. • Cleaning the interior of ovens. • Cleaning ceiling vents. • Degreasing and deep cleaning behind and underneath stoves on a bi-annual basis by Maintenance. The DSM will review the cleaning logs daily to ensure all assigned tasks have been completed. The ED and DSM will conduct and document a weekly kitchen sanitation audit to inspect all kitchen areas, equipment, floors, walls, drains, storage areas, and food service surfaces for cleanliness and sanitation. Any deficiencies identified during the audit will be corrected promptly and documented. B. Repair of Ceiling in Dry Storage Area The facility identified a large hole in the ceiling of the dry storage area that exposed piping. The area has been temporarily covered with plastic to prevent contamination while permanent repairs are being arranged. A licensed plumbing contractor has evaluated the piping, and the facility is awaiting final bids for the necessary pipe replacement. Once the bid has been approved, the plumbing repair will be completed. Following completion of the plumbing work, Maintenance will permanently repair and restore the ceiling to a smooth, cleanable, and sanitary condition. The ED will monitor the repair process and ensure the temporary protective covering remains intact until permanent repairs are completed. The ED will review the status of the repair weekly until completion. Following completion, the area will be included in the routine kitchen sanitation and maintenance inspections. C. Cutting Boards and Food Preparation Surfaces All portable cutting boards identified as heavily scored or stained have been removed and replaced. The white cutting surface on the steam table will be resurfaced or replaced by the Maintenance Department to ensure that the surface is smooth, cleanable, and maintained in good repair. Kitchen staff have been instructed to inspect food preparation and cutting surfaces routinely and remove any cutting board or food contact surface that becomes excessively worn, deeply scored, cracked, stained, or unable to be effectively cleaned and sanitized. The DSM will inspect cutting boards and food preparation surfaces weekly during the kitchen audit. Any deficient equipment will be removed from service and replaced or repaired as necessary. D. Food Dating and Discarding of Expired Food All kitchen staff have been re-educated regarding proper food labeling, dating, storage, and discard procedures. A standard practice has been implemented requiring all opened or prepared food items to be properly labeled with the date opened or prepared and discarded according to facility policy, manufacturer instructions, and applicable food sanitation requirements. Food items that are past their discard date, past the manufacturer’s use-by or expiration date, or otherwise unsuitable for use will be discarded immediately. This requirement will be formally addressed and documented during the staff meeting scheduled for September 10, 2026. Proper food labeling, dating, storage, and discard procedures will also be discussed and reinforced with kitchen staff bi-monthly moving forward to ensure continued understanding and compliance. Kitchen staff will conduct routine food dating checks as part of their daily cleaning and food storage responsibilities. The DSM will audit refrigerated and cold storage items daily for appropriate labeling, dating, product quality, package integrity, and expiration dates. The DSM and ED will further review compliance during the weekly kitchen sanitation audit. Any deficiencies identified will be corrected immediately, documented as appropriate, and staff will receive additional education or corrective action as needed to prevent recurrence. E. Cottage cheese was thrown out at that time. F. Food Storage and Protection From Contamination Kitchen staff have been re-educated regarding the requirement that all food items be properly covered, protected from contamination, and stored securely when not in use. A standard procedure has been implemented requiring staff to ensure opened food items are covered or otherwise protected and appropriately stored immediately after use. Food storage areas will be inspected daily as part of the kitchen cleaning and food storage audit. The DSM will monitor food storage practices daily, and the ED and DSM will review compliance weekly during the kitchen sanitation audit. G. Protection and Storage of Food Contact Surfaces Kitchen staff have been re-educated regarding proper cleaning, sanitizing, and storage of food contact surfaces and equipment. Food contact surfaces, utensils, and equipment will be cleaned and sanitized after use and stored in a manner that protects them from dust, splash, debris, and other potential sources of contamination. The DSM will monitor compliance daily and review food contact surface storage and sanitation during the weekly kitchen audit. Any concerns identified will be corrected immediately and staff will be re-educated as necessary. H. Prevention of Cross-Contamination During Food Service The facility has purchased additional tongs and service utensils for use on the cook line and service line. Kitchen staff have been re-educated regarding proper glove use, hand hygiene, and prevention of cross-contamination when handling ready-to-eat food. Staff are instructed to change gloves and wash hands when gloves become contaminated or after touching non-food contact surfaces, such as drawer handles, equipment handles, or other potentially contaminated surfaces. Separate service utensils will be readily available to minimize unnecessary handling of ready-to-eat food. The DSM will observe food preparation and service practices daily. The ED and DSM will conduct weekly observations and audits to monitor compliance with proper glove use, utensil use, hand hygiene, and cross contamination prevention. I. Handwashing Sink and Beverage Contamination Prevention A procedure has been implemented requiring beverages and other food items to be maintained at least 12–18 inches away from the handwashing sink to reduce the risk of splash contamination. Staff have been re-educated regarding maintaining a clear and sanitary area around the handwashing sink. The DSM will monitor the handwashing and beverage service areas daily, and the ED and DSM will inspect the area as part of the weekly kitchen sanitation audit. J. Protection of Beverages During Room Tray Delivery The facility has implemented the use of perforated protective wrap on all beverages leaving the kitchen for delivery to resident rooms. This procedure is intended to protect beverages from potential contamination during transport. Kitchen staff have been educated on this requirement and are responsible for ensuring all beverages placed on room trays are appropriately covered or protected before leaving the kitchen. The DSM will monitor room tray preparation and beverage protection daily. Compliance will also be reviewed by the DSM and ED during the weekly kitchen sanitation audit. STAFF EDUCATION AND ONGOING COMPLIANCE All kitchen and applicable dietary staff will be re-educated regarding: • Proper kitchen cleaning and sanitation practices. • Completion of daily, weekly, and monthly cleaning assignments. • Proper food labeling, dating, storage, and discard procedures. • Protection of food from contamination. • Proper storage and protection of food contact surfaces and utensils. • Hand hygiene and proper glove use. • Prevention of cross-contamination. • Proper protection of beverages and food during transport. • Reporting maintenance concerns and equipment in need of repair. New kitchen employees will receive education regarding these procedures during orientation, and additional education will be provided as needed based on audit findings or observed concerns. MONITORING AND EVALUATION The Dining Services Manager is responsible for the day-to day implementation and monitoring of this Plan of Correction, including daily review of cleaning assignments, food storage practices, dating, sanitation, and kitchen operations. The Executive Director and Dining Services Manager will jointly conduct and document a comprehensive weekly kitchen sanitation audit. The audit will include review of: • Floors, walls, corners, and areas underneath and behind equipment. • Drains and doorways. • Major kitchen equipment and food preparation surfaces. • Refrigerators, walk-in coolers, ovens, microwaves, and other equipment. • Shelving, storage racks, speed racks, food storage bins, and trash areas. • Food dating, labeling, expiration dates, and product quality. • Food storage and protection from contamination. • Food contact surfaces and utensil storage. • Handwashing and glove use. • Beverage and room tray protection. • Outstanding maintenance and repair concerns. • Completion of required cleaning schedules. Any deficiencies identified during monitoring will be corrected immediately. The responsible staff member will be re-educated when appropriate, and repeat concerns will be addressed through additional corrective action and performance management as necessary. The ED will review the weekly audit results and cleaning documentation to evaluate the effectiveness of the corrective actions and determine whether additional education, monitoring, equipment repair, or process changes are needed. Weekly audits will continue ongoing to ensure sustained compliance and to prevent recurrence of the deficiencies identified under Tag C240.

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 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: