Print Inspection: KIT013989

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: ain the kitchen in good repair and in a sanitary manner and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. include, but are not limited to: Observation of the three cottage kitchens and facility food storage areas on 08/31/26, from 10:45 am through 1:30 pm, revealed the following: 1. Cottage C a. The kitchen had an accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease which was visible on, underneath, or between the following: * Interior of reach-in refrigerators and freezers, including seals; * Stainless steel shelving in dry storage; * Range top; * Grill top; * Drip pan under stove top; * Countertop next to stove had a large amount of oil/grease residue build-up from piping above area; * Walls beside the cooking equipment and hood; * Floors behind and underneath ovens/range; * Stainless steel shelving storing pots/pans; * Juice machine where nozzles rest; * White bulk food bins/buckets and lids; * Floors by dish machine area; * Knife holder; * Industrial can opener and housing; * Light fixtures; * Ceiling vents; and * Black utility cart. b. The following items were noted to need repair; * Two light fixtures were out, leaving only 1 one operational light for food preparation and service area; and * The shelving in the dry storage area was broken. c. Multiple food items were stored in reach-in coolers or freezers that were not properly closed/sealed or covered after they were opened/prepared to prevent potential contamination during storage. d. Multiple food items were observed stored in reach-in coolers without open and/or prepared dates. Some items were found past seven days from preparation date and needed to be discarded. e. A staff drink was noted to be stored next to the food preparation area and was not covered as required. f. Multiple dishes were stored uncovered next to food preparation area, and the food contact surfaces of these dishes were exposed to contamination from meal preparation tasks. g. Staff 2 (Cook/Dedicated Person in Charge) was observed to handle ready-to-eat foods with gloves that were contaminated from touching unclean surfaces, such as the cooler door handles and items taken from the refrigerator. h. Multiple plates of pureed food products were sitting on the countertop uncovered from 11:18 am through 11:32 am, allowing hot food items to cool. The items were covered at 11:32 am and then set into a heated cart to deliver to another cottage. During preparation, Staff 2 was noted to add water to the puree food items. This practice dilutes the flavor and nutrition of the food products. Staff 2 was not aware of the practice of adding other nutrient-rich ingredients instead of water to help preserve flavor/nutrition. The surveyor provided guidance for this practice. i. Staff 3 (Dietary Aide) was observed to wash multiple racks of dirty dishes. The staff member did not change or remove their apron after completion of the dirty task. He proceeded to wear the apron when he went out of the house and into the next cottage, where he and plated and served residents food while wearing the dirty/contaminated apron. 2. Cottage B a. The Cottage B kitchen had an accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease which was visible on, underneath, or between the following: * Industrial can opener and housing; * Interiors of reach-in freezer and cooler; * Walls with splatter; * Grill top; * Kitchen drains; * Floor and walls near/under dish machine; and * Juice machine area by nozzles and the nozzles. b. The pureed items made in Cottage C were delivered to the cottage and set on a countertop and were considered “ready-to-serve” to residents. The surveyor interviewed Staff 3 (Dietary Aid), who was serving the food, about what the process was for ensuring puree items were served hot. Staff 3 indicated they were not checking temperatures of puree items. Surveyor asked Staff 3 to check the temperatures and found the following: the chicken was 77 degrees F, the pasta was 105 degrees F, and the carrots were 98 degrees F. Staff 3 acknowledged this was these were not a palatable temperatures for hot foods. The food was then warmed to 135 degrees F prior to being served to the resident. 3. Cottage A a. Cottage A kitchen had an accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease which was visible on, underneath, or between the following: * Interiors of reach-in freezer/cooler and seals; * Large metal can rack; * Shelving in dry storage area; * Light fixture in dry storage area; * Interior of plastic shelves storing utensils/cooking equipment; * Drains; and * Flooring under sinks/dishwashing area. b. Multiple food items were observed to be stored without open and/or prepared dates. c. Different animal meats were noted to be stored in the same containers/bins, causing potential contamination. A bag of raw chicken was observed leaking chicken juices onto the cooler shelf. Protein products were not appropriately stored to limit and/or prevent contamination. d. Multiple items were found cooled and stored in the metal baking pans stacked on top of each other. Staff 3 was interviewed about cooling processes, and he was not able to accurately discuss proper cooling techniques nor was he able to review the two-step process and the proper time and temperature levels to safely cool foods. Staff 3 was also not aware of the correct reheating temperature. Staff 3 indicated that he would not be reheating any leftovers because the care staff would do that. The surveyor interviewed two care staff on duty who did not know the correct reheating temperature. d. The following items were found in need of repair; * The nozzle in the sink was leaking/draining; * The metal shelving in the dry storage area was broken; and * The reach-in freezer not keeping food (ice cream) frozen. At 1:00 pm on 08/31/26, the above areas were reviewed with Staff 1 (Administrator), who acknowledged the items needing corrective action.

C 240 1. The rule violations are being corrected as follows: Sanitation and repair: All kitchen areas and equipment found to be deficient in sections 1a, 1b, 2a, 3a 3d are in the process of being cleaned and repaired. Food storage: Immediate corrections were made to address deficiencies in sections 1c, 1d, 3b, 3c, and 3d including sealing, covering, dating, discarding and separating food appropriately to prevent cross contamination. Staff practices: Staff are being educated on their work flow practices related to cross contamination identified in sections 1e, 1f, 1g, and 1i, including appropriate use of gloves and aprons, and safe storage of dishes and personal drinks. Pureed foods: Staff are being educated on best practices for keeping pureed food palatable by using nutrient-rich liquids, temperature monitoring, and reheating as needed to address the deficiencies identified in sections 1h and 2b. Cooling and re-heating: to correct the deficiency identified in section 3d, culinary and care staff are being educated on proper cooling and reheating processes. 2. To prevent recurrence of the deficiencies identified in sections 1a, 2a, and 3a, a kitchen cleaning schedule sufficient to maintain sanitation will be implemented. Regular maintenance inspections of the kitchen environment and equipment will be conducted to prevent recurrence of the deficiencies identified in sections 1b and 3d. To prevent recurrence of the deficiencies identified in sections 1c-i, 2b, and 3b-c, an audit tool to monitor staff practices related to food storage, cross contamination, pureed food, and cooling and re-heating processes will be developed and implemented. 3. Evaluation of the corrections for sections 1a, 2a, 3a will occur per the established cleaning schedule. The schedule will be monitored weekly until all deficiencies are corrected and monthly thereafter. Regular maintenance inspections will occur weekly until repairs are completed and monthly thereafter to evaluate the corrections for sections 1b and 3d. To evaluate the corrections for sections 1c-i, 2b, and 3b-c, monitoring staff practices will occur per the audit tool schedule. The audit tool will be reviewed weekly until all staff have been trained, and monthly thereafter. 4. The Culinary Services Director will be responsible to see that corrections for 1a, 1c-I, 2a-b, and 3a-c are being completed and monitored. The Executive Director and Maintenance Director will be responsible for overseeing corrections and monitoring for sections 1b and 3d.

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.

Z 142 1. Refer to the corrective actions identified under C240. 2. Refer to the systems corrections identified under C240. 3. Refer to the evaluation schedule identified under C240. 4. Refer to the responsible parties identified under C240.