Print Inspection: KIT013995

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 facility kitchen on 09/01/26 from 10:30 am through 2:00 pm revealed the following deficient practices: 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 under multiple tables in the dining room; * Cabinets/countertop of the beverage station in the dining room; * Pipes, drain, walls, and flooring behind/underneath the dish machine; * Kitchen drains; * Flooring in corners, edges, and under and between equipment; * Industrial mixer; * Industrial can opener and housing; * Juice machine (area by nozzles and grate); * Interior of reach-in cooler in front of the service line; * Cream colored utility cart; * Interior of lower cabinets under the beverage station; * Metal can rack; * Exterior of white bulk food bins; * Lids of bulk food bins; * Tall movable metal rack; * Open shelving under the steam line; * Interior of the ice machine; * Light fixtures; * Sprinkler heads; * Flooring under heavy cooking equipment (grill/stove/steam table/steamer); * Seal around the door to the walk-in cooler; * Wall beside steamer; * Flooring throughout the kitchen; * Stove top; * Top of the steamer; * Clean side of the dish washing area; * Interior of the bread drawer; and * Wall behind the trash can. b. The following areas needed repair: * The dish machine did not advance to the Sanitize rinse cycle; * The non-slip/skid surface of floor on the interior of the walk-in cooler was ripped/torn and in need of replacement or repair; * The long white surface on the service line was heavily stained and scored and in need of repair or replacement; * There was a large accumulation of water on the floor by the dish machine area, creating a slick and slippery surface; * The wood cabinet under and around the steam line had multiple areas that were chipped/cracked and peeling, exposing wood surfaces; and * Some pipe downspouts reached inside the floor drains, which did not leave an air gap and during a drain back-up would cause a potential backflow issue. c. The dish machine did not effectively sanitize dishes and equipment. Water temperature maximums were reaching 160 degrees F. Staff 2 (Culinary Director) was unaware dishes were not being sanitized. The facility did not know how long the dish machine had been malfunctioning. Staff 2 indicated that the dishes would be sanitized using chemical sanitize dip; however, Staff 2 failed to inform the dishwasher about the needed process and several unsanitized dishes were put away as sanitized. The surveyor instructed the dishwasher on the need to chemically sanitize the dishes until the dish machine was repaired and properly sanitizing dishes. d. Multiple food items were observed without open or prepared dates. e. Multiple food items were found past seven days after opening/preparation and needed to be discarded. f. Bulk food bins were observed with the scoop stored inside the bins with the handles touching the food products, causing potential contamination. g. A cook was observed to not change his gloves after handling potentially contaminated items and before touching ready-to-eat food products. h. Dishwashing racks and large baking pans were observed stored on the floor. i. Multiple cutting boards were damaged/stained or heavily scored and in need of replacement. Multiple sauté pans and one serving scoop were damaged/scored and in need of replacement. j. There was silverware for the noon meal set on dining room tables at 10:30 am, and they were not covered or inverted as required. Pitchers of ice water were placed on the tables at 11:00 am and were not covered or protected from contamination k. The facility did not have an effective system in place for identification and communication of residents’ food allergies. When kitchen staff were interviewed, they indicated they only had one resident with an allergy to strawberries. This was not written or communicated visually anywhere in the kitchen. The staff interviewed indicated the resident would tell them they were allergic to strawberries. The surveyor asked the facility to run a report from their electronic health record system, and it was determined that four residents had documented food allergies. Kitchen staff were unaware of the allergies. The facility immediately posted the residents’ apartment numbers and food allergies on the diet communication board. Staff 1 (Administrator) and Staff 2 (Culinary Director) denied any known allergic reactions with residents or guests. Staff 2 toured the kitchen with the surveyor and acknowledged the findings. On 09/01/26 at 1:30 pm, Staff 1 (Executive director) was interviewed and acknowledged the above areas in need of correction.

Kitchen Correction plan 2026 Cleaning: Food Debris and Spills Dining Room: Tables: Surfaces, legs, chairs, floors underneath After each meal service, tables, legs, chairs and floors to be cleaned and sanitized per daily task sheet. Assigned to servers, dish washers, and NOC shift caregivers. Drink Station and Snack Fridge: Cleaned daily by dish washer in AM, Servers after PM meal. Snack fridge to be cleaned by kitchen crew daily before stocking. Assigned to servers and cooks. To be monitored by CD with check lists to be turned in daily. Dish Machine Area: Pipes, Floors, Floor drains, outside of dish machine To be cleaned nightly per updated closing task sheet. Kitchen floor drains to be cleaned weekly per dish washer task sheet. To be monitored by CD with check lists to be turned in daily. Floors: Floors to be swept and mopped to include edges, under equipment and tables, and in between equipment, nightly per daily closing task sheet. Deeper cleaning to be done weekly to include equipment edges moving equipment were necessary if possible. Cleaning of shelves under steam table as well as above the cook line to be cleaned weekly per updated weekly cleaning schedule unless needed sooner due to spillage. Assigned to cooks and dish washer. To be monitored by CD with daily visual checks and turned in daily closing task sheetsStanding Mixer and Table: To be cleaned after each use per general kitchen guidelines. Industrial Can Opener: To be cleaned after each use, including the attachment bracket, per general kitchen guidelines. Sprinkler heads and Light fixtures: Added to updated monthly cleaning schedule. Ice Machine: Updated cleaning procedure to include a more detailed process to include the documented back section. Speed rack: Added to weekly cleaning schedule. To be monitored daily by cooks and cleaned accordingly to prevent and build up in between weekly cleanings. Assigned to cooks cleaning tasks To be monitored by CD Bulk Food Bins: Cleaning of outsides of bins, including lids, has been added to the weekly cleaning schedule. Any necessary cleaning of spills in addition to the weekly cleaning has been addressed and added to the general kitchen practices. Assigned to cooks To be monitored by CD Metal Can Bulk Storage Rack: Added to monthly cleaning schedule Assigned to cooks To be monitored by CDServer Station (Kitchen interior): Juice Machine nozzles to be cleaned daily per updated daily task sheet Juice Machine Drip trays to be cleaned daily per updated daily task sheet Juice Machine exterior to be cleaned and sanitized daily per updated daily task sheet Juice Machine table to be cleaned and sanitized daily per updated daily task sheet Utility Carts to be cleaned and sanitized before and after each meal service per daily task sheet Cabinets in server area to be cleaned and sanitized daily per daily task sheet and deep cleaned weekly per weekly cleaning schedule Reach in fridge to be cleaned weekly per updated cleaning schedule unless otherwise needed based on general kitchen practices Assigned to servers To be monitored by CD visually and by daily task sheet audits Stove Top Burners and Steamer: To be cleaned weekly per weekly cleaning schedule unless otherwise needed based on general kitchen practices Outside of steamer to be cleaned weekly per weekly cleaning schedule unless otherwise needed based on general kitchen practices Assigned to cooks To be monitored by CD visually and by weekly cleaning schedules. Bread Drawer: To be cleaned daily per daily task sheet Assigned to cooks Kitchen Walls: To be cleaned monthly per monthly cleaning schedule unless otherwise needed due to spills and splashes based on general kitchen practices Dish Machine Repairs: Coastal Refrigeration replaced the broken gauge on 9/9/2026. They tested and calibrated the machine ensuring that the rinse cycle was implemented and the proper temperature was being reached. Also, they replaced a couple bolts to better hold the door seals to help mitigate the excessive water flow. Single-use test strips have been purchased and added to our monthly check list as a safety measure. Steam Table Cutting Board: New cutting board has been installed on 9/18/2026. The cooks have been instructed to use additional cutting boards for food preparation to help mitigate scratching and staining. Steam Table Shelf Repair: Maintenance work order has been placed. The plan is to sand and seal shelves then apply a metal facing to the front of the shelves to help mitigate chips and exposed wood. Estimated time of repair 10/2/2026 Label/Date Procedures as well as General Kitchen Practices: Refresher training and review of state survey, for all kitchen staff including servers, dish washers, and cooks. Mandatory meeting to be held September 28th. The meeting will include packets and quizzes covering proper food storage, time and temperature procedures, proper use of date labels, utensil and pan usage and storage. As well as reestablishing our general kitchen standards and practices. Culinary Communications for Residents: We have a temporary posting of resident dietary allergies and medical concerns. I have the nurse and RSD gathering any documentation regarding food allergies, dietary needs like diabetic concerns or mechanical assistance, as well as and food interactions with medications that we need to be aware of. This information will be kept in the CD office with a quick reference sheet added to the server communication board in the server area.