Print Inspection: KIT014151

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, interview, and record review, 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: On 09/15/26, between 09:15 am and 01:30 pm and on 09/17/26 between 08:00 am and 11:30 pm, the facility kitchens were observed, and the following was identified: The campus included one long term skilled nursing facility (SNF), three assisted living buildings (B, C, D), and one residential memory care community. The SNF kitchen prepared food for the entire campus. 1. Areas in need of cleaning and maintenance: Skilled Nursing Facility Kitchen (Building E): • Cutting boards were heavily scored, stained, and no longer cleanable; • Fry pans were scored or missing nonstick coating; • Spatulas were cracked, stained, and non-cleanable; and • Ceiling vents were dusty, and one was detached. Memory Care Building A: *The garbage can did not have a lid. 2. Sanitation Concerns Skilled Nursing Facility Kitchen: • Sanitizer bucket concentration was not being monitored. On 09/15/26 at approximately 12:30 pm, the dish machine wash temperature was 134°F, below the required 150°F. Review of facility temperature logs showed three weeks of failing to reach the required temperature. Staff were unaware of the required levels; education was provided. On 09/17/26 at approx. 9:00 am, the dish machine still failed to reach required temperature; issue reported to Staff 5 (Maintenance Director) and Staff 3 (ED). Assisted Living – Building A: • No pH test strips were available as a sanitizer; concentrations were not monitored; • Non approved chemicals (e.g., medical grade disinfecting wipes) were being used for surface sanitation; and • Dish machine temperatures were not monitored. On 09/15/26 at approximately 11:30 am, surveyor reviewed the documents for the dish machine wash temperature at 102 degrees F, below the required 150 degrees F and rinse temperature at 140 degrees F, below the required 180 degrees F. The most recent recording was on 09/02/26. Caregivers reported using the machine and did not know the requirements. Staff 1 (Dietary Manager) Staff 2 (Administrator) and Staff 5 were notified. Staff planned to use the adjacent building for ware washing until the repair was made. On 09/17/26 at approximately 08:30 am, surveyor observed staff using the dish machine and verified that the wash temperature was meeting requirements, at 155 degrees F and the rinse temperature was meeting requirements, at 183 degrees F. The areas of concern were observed and/or discussed with Staff 1, Staff 2, Staff 3 (Executive Director) Staff 5, Staff 6 (Regional Maintenance Director), Witness 1 (Vanda Consultant) and Witness 2 (Vanda Consultant) at approximately 11:30 pm on 09/17/26. Staff acknowledged the findings.

Immediate actions taken to correct the rule violation is as follows: A. Cleaning and Maintenance Concerns ? Cutting Boards: New cutting boards have been ordered, received and in use as of 9/28/26. All damaged, scoured cutting boards have been discarded. ? Fry Pans: New fry pans have been ordered, received and in use as of 9/24/26. All damaged fry pans have been discarded. ? Spatulas: New spatulas have been ordered, received and in use as of 9/24/26. All damaged spatulas have been discarded. ? Ceiling Vents: All ceiling vents throughout the facility kitchen and food preparation areas have been thoroughly cleaned, and repaired to sanitation standard compliance as of 9/25/26. B. Sanitation Concerns: ? Sanitizer bucket: Sanitizing test strips have been ordered, delivered, and are currently actively in use across all facilities as of 9/24/26. ? Sanitizing machine: All commercial dish sanitizing machines have been inspected and adjusted to ensure they consistently reach the required minimum wash temperature level of 150°F as of 9/24/26. ? Non-approved chemicals: Ecolab setup of automated chemical distribution machines has been initiated to standardize surface sanitation. This will be fully operational no later than 11/1/26. Individual bottles that are clearly labeled will be in use starting 9/24/26. ? Unapproved medical-grade wipes have been removed from food contact surfaces as of 9/21/26. ? The garbage can with no lid has been removed as of 9/25/26. A new garbage can with lid will be purchased no later than 9/26/26. 2. How this system will be corrected so this violation will not happen again: A. All dietary staff members will undergo re-education and formal training no later than 11/1/26, regarding kitchen cleaning schedules, equipment sanitation, proper storage techniques, and routine kitchen supply inspections. B. The Dietary team will conduct comprehensive weekly audits of kitchen supplies, posted cleaning completion logs, sanitation compliance, and physical kitchen conditions across all facility buildings. C. Sanitizing bucket chemical concentrations will be checked up to 3 times per shift (at the start of each meal's dish run for breakfast, lunch, and dinner). All concentration readings will be formally logged in the kitchen binder, and immediate corrective actions will be executed and documented if concentrations fall outside approved parameters. D. Staff were educated on 9/24/26 on the minimum temperature standards and temperature strip verification. E. All dietary and any staff member will have the proper education and training to ensure that all sanitation buckets and machines are being utilized appropriately. Training to be completed on 9/24/26. F. All Safety Data Sheets (SDS) are updated and readily accessible in designated kitchen binders for staff review at any time. Staff have been educated on 9/24/26. 3. The area(s) needing corrections will be reviewed: A. The Dietary Manager will review all weekly audit findings, and the Facility Administrator will maintain administrative oversight with monthly reviews and evaluations to ensure ongoing compliance and prevent deficiency recurrence. 4. The Dietary Manager and Administrator will be responsible to ensure the corrections are completed and monitored.

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.

Please reference information listed for C240.