Print Inspection: KIT014153

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, the facility failed to ensure kitchen practices complied with OAR 333-150-0000. Findings include: On 09/15/26, between 9:15 am and 1:30 pm and on 09/17/26 between 8:00 am and 11:30 pm, the facility campus kitchens were observed, and the following were 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. Cleaning and Maintenance Issues 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. Assisted Living – Building B: • Freezer had heavy ice build-up and frost damaged food; and • No fine tip thermometer was available. Assisted Living – Building C: • Cracked, non cleanable countertop Assisted Living – Building D: • A sponge was being used for ware washing; and • No fine tip thermometer was available. 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 – Buildings B, C, D: • 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. Additional Finding in Building D: On 09/16/26 at approximately 9:30 am, the dish machine was observed set to a one hour wash cycle with no sanitation indicator light at cycle end. Staff reported they were unaware of machine requirements. 3. Modified Diets Skilled Nursing Facility (main kitchen): • Therapeutic diets (diabetic, no concentrated sweets, controlled carbohydrate, heart healthy, no added salt) were not prepared as ordered, and portion sizes were incorrect; and • Soft and bite size diet modification were not prepared correctly. Assisted Living Buildings B, C, D: • Therapeutic diets were not delivered as ordered, and portion sizes were inconsistent. The findings were reviewed with Staff 1 (Dietary Manager), Staff 2 (Administrator), Staff 3, Staff 5, Staff 6 (Regional Maintenance Director), Witness 1 (Consultant) and Witness 2 (Consultant) at approximately 11:30 am 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 are in use as of 9/28/26. All damaged and scored 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. Building B: ? Freezer: All exposed, unsealed, or potentially compromised food items within the freezer were immediately discarded to prevent cross-contamination. The freezer unit has undergone a complete deep cleaning, defrosting, and sanitation, completed on 9/24/26. ? Fine Tip Thermometer: High-accuracy, fine-tip food probes and temperature monitoring thermometers have been ordered, received, and strategically deployed in every building kitchen to ensure accurate internal food temperature monitoring, as of 9/25/26. C. Building C: ? Countertop: Repair and resurfacing materials have been formally ordered with an expected vendor delivery date of 09/29/2026. Maintenance is scheduled to complete all countertop restoration and surface sealing no later than 10/19/2026. D. Building D: ? Sponges: All non-compliant kitchen sponges were removed on 9/17/26, and disposed of immediately across all meal preparation stations to adhere strictly to food sanitation codes. ? Fine Tip Thermometer: Calibrated fine-tip probes have been obtained and distributed to each kitchen line on 9/21/26 to maintain consistent temperature compliance during cooking and holding. E. 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. F. Modified Diets ? Dietitian Oversight & Staff Education: The Registered Dietitian (RD) will conduct comprehensive reviews of all physician-ordered modified diets. The RD will educate and train the dietary team on precise food preparation, proper texture modifications adhering to IDDSI standards, and standardizing portion sizes across all meals. Hands-on training sessions with mandatory return demonstrations will be conducted directly with all dietary personnel to validate staff competency. ? Mandatory Pre-Service Review & Triple-Check Verification: Prior to meal plates leaving the kitchen or being loaded onto transport carts/trays, the dietary team and a designated member of management must conduct a thorough review of every modified diet serving. This process incorporates a mandatory triple-check verification system—involving the cook, dietary staff, and care staff—to verify that served items match specific physician diet orders and texture requirements. 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. G. Management Audit & Onsite RD Oversight: A member of management will perform daily audits during meal services to ensure the Dietitian has evaluated modified diet preparations while onsite. Active meal plate and tray observation logs will be maintained for each breakfast, lunch, and dinner service H. A member of management will perform daily audits during meal services to ensure the Dietitian has evaluated modified diet preparations while onsite. Active meal plate and tray observation logs will be maintained for each breakfast, lunch, and dinner service 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.