Print Inspection: KIT014188

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 that the facility failed to maintain the kitchen areas in good repair and in a sanitary manner, as required by Food Sanitation Rules, OAR 333 150 000. Deficiencies were identified across the main food storage area and four cottage kitchens. Findings include, but are not limited to, the following: During observations on 09/09/26 from 10:30 a.m. to 1:15 p.m., the following issues were identified: 1. Main Food Storage (Cooks’ Shack): a. Sanitation Concerns Visible accumulations of food spills, splatters, loose food and trash debris, dirt, dust, grease, and/or black matter were observed on or beneath: * Painted wood shelving in dry storage; and * Metal racks in the walk in cooler. b. Physical Facility in Disrepair: Areas requiring repair included: * Concrete flooring in dry storage with large cracks; * Metal racks in walk in cooler with rust accumulation; and * Painted wood shelving in dry storage had chipped, peeling, or worn paint. c. Improper Food Storage: Multiple food items were stored directly on the floor in the dry storage area. 2. House 156: a. Sanitation Concerns: Accumulations of spills, splatters, loose food and trash debris, dirt, dust, and/or black matter were observed on or beneath: * Backsplash behind countertop; * Interior of cabinets and drawers; and * Tabletop mixer. b. Improper Food Labeling: Potentially hazardous foods in the reach in refrigerator were found without required open dates. c. Unprotected Food Contact Surfaces: Single use plates and utensils in dry storage were uncovered and unprotected from contamination. d. Improper Hygienic Practices: A cook was observed preparing food without effectively restraining facial hair. 3. House 172: a. Improper Food Labeling: Multiple potentially hazardous foods in the reach in refrigerator lacked open dates. b. Resident Food Handling Issues: Resident specific foods and beverages were observed open without dates; a can of soda was uncovered and lacked resident identification. c. Unprotected Food Contact Surfaces: Single use plates and utensils were stored uncovered in dry storage. d. Improper Food Storage: Food items were stored directly on the floor in dry storage. e. Improper Sanitizing Practices: A cook did not effectively sanitize a probe thermometer between temperature checks. f. Glove Contamination: A cook handled contaminated surfaces while wearing gloves and then touched ready to eat foods without changing gloves. g. Improper Hygiene Practices: A cook was observed serving and plating food without effectively restraining facial hair. 4. House 184: a. Sanitation Concerns: Accumulations of spills, splatters, loose food and trash debris, dirt, dust, and/or black matter were observed on or beneath: * The reach in refrigerator; and * The ice and water dispensers. b. Dishwashing Practice: Care staff reported using the quick cycle on the dishwasher and were unaware of the correct sanitation cycle. Staff 2 (Lead Cook/Person in Charge) confirmed that the quick cycle did not meet sanitation requirements. c. Improper Food Labeling: Multiple potentially hazardous foods in the reach in refrigerator lacked open dates. d. Improper Food Storage: Food items were stored directly on the floor in dry storage. 5. House 190: a. Sanitation Concerns: Accumulations of spills, splatters, loose food and trash debris, dirt, dust, and/or black matter were observed in the water and ice dispenser. b. Improper Food Labeling: Multiple cold food items in the reach in refrigerator lacked open dates. c. Temperature Control: The reach in refrigerator and food items inside measured 46°F. Staff 2 acknowledged the refrigerator was not maintaining the required 41°F or below. Staff confirmed that any food found above 41°F would be discarded. Maintenance was notified to adjust or replace the refrigerator. d. Improper Food Storage: Food items were stored directly on the floor in dry storage. 6. House 196: a. Sanitation Concerns: Accumulations of spills, splatters, loose food and trash debris, dirt, dust, and/or black matter were noted on or within: * Removable hood vents; and * Interior of cabinets and drawers. b. Physical Facility and Equipment in Disrepair: * The countertop exhibited chips and cracks; and * Multiple pots and pans were damaged and required replacement. c. Improper Food Labeling: Potentially hazardous foods in the reach in refrigerator lacked open dates. d. Temperature Control: The reach in refrigerator was found at 50°F; food items inside were also above 41°F. Temperature logs for 09/09/26 were reviewed and were found incomplete. Staff 2 acknowledged all foods above 41°F must be discarded. Surveyor observed disposal of unsafe foods. Maintenance later determined the cooling setting was too high and adjusted it. At 1:00 p.m., the surveyor reviewed all findings with Staff 1 (Administrator) and Staff 2. Both acknowledged the findings.

C0240 Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen areas in good repair and in a sanitary manner, as required by Food Sanitation Rules,OAR 333 150 000.Findings include,but are not limited to, the following:During observations on 09/09/26 from 10:30 am to 1:15 pm,deficiencies were identified across the main food storage area and four cottage kitchens:1.Main Food Storage(Cooks’ Shack):1(a)Sanitation Concerns Finding: Visible accumulations of food spills,splatters,loose food and trash debris,dirt,dust, grease,and/or black matter were observed on or beneath the painted wood shelving in the dry storage area and metal racks in the walk-in cooler.1.The Kitchen Coordinator deep-cleaned the painted wood shelving in the dry storage area.The Kitchen Coordinator removed the metal racks in the walk-in cooler and replaced them with new metal racks.The Kitchen Coordinator inspected the dry storage shelving and walk-in cooler after corrective action to ensure the identified debris and sanitation concerns were resolved.2.The Kitchen Coordinator added the dry storage shelving and walk-in cooler racks to the kitchen sanitation audit.The audit requires inspection and cleaning of the shelving and racks and identification of any condition that prevents the surfaces from being kept clean and sanitary.The Kitchen Coordinator will report any maintenance concerns identified during the inspection for correction.3.The Kitchen Coordinator will inspect the painted wood shelving in the dry storage area and the metal racks in the walk-in cooler monthly as part of the kitchen sanitation audit.Any sanitation or maintenance concern identified during an inspection will be corrected or reported for correction when identified.4. The Kitchen Coordinator is responsible for completing and maintaining the monthly kitchen sanitation audits and ensuring identified concerns are corrected or reported for correction.The Administrator or designee will provide oversight to ensure the audits are completed as scheduled and identified corrective actions are addressed.1(b)Physical Facility in Disrepair Areas requiring repair included:*The concrete flooring in the dry storage area had large cracks; *Metal racks in the walk-in cooler had an accumulation of rust; and *The painted wood shelving in the dry storage area had chipped, peeling,or worn paint.1.The rusted metal racks in the walk-in cooler were removed and replaced with new metal racks.The cracked concrete flooring in the dry storage area will be repaired and coated with an epoxy flooring system to provide a smooth, durable, and cleanable surface.The painted wood shelving with chipped,peeling,or worn paint will be repaired and repainted to restore the surface to a condition that can be cleaned and maintained effectively.2. The Kitchen Coordinator added inspection of dry storage flooring,shelving, and walk-in cooler racks to the kitchen audit process.The inspection will identify cracks, rust, peeling or deteriorated finishes, and other conditions that could prevent surfaces from being properly cleaned or maintained. Identified repair needs will be reported to Maintenance for corrective action.3.The Kitchen Coordinator will inspect the dry storage flooring, shelving, and walk-in cooler racks monthly as part of the kitchen audit.The Kitchen Coordinator will report any damaged or deteriorated surface identified during the inspection to Maintenance and track it through completion.4.The Kitchen Coordinator is responsible for completing the monthly inspection and reporting identified maintenance concerns.The Maintenance Director is responsible for completing necessary repairs.The Administrator or designee will provide oversight to ensure identified deficiencies are corrected.1(c)Improper Food Storage Multiple food items were stored directly on the floor in the dry storage area.1.The Kitchen Coordinator immediately removed all food items stored directly on the floor in the dry storage area and relocated the items to appropriate food storage areas.2.The Kitchen Coordinator ordered additional shelving for the dry storage area to provide adequate storage capacity and prevent food from being stored directly on the floor.Kitchen staff will be instructed that food and food containers are to be stored on designated shelving and not directly on the floor. The Kitchen Coordinator will reinforce proper food storage requirements with staff responsible for receiving, stocking, and organizing food deliveries.3.The Kitchen Coordinator will inspect the dry storage area weekly,including during stocking and organization of food supplies, to verify that food items are stored on designated shelving and not directly on the floor.The Kitchen Coordinator will immediately relocate any improperly stored food identified during an inspection, and the staff involved will receive corrective instruction.4.The Kitchen Coordinator is responsible for ensuring proper food storage, completing the weekly dry storage inspection, and providing corrective instruction as needed.The Administrator or designee will provide oversight to ensure the corrective system is maintained.2.House 56 2(a) Sanitation Concerns Visible accumulations of spills, splatters, loose food and trash debris,dirt, dust, and/or black matter were observed on or beneath:-The backsplash behind the countertop;-The interiors of cabinets and drawers; and-The tabletop mixer.1.The backsplash behind the countertop,interiors of the cabinets and drawers, and tabletop mixer were immediately deep-cleaned.A NOC shift deep-cleaning schedule was implemented to ensure the identified areas and other scheduled kitchen areas are routinely cleaned and maintained in a sanitary condition.2.The NOC shift deep-cleaning schedule assigns specific cleaning tasks each night.The staff member completing each assigned task must document completion on the deep-cleaning checklist. The NOC Shift Supervisor will verify completion of the assigned cleaning and sign the checklist.Completed checklists will be submitted weekly to Administration for review and oversight.3.Staff will complete and document assigned deep-cleaning tasks nightly.The NOC Shift Supervisor will verify completion each night, Administration will review the completed checklists weekly, and the Kitchen Coordinator will conduct a monthly kitchen sanitation audit to verify that cleaning standards are being maintained.4.NOC shift staff must complete and document assigned cleaning tasks. The NOC Shift Supervisor is responsible for verifying completion of the nightly tasks. The Kitchen Coordinator is responsible for the monthly kitchen sanitation audit, with the Administrator or designee overseeing the corrective system.2(b) Improper Food Labeling Potentially hazardous foods in the reach-in refrigerator were found without the required open dates.1.Staff immediately removed and discarded all potentially hazardous foods in the reach-in refrigerator that lacked the required open date. Staff placed reminder signage regarding open-date requirements on each refrigerator for visibility.2.Administration reinforced proper food labeling and storage requirements through a“Question of the Day”regarding open dating and storage of opened food items. During the September 2026 all-staff meeting, staff were re-educated on the facility’s open-date requirements and completed a questionnaire to reinforce understanding.The NOC deep-cleaning process also includes review of refrigerated food items for required open dates, with any improperly labeled items removed when identified.3.Staff responsible for food handling and storage are expected to properly label food when it is opened. The NOC shift will inspect refrigerated food for required open dates weekly as part of the deep-cleaning schedule.The NOC Shift Supervisor will verify completion of the assigned task, and the Kitchen Coordinator will independently review food labeling during the monthly kitchen audit. Any food identified without a required open date will be removed and discarded.4.Staff handling food are responsible for properly labeling opened food items.The NOC Shift Supervisor is responsible for verifying completion of the weekly labeling inspection. The Kitchen Coordinator is responsible for monitoring compliance during the monthly kitchen audit, with the Administrator or designee providing oversight.2(c) Unprotected food contact surfaces:Single-use plates and utensils in the dry storage area were uncovered and unprotected from potential contamination.1.All single-use plates and utensils identified as uncovered in the dry storage area were immediately placed in protective bags to protect them from potential contamination.2.The Kitchen Coordinator will educate cooks responsible for distributing single-use plates and utensils to the cottage kitchens that these items must remain in their original protective packaging or other protective covering during distribution and storage until use. Staff also reviewed this requirement during the September 2026 all-staff meeting. 3.The Kitchen Coordinator will inspect the dry storage area weekly to verify that single-use plates and utensils are stored in original protective packaging or other protective covering during distribution and storage until use. The Kitchen Coordinator will correct any improperly stored items identified during an inspection immediately.4.The Kitchen Coordinator is responsible for staff education and the weekly inspection of single-use plates and utensils. The Administrator or designee will provide oversight to ensure the corrective process is maintained.2(d) Improper Hygienic Practices A cook was observed preparing food without effectively restrained facial hair. 1.The Kitchen Coordinator immediately ensured that beard nets were available in each cottage kitchen and reviewed facial-hair restraint requirements with the cook team.Staff responsible for food preparation were instructed to use an effective facial-hair restraint when applicable during food preparation and service.2.The Kitchen Coordinator will maintain an adequate supply of beard nets in each cottage kitchen and will ensure cooks are trained on when facial-hair restraints are required. The Kitchen Coordinator will incorporate facial-hair restraint requirements into ongoing food safety expectations for staff involved in food preparation and service. 3.The Kitchen Coordinator will verify the availability of beard nets weekly and will observe compliance with facial-hair restraint requirements during routine kitchen and meal-service observations. The Kitchen Coordinator will also review compliance during the monthly kitchen audit.Any noncompliance observed will be corrected at the time of observation and followed by re-education of the staff member involved.4.The Kitchen Coordinator is responsible for maintaining beard-net supplies, educating cooks on facial-hair restraint requirements, and monitoring compliance.The Administrator or designee will provide oversight through review of the kitchen audit process.3.House172 3(a)Improper Food Labeling Multiple potentially hazardous foods in the reach-in refrigerator lacked open dates. 1.Staff immediately removed and discarded all potentially hazardous food items in the reach-in refrigerator that lacked the required open date. Staff placed reminder signage regarding open-date requirements on the refrigerator for visibility.2.Administration reinforced proper food labeling and storage requirements through a “Question of the Day” regarding the importance of open dating and proper storage of opened food items.During the September 2026 all-staff meetings, staff were re-educated on the open-date policy and completed a questionnaire to reinforce understanding. The NOC deep-cleaning process also includes review of refrigerated food items for required open dates.3.The NOC shift will inspect refrigerated food for required open dates weekly as part of the deep-cleaning schedule. The NOC Shift Supervisor will verify completion of the inspection, and the Kitchen Coordinator will independently review food labeling during the monthly kitchen audit. Any food identified without a required open date will be removed and discarded. 4.Staff handling food are responsible for properly labeling opened food items. The NOC Shift Supervisor is responsible for verifying completion of the weekly refrigerator inspection and correction of any improperly labeled items.The Kitchen Coordinator monitors compliance during the monthly kitchen audit, with the Administrator or designee providing oversight.3(b)Resident Food Handling Issues:Resident-specific foods and beverages were observed open without dates;a can of soda was uncovered and lacked resident identification. 1.Staff immediately removed and discarded the uncovered can of soda that lacked resident identification.Staff also removed and discarded resident-specific food and beverage items identified as open without the required dates.2.Administration reinforced proper handling and labeling of resident-specific food and beverages through a “Question of the Day,”including requirements for open dating, resident identification, and proper storage of opened items. During the September 2026 all-staff meetings, staff were re-educated on these requirements and completed a questionnaire to reinforce understanding.The NOC deep-cleaning process also includes review of resident-specific food and beverages for proper labeling and storage.3.The NOC shift will inspect resident-specific food and beverage items weekly as part of the deep-cleaning schedule to verify that opened items have the required open date and resident identification and are appropriately covered and stored.The NOC Shift Supervisor will verify completion of the inspection, and the Kitchen Coordinator will independently review resident-specific food storage and labeling during the monthly kitchen audit. Any improperly labeled or stored items identified during an inspection will be corrected or discarded as appropriate. 4.Staff handling resident-specific food and beverages are responsible for proper labeling and storage. The NOC Shift Supervisor is responsible for verifying completion of the weekly inspection and correction of identified concerns.The Kitchen Coordinator monitors compliance during the monthly kitchen audit, with the Administrator or designee providing oversight.3(c)Unprotected Food Contact Surfaces Single-use plates and utensils were stored uncovered in the dry storage area.1.All single-use plates and utensils identified as uncovered in the dry storage area were immediately placed in protective bags to protect them from potential contamination.2.The Kitchen Coordinator will educate cooks responsible for distributing single-use plates and utensils to the cottage kitchens that these items must remain in their original protective packaging or other protective covering during distribution and storage until use.Staff also reviewed this requirement during the September 2026 all-staff meeting. 3.The Kitchen Coordinator will inspect the dry storage area weekly to verify that single-use plates and utensils are stored in original protective packaging or other protective covering during distribution and storage until use. The Kitchen Coordinator will correct any improperly stored items identified during an inspection immediately.4.The Kitchen Coordinator is responsible for staff education and the weekly inspection of single-use plates and utensils. The Administrator or designee will provide oversight to ensure the corrective process is maintained.3(d) Improper Food Storage Food items were stored directly on the floor in the dry storage area.1.All food items identified as stored directly on the floor were immediately removed and relocated to appropriate shelving in the dry storage area.2.Signage was placed on the lower shelving in the dry storage area reminding staff that food items may not be stored directly on the floor.Staff responsible for receiving, stocking,and organizing food supplies will be instructed to place all food items in designated storage areas and not directly on the floor.Proper food storage is also included in the NOC shift deep-cleaning process.Staff also reviewd this requirement during the September 2026 all-staff meeting.3.The NOC shift will inspect the dry storage area weekly as part of the deep-cleaning schedule to verify that food is appropriately stored and that no food items are stored directly on the floor.The NOC Shift Supervisor will verify completion of the assigned task, and the Kitchen Coordinator will independently review food storage during the monthly kitchen audit. Staff will relocate any improperly stored food immediately.4.Staff receiving and stocking food are responsible for proper food storage.The NOC Shift Supervisor is responsible for verifying completion of the weekly dry storage inspection. The Kitchen Coordinator monitors compliance during the monthly kitchen audit, with the Administrator or designee providing oversight.3(e) Improper Sanitizing Practices A cook did not effectively sanitize a probe thermometer between temperature checks.1.The cook involved received additional food sanitation training through Oregon Care Partners and completed a quiz to verify understanding.Following the training, the Kitchen Coordinator conducted a direct observation audit of the cook's food preparation and sanitation practices to verify application of the training.2.The Kitchen Coordinator reviewed proper probe thermometer sanitation practices with the cook team and reinforced that probe thermometers must be properly cleaned and sanitized between temperature checks to prevent cross-contamination. Proper thermometer sanitation will remain part of the facility's food-safety expectations for all cooks responsible for food preparation and temperature monitoring.3.The Kitchen Coordinator will observe probe thermometer sanitation practices weekly during food preparation to verify that thermometers are being properly cleaned and sanitized between uses. Compliance will also be reviewed during the monthly kitchen audit.Any improper practice identified will be corrected at the time of observation and followed by additional education and observation as necessary.4.Cooks are responsible for properly cleaning and sanitizing probe thermometers between uses.The Kitchen Coordinator is responsible for staff education, weekly observation of thermometer sanitation practices, and follow-up when noncompliance is identified.The Administrator or designee will provide oversight through the kitchen audit process.3(f) Glove Contamination A cook handled contaminated surfaces while wearing gloves and then touched ready-to-eat foods without changing gloves.1.The Kitchen Coordinator immediately reviewed proper glove use and glove-changing requirements with the cook team.Cooks were provided OHA Food Code Fact Sheet #10 regarding proper glove use and were required to read and initial the material to document completion of the education. 2.The Kitchen Coordinator reinforced that single-use gloves are used for one task and must be changed when they become contaminated, when changing tasks, and before handling ready-to-eat food following contact with contaminated surfaces.Proper hand hygiene and glove-changing requirements will remain part of ongoing food-safety education for cooks and other staff involved in food preparation.3.The Kitchen Coordinator will observe glove use and food-handling practices weekly during food preparation and meal service to verify appropriate glove changes and prevention of cross-contamination.

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.

C240 cont.The Kitchen Coordinator will also review compliance during the monthly kitchen audit. The Kitchen Coordinator will correct any improper glove use observed immediately, and the staff member involved will receive re-education.4.Staff involved in food preparation are responsible for proper hand hygiene and glove use. The Kitchen Coordinator is responsible for staff education and weekly observation of glove practices.The Administrator or designee will provide oversight through the kitchen audit process.3(g) Improper Hygiene Practices:A cook was observed plating and serving food without effectively restrained facial hair. 1.The Kitchen Coordinator immediately ensured that beard nets were available in each cottage kitchen and reviewed facial-hair restraint requirements with the cook team.Staff responsible for food preparation and service were instructed to use an effective facial-hair restraint when applicable.2.The Kitchen Coordinator will maintain an adequate supply of beard nets in each cottage kitchen and will ensure cooks are trained on when facial-hair restraints are required. Facial-hair restraint requirements will be incorporated into ongoing food-safety expectations for staff involved in food preparation and service.3.The Kitchen Coordinator will verify the availability of beard nets weekly and will observe compliance with facial-hair restraint requirements during routine food preparation and meal-service observations.The Kitchen Coordinator will also review compliance during the monthly kitchen audit. Any noncompliance observed will be corrected at the time of observation and followed by re-education of the staff member involved.4.The Kitchen Coordinator is responsible for maintaining beard-net supplies, educating cooks on facial-hair restraint requirements, and monitoring compliance. The Administrator or designee will provide oversight through the kitchen audit process.4.House184 4(a)Sanitation Concerns Visible accumulations of spills, splatters, loose food and trash debris, dirt, dust, and/or black matter were observed on or beneath:*The reach-in Refrigerator; and *the ice and water dispensers.1.The Kitchen Coordinator immediately deep-cleaned the reach-in refrigerator and ice and water dispensers to remove the identified accumulation and restore the areas to a clean, sanitary condition.2.The reach-in refrigerator and ice and water dispensers have been incorporated into the NOC shift deep-cleaning schedule. The staff member completing each assigned cleaning task must document completion on the deep-cleaning checklist.The NOC Shift Supervisor will verify completion of the assigned cleaning and sign the checklist. Completed checklists will be submitted weekly to Administration for review and oversight.3.Staff will complete and document assigned deep-cleaning tasks weekly.The NOC Shift Supervisor will verify completion, Administration will review the completed deep-cleaning checklists weekly, and the Kitchen Coordinator will independently inspect these areas during the monthly kitchen sanitation audit. Any sanitation concern identified will be corrected when identified.4.NOC shift staff are responsible for completing and documenting the assigned cleaning tasks. The NOC Shift Supervisor is responsible for verifying completion. The Kitchen Coordinator is responsible for the monthly kitchen sanitation audit, with the Administrator or designee overseeing the corrective system.4(b) Dishwashing Practice Care staff reported using the dishwasher quick cycle and were unaware of the correct sanitation cycle. Staff 2 (Lead Cook/Person in Charge) confirmed that the quick cycle did not meet sanitation requirements. 1.The staff member involved was immediately educated on the correct dishwasher sanitation cycle. The Kitchen Coordinator also created laminated signage identifying the correct sanitation cycle and explaining that the quick cycle does not meet sanitation requirements. The Kitchen Coordinator placed the signage on the dishwashers for staff reference.2.The Kitchen Coordinator reinforced dishwasher sanitation requirements with staff through a "Question of the Day" and during the September 2026 all-staff meeting.Staff were educated on the required dishwasher cycle and the importance of using the correct cycle to ensure dishes and utensils are properly sanitized.Laminated instructions identifying the correct cycle will remain posted on each dishwasher as a point-of-use reminder.3.The Kitchen Coordinator will observe dishwasher operation weekly to verify that staff are using the correct sanitation cycle and that the instructional signage remains present and legible. The Kitchen Coordinator will also review dishwasher operation and signage during the monthly kitchen audit.The Kitchen Coordinator will correct any incorrect dishwasher use observed immediately and follow up with re-education of the staff member involved.4.Staff operating the dishwasher are responsible for selecting the correct sanitation cycle. The Kitchen Coordinator is responsible for staff education, maintaining the instructional signage, and monitoring dishwasher operation. The Administrator or designee will provide oversight through the kitchen audit process.4(c) Improper Food Labeling Multiple potentially hazardous foods in the reach-in refrigerator lacked open dates.1.Staff immediately removed and discarded all potentially hazardous food items in the reach-in refrigerator that lacked the required open date. Reminder signage regarding open-date requirements was placed on the refrigerator for staff visibility. 2Administration reinforced proper food labeling and storage requirements through a "Question of the Day" regarding the importance of open dating and proper storage of opened food items. During the September 2026 all-staff meetings, staff were re-educated on the open-date policy and completed a questionnaire to reinforce understanding.The NOC deep-cleaning process also includes review of refrigerated food items for required open dates. 3.The NOC shift will inspect refrigerated food for required open dates weekly as part of the deep-cleaning schedule. The NOC Shift Supervisor will verify completion of the inspection, and the Kitchen Coordinator will independently review food labeling during the monthly kitchen audit. Any food identified without a required open date will be removed and discarded. 4.Staff handling food are responsible for properly labeling opened food items. The NOC Shift Supervisor is responsible for verifying completion of the weekly refrigerator inspection and correction of any improperly labeled items. The Kitchen Coordinator is responsible for monitoring compliance during the monthly kitchen audit, with the Administrator or designee providing oversight.4(d) Improper Food Storage Food items were stored directly on the floor in the dry storage area.1.All food items identified as stored directly on the floor were immediately removed and relocated to appropriate shelving in the dry storage area.2.Signage will be placed on the lower shelving in the dry storage area reminding staff that food items may not be stored directly on the floor. Staff responsible for receiving,stocking,and organizing food supplies will be instructed to place all food items in designated storage areas and not directly on the floor. Proper food storage is also included in the NOC shift deep-cleaning process.During the September 2026 all-staff meeting, staff were re-educated on the requirement. 3.The NOC shift will inspect the dry storage area weekly as part of the deep-cleaning schedule to verify that food is appropriately stored and that no food items are stored directly on the floor.The NOC Shift Supervisor will verify completion of the assigned task, and the Kitchen Coordinator will independently review food storage during the monthly kitchen audit. Staff will relocate any improperly stored food immediately. 4.Staff receiving and stocking food are responsible for proper food storage.The NOC Shift Supervisor is responsible for verifying completion of the weekly dry storage inspection. The Kitchen Coordinator is responsible for monitoring compliance during the monthly kitchen audit, with the Administrator or designee providing oversight.5.House 190 5(a) Sanitation Concerns Visible accumulations of spills, splatters, loose food and trash debris, dirt, dust, and/or black matter were observed in the ice and water dispenser.1.The Kitchen Coordinator immediately deep-cleaned the ice and water dispenser to remove the identified accumulation and restore the dispenser to a clean, sanitary condition.2.The ice and water dispenser has been incorporated into the NOC shift deep-cleaning schedule. The staff member completing the assigned cleaning task must document completion on the deep-cleaning checklist. The NOC Shift Supervisor will verify completion of the assigned cleaning and sign the checklist. Completed checklists will be submitted weekly to Administration for review and oversight.3.The assigned deep-cleaning task will be completed and documented weekly. The NOC Shift Supervisor will verify completion, Administration will review the completed deep-cleaning checklists weekly, and the Kitchen Coordinator will independently inspect the dispenser during the monthly kitchen sanitation audit. Any sanitation concern identified will be corrected when identified.4.NOC shift staff are responsible for completing and documenting the assigned cleaning task. The NOC Shift Supervisor is responsible for verifying completion. The Kitchen Coordinator is responsible for the monthly kitchen sanitation audit, with the Administrator or designee overseeing the corrective system.5(b)Improper Food Labeling Multiple cold food items in the reach-in refrigerator lacked open dates.1.Staff immediately removed and discarded all food items in the reach-in refrigerator that lacked the required open date. Staff placed reminder signage on the refrigerator for visibility.2.Administration reinforced proper food labeling and storage requirements through a "Question of the Day" regarding the importance of open dating and proper storage of opened food items. During the September 2026 all-staff meetings, staff were re-educated on the open-date policy and completed a questionnaire to reinforce understanding.The NOC deep-cleaning process also includes review of refrigerated food items for required open dates.3.The NOC shift will inspect refrigerated food for required open dates weekly as part of the deep-cleaning schedule.The NOC Shift Supervisor will verify completion of the inspection, and the Kitchen Coordinator will independently review food labeling during the monthly kitchen audit. Any food identified without a required open date will be removed and discarded.4.Staff handling food are responsible for properly labeling opened food items. The NOC Shift Supervisor is responsible for verifying completion of the weekly refrigerator inspection and correction of any improperly labeled items.The Kitchen Coordinator monitors compliance during the monthly kitchen audit, with the Administrator or designee providing oversight.5(c)Temperature Control The reach-in refrigerator and food items inside measured 46Degrees. Staff 2 acknowledged the refrigerator was not maintaining the required 41°F or below. Staff confirmed that any food found above 41 degrees would be discarded.1.All food items identified as being above 41°F were immediately removed and discarded.Maintenance inspected the reach-in refrigerator and determined that the temperature control panel had been incorrectly adjusted. Maintenance corrected the temperature setting and placed the control panel into lock mode to prevent inadvertent adjustment.The team then monitored the refrigerator temperature to ensure it returned to and maintained the required temperature of 41°F or below.2.Cooks and designated staff are required to check and document the reach-in refrigerator temperature daily on the refrigerator temperature log.Staff were reminded that refrigeration equipment used for cold food storage must maintain food at 41°F or below and that temperatures outside the acceptable range must be reported immediately so staff can take corrective action.During the September 2026 all-staff meeting, Staff received additional education regarding refrigerator temperature monitoring and the required response to out-of-range temperatures, and staff completed a questionnaire to reinforce understanding.3.Reach-in refrigerator temperatures will be checked and documented daily. Any temperature above 41°F will require immediate evaluation of the refrigerator and affected food, with Maintenance notified when the refrigerator is not maintaining the required temperature.The NOC Shift Supervisor will review the refrigerator temperature logs weekly to verify that daily temperature checks have been completed and documented and that any out-of-range temperatures received appropriate follow-up.The Kitchen Coordinator will independently review the temperature logs during the monthly kitchen audit.4.Cooks and designated staff are responsible for completing and documenting daily refrigerator temperature checks and immediately reporting temperatures outside the acceptable range.The NOC Shift Supervisor is responsible for weekly verification that the temperature logs are complete. Maintenance is responsible for evaluating and correcting equipment-related concerns. The Kitchen Coordinator is responsible for monthly oversight of temperature-control compliance, with the Administrator or designee providing overall oversight.5(d) Improper Food Storage Food items were stored directly on the floor in the dry storage area. 1.All food items identified as stored directly on the floor were immediately removed and relocated to appropriate shelving in the dry storage area.2.Signage will be placed on the lower shelving in the dry storage area reminding staff that food items may not be stored directly on the floor. Staff responsible for receiving, stocking, and organizing food supplies will be instructed to place all food items in designated storage areas and not directly on the floor. Proper food storage is also included in the NOC shift deep-cleaning process.3.The NOC shift will inspect the dry storage area weekly as part of the deep-cleaning schedule to verify that food is appropriately stored and that no food items are stored directly on the floor. The NOC Shift Supervisor will verify completion of the assigned task, and the Kitchen Coordinator will independently review food storage during the monthly kitchen audit. Staff will relocate any improperly stored food immediately. 4. Staff receiving and stocking food are responsible for proper food storage. The NOC Shift Supervisor is responsible for verifying completion of the weekly dry storage inspection.The Kitchen Coordinator is responsible for monitoring compliance during the monthly kitchen audit, with the Administrator or designee providing oversight.6.House 196 6(a) Sanitation Concerns Visible accumulations of spills,splatters,loose food and trash debris, dirt, dust, and/or black matter were observed on or within:-Removable hood vents; and -the interiors of cabinets and drawers.1.The Kitchen Coordinator immediately deep-cleaned the removable hood vents in House196.The Kitchen Coordinator added the cabinet and drawer interiors to the NOC shift deep-cleaning schedule for immediate cleaning to remove the identified accumulation and restore the areas to a clean, sanitary condition.2.The Kitchen Coordinator added the removable hood vents to the kitchen sanitation audit.Cabinet and drawer interiors have been incorporated into the NOC shift deep-cleaning schedule.The staff member completing each assigned cleaning task must document completion on the deep-cleaning checklist.The NOC Shift Supervisor will verify that the assigned cleaning was completed and sign the checklist.Completed checklists will be submitted weekly to Administration for review and oversight.3.The NOC will complete and document assigned deep-cleaning tasks according to the established deep-cleaning schedule.The NOC Shift Supervisor will verify completion of assigned tasks,Administration will review the completed deep-cleaning checklists weekly,and the Kitchen Coordinator will independently inspect the hood vents, cabinets, and drawers during the monthly kitchen sanitation audit.Any sanitation concern identified will be corrected when identified.4.NOC shift staff are responsible for completing and documenting assigned deep-cleaning tasks.The NOC Shift Supervisor is responsible for verifying completion.The Kitchen Coordinator is responsible for the monthly kitchen sanitation audit, with the Administrator or designee overseeing the corrective system.6(b)Physical Facility and equipment in disrepair:-The countertop had chips and cracks; and -Multiple pots and pans were damaged and required replacement.1.Maintenance will repair the identified chips and cracks in the countertop using laminate to restore a smooth, durable, and cleanable surface.The Kitchen Coordinator immediately removed the damaged pots and pans from use and ordered replacements.2.The Kitchen Coordinator has added the condition of kitchen countertops,cabinets, pots,and pans to the monthly kitchen audit.The audit will identify cracks,chips,damaged surfaces,excessive wear,or damaged cookware that may prevent effective cleaning or safe use.The Kitchen Coordinator will report countertop or cabinet repair needs identified during the audit to Maintenance for corrective action.The Kitchen Coordinator will immediately remove any damaged pots or pans identified during the audit from use and replace them. Maintenance will also inspect kitchen countertops in each house annually to identify repair needs.3.The Kitchen Coordinator will inspect countertops, cabinets, pots, and pans monthly as part of the kitchen audit. Maintenance will inspect kitchen countertops annually and will address repair needs reported between annual inspections.The Kitchen Coordinator will remove any damaged cookware identified during an inspection and replace it.4.The Kitchen Coordinator is responsible for completing the monthly kitchen audit, removing damaged cookware from use, and reporting physical-facility repair needs to Maintenance.The Maintenance Director is responsible for completing necessary countertop and cabinet repairs.The Administrator or designee will provide oversight to ensure identified deficiencies are corrected. 6(c) Improper Food Labeling Multiple potentially hazardous foods in the reach-in refrigerator lacked open dates.1.Staff immediately removed and discarded all potentially hazardous food items in the reach-in refrigerator that lacked the required open date.Staff placed reminder signage regarding open-date requirements on the refrigerator for visibility.2.Administration reinforced proper food labeling and storage requirements through a “Question of the Day” regarding the importance of open dating and proper storage of opened food items.During the September 2026 all-staff meetings, staff were re-educated on the open-date policy and completed a questionnaire to reinforce understanding.The NOC deep-cleaning process also includes review of refrigerated food items for required open dates.3.The NOC shift will inspect refrigerated food for required open dates weekly as part of the deep-cleaning schedule.The NOC Shift Supervisor will verify completion of the inspection, and the Kitchen Coordinator will independently review food labeling during the monthly kitchen audit. Any food identified without a required open date will be removed and discarded.4.Staff handling food are responsible for properly labeling opened food items. The NOC Shift Supervisor is responsible for verifying completion of the weekly refrigerator inspection and correction of any improperly labeled items. The Kitchen Coordinator monitors compliance during the monthly kitchen audit, with the Administrator or designee providing oversight.6(d)Temperature Control The reach-in refrigerator and food items inside measured 50 degrees F;food items inside were also above 41 degrees F.Temperature logs for 9-9-26 were reviewed and found incomplete. Staff 2 confirmed that any food found above 41 degrees would be discarded. 1.All food items identified as being above 41°F were immediately removed and discarded.Maintenance inspected the reach-in refrigerator and determined that the temperature control panel had been incorrectly adjusted.Maintenance corrected the temperature setting and placed the control panel into lock mode to prevent inadvertent adjustment. Staff were also reminded to complete the refrigerator temperature log each day.2.Cooks and designated staff are required to check and document the reach-in refrigerator temperature daily on the refrigerator temperature log. Staff were educated that refrigeration equipment used for cold food storage must maintain a temperature of 41°F or below and that temperatures outside the acceptable range must be reported immediately so corrective action can be taken.Staff were also re-educated on the requirement to complete the temperature log each day.The September 2026 all-staff meeting reinforced refrigerator temperature monitoring, documentation requirements,and the response to out-of-range temperatures.3.Reach-in refrigerator temperatures will be checked and documented daily. Any temperature above 41°F will require immediate evaluation of the refrigerator and affected food, with Maintenance notified when the refrigerator is not maintaining the required temperature.The NOC Shift Supervisor will review the refrigerator temperature logs weekly to verify that daily temperature checks have been completed and documented and that any out-of-range temperatures received appropriate follow-up.The Kitchen Coordinator will independently review the temperature logs during the monthly kitchen audit.4.Cooks and designated staff are responsible for completing and documenting daily refrigerator temperature checks and immediately reporting temperatures outside the acceptable range.The NOC Shift Supervisor is responsible for weekly verification that the temperature logs are complete.Maintenance is responsible for evaluating and correcting equipment-related concerns.The Kitchen Coordinator is responsible for monthly oversight of temperature-control compliance, with the Administrator or designee providing overall oversight. Z0142 This rule is not met as evidenced by:Based on observation interview, and record review,it was determined the facility railed to follow licensing rules for Residential Care and Assisted Living Faclilities.Findings include, but are not limited to:Refer to C240.Please refer to our C0240 submissions above.

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: