OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide effective administrative oversight over the operation of the kitchen. Findings include, but are not limited to: During the third revisit to the annual kitchen survey of 09/10/24, conducted on 05/07/25, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the number of repeat citations. Refer to C240.

1) Daily standup meeting with heads of department. Walk throughs of community at least twice daily, including the exterior. 2) Standup meetings; clinical meetings; 1:1 heads of department meetings. 3) Five days a week, Weekly 4) Administrator

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by:

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 ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 09/10/24 at 11:25 am the facility kitchen was observed to need cleaning and/or repairs in the following areas: The following areas throughout the kitchen and dry food storage area had build up of significant dust/food debris/grease and/or rust: * Ceiling pipes; * Ceiling area above stove/grill/food service; * Ceiling light covers in prep area; * Fans; * Wall behind shelves in dry storage; * Hood vents above stove/grill; * Shelving above food service area; and * Cord holding up spray hose in three sink area. Improper storage of food was observed in the following areas: *Four door stainless steel refrigerator: – Interior temperature registered 50.9 degrees F in the back of the refrigerator; - Refrigerator temperature gauge registered between 6 and 8 degrees Celsius (42.8 and 46.4 degrees F respectively) (Per Staff 1 (Dietary Aide/Cook the cover had broken off temperature gauge and may had affected the registered temperature of refrigerator interior); - At 12:40 pm the surveyor requested temperatures be taken of milk-based food products stored inside – buttermilk was 51.8 degrees F; yogurt was 47.3 degrees F, other food items stored in refrigerator included salad dressings, cut fruit and chicken-based broth. - Surveyor requested milk and protein-based food items be disposed of, ,staff immediately removed potentially tainted food items and placed in garbage; - Temperature logs were not filled out for September 2024, Staff 1 presented blank document; and - August log was blank the last weeks of August 2024. *Dry storage: - Scoops/cups were stored in food container containing cake flour, sugar, cream of wheat, oatmeal, panko crumbs, brown sugar, powdered sugar, rice; - Lids on food storage containers were loose, creating the potential for contamination and had food debris on them; and - Two bags of rolled oats were stored directly on the floor. Areas needing repair and/or replacement included: * Flooring throughout the kitchen was chipped, cracked and/or stained lending it an uncleanable surface, in need of significant repair/replacement; * Kitchen windows above three sinks and preparation area had cardboard taped and/or propped up against the windows were in need of repair; * Commercial can opener blade had finish worn off, creating an uncleanable surface and possible cross contamination; * Color coded cutting boards had significant gouges and very worn finishing creating uncleanable surface and possible cross contamination; and * Ceiling lights in dry storage, above grill/stove and three sink area did not have covers. Garbage near prep/service area not covered when not in use The areas of concern were observed and discussed with Staff 1 (Dietary Aide/Cook) and discussed with Staff 2 (Administrator) on 09/10/24. The findings were acknowledged.

POC For C240 A. 1) *Ceiling Pipes-Pipes have been cleaned. *Ceiling area above stove, grill, food service area-Ceiling has been cleaned. *Fans-One fan has been cleaned and the other was taken apart and deep cleaned. *Wall behind shelves in dry storage-Each shelf will be power washed and walls washed behind them. *Hood vents above the stove and grill-Vents have been cleaned. *Shelving above the food service area-Spice rack has been cleaned and shelf cleaned. *Cord holding up spray hose in three sink areas-This has been removed. 2)*Ceiling Pipes-A workflow has been created for housekeeping and Management to be cleaned. *Ceiling area above stove, grill, food service area-A workflow task has been added to dietary aids weekly workflow chart to be cleaned. *Fans-A workflow task has been added to dietary aids weekly workflow chart to be cleaned. *Wall behind shelves in dry storage-A workflow task has been added to housekeeping and Managements monthly workflow chart to be cleaned. *Hood vents above stove and grill-A workflow task has been added to housekeeping and Managements monthly workflow chart to be cleaned. *Shelving above the food service area-A workflow task has been added to dietary aids weekly workflow chart to be cleaned. *Cord holding up spray hose in three sink areas- Has been removed. 3)*Ceiling Pipes- Weekly or as needed. *Ceiling area above stove, grill, food service area-Weekly or as needed. *Fans- Monthly or as needed. *Wall behind shelves in dry storage-Monthly or as needed. *Hood vents above stove and grill-Weekly or as needed. *Shelving above the food service area-Monthly or as needed. *Cord holding up spray hose in three sink areas-Removed. 4)*Ceiling Pipes-Housekeeping and Management. *Ceiling area above stove, grill, food service area-Dietary Aids. *Fans-Dietary Aides. *Wall behind shelves in dry storage-Housekeeping and Management. *Hood vents above stove and grill-Housekeeping and Management. *Shelving above the food service area-Dietary Aides. *Cord holding up spray hose in three sink areas-Removed. Poc For C240 B. 1) *Four door stainless steel refrigerator-Middle divider was broken allowing cool air to seep out and that piece has been ordered (awaiting part arrival and repair) All Items have been removed and now being stored in the other refrigerator. Food temperature logs are now in place to insure at proper temperature before serving and storing. New strict rules on completing Daily refrigerator logs for each refrigerator. *Dry Storage-Bags on the ground have been picked up and no longer allowed on the floor. Scoops and bowls have been removed from all dry food containers. New lids have been ordered or replaced on said containers. Dates of opening dried items and expiration dates have been added to each container. All containers and lids have been emptied, cleaned and labeled. 2)*Four door stainless steel refrigerator-Food and drink temperatures will be recorded twice daily while in the refrigerators and before meals and snack times. Logs will be checked daily by management. *Dry Storage- Dry food containers are not allowed to have scoopers left in them. They will be checked daily for scoops or bowls. Any broken lids will be replaced and lids will be checked daily for secure fittings. Dates are required on all Containers or thrown out. Dry goods aren't allowed to be stored on the floor 3)*Four door stainless steel refrigerator-Refrigerator temperatures and food temperatures are to be taken multiple times daily. Logs are to be filled out daily by each shift. *Dry Storage-Dry storage bins are to be checked daily for scoops and bowls, and proper fitted lids and cleanliness. dates on said bins should be checked before each use. The dry storage pantry will be checked daily for food stored on the floor. 4)*Four door stainless steel refrigerator-Dietary Aides and Cooks will check refrigerator and food Temperatures daily before serving. They'll log temps, sign and date all logs on refrigerators and food daily. Management will check that all logs are being filled out weekly. *Dry Storage- Dietary Aides and cooks will check dates on dry food bins before each use. They’ll check at the end of each shift that all scoops are removed and lids are properly shut. Management will check bins daily for dates, scoops, lids and cleanliness. Poc for C240 C. 1)*Flooring throughout the kitchen was chipped or cracked-We are seeking bids for replacing the kitchen floor. *Kitchen windows needing repairs-We have accepted a bid for replacement of kitchen windows. *Commercial can opener blade had the finish worn off-The can opener replacement has been ordered. *Color coded cutting boards had gouges and worn finish- The cutting boards have been replaced. *Ceiling lights in the dry storage pantry, above stove and grill, and three sink area did not have covers-Covers have been placed over lights in all areas. 2)*Flooring throughout the kitchen was chipped or cracked-Report and cracks or broken tile to maintenance immediately after replacement of the old floor. *Kitchen windows needing repairs- Annually window inspections will be done. *Commercial can opener blade had the finish worn off-Daily cleaning and inspecting for worn parts. *Color coded cutting boards had gouges and worn finish-Cutting boards will be replaced annually or as needed. *Ceiling lights in the dry storage pantry, above stove and grill, and three sink area did not have covers- Monthly inspection to make sure they haven't been removed. 3)*Flooring throughout the kitchen was chipped or cracked- Annually and as needed. *Kitchen windows needing repairs-Annually and as needed. *Commercial can opener blade had the finish worn off- Daily. *Color coded cutting boards had gouges and worn finish- Annually and as needed. *Ceiling lights in the dry storage pantry, above stove and grill, and three sink area did not have covers- Monthly. 4)*Flooring throughout the kitchen was chipped or cracked-Dietary aides, cook, and management. *Kitchen windows needing repairs-Dietary aides, cook, and management. *Commercial can opener blade had the finish worn off-Dietary aides, cook, and management. *Color coded cutting boards had gouges and worn finish-Dietary aides, cook, and management. *Ceiling lights in the dry storage pantry, above stove and grill, and three sink area did not have covers-Dietary aides, cook, and management. Poc for C240 D 1)*Garbage near the prep/service area was not covered when not in use-A garbage can lid has been added to the garbage can. 2)*Garbage near the prep/service area was not covered when not in use- Daily inspection to make sure the lid is on while not in use. 3)*Garbage near the prep/service area was not covered when not in use- Daily. 4)*Garbage near the prep/service area was not covered when not in use-Dietary aides, cook, and management.

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 ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to: On 10/10/24 at 12:30 pm, the facility kitchen was observed to need cleaning and/or repair in the following areas: a. The following areas throughout the kitchen had buildup of significant dust/food debris: * Portable fans in the kitchen and dry storage area; and * A fan inside the stainless steel two door refrigerator. b. Areas needing repair and/or replacement included: * Flooring throughout the kitchen was chipped, cracked and/or stained lending it an uncleanable surface, in need of significant repair/replacement; * Kitchen windows above three sinks and preparation area had cardboard taped and/or propped up against the windows and were in need of repair; and * Ceiling lights above the three sink area did not have covers. At 1:00 pm Staff 4 (Administrator Designee) was informed of above areas in need of continued correction, and they acknowledged the identified areas.

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:

1. Floors: throughout will be replaced by 4/30/25 cabinets will be repaired by 4/30/25 Wall behind prep table will be finished painted and a cleanable surface by 4/30/25 2. Kitchen maintenance and up keep will be inspected monthly and add needed for upkeep and repairs. 3. Monthly, as needed 4. Kitchen manager, kitchen staff, maintenance, asst. Admin, and administrator

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 ensure the kitchen was kept in good repair in accordance with the Food Sanitation Rules OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to: On 05/07/25 at 9:52 am, the kitchen was observed to need repair in the following areas: * Flooring throughout the kitchen and dry storage was chipped and cracked lending it an uncleanable surface, in need of repair or replacement; * Wooden cabinets throughout the kitchen had chipped and missing paint, missing drawers with exposed porous wood which rendered the surface uncleanable; * There was holes in the wall approximately 12 inches in diameter surrounding the electrical panel in the staff office. The office area was also used to store dry food storage; * The drain hose from the three-compartment sink was disconnected allowing water to drain into a mixing bowl; and * The handwashing sink and eye wash station were blocked with serving carts and multiple items piled up in the sink rendering the sink unusable. On 05/07/25 at 11:10 am Staff 3 (Administrator), Staff 4 (Administrator Designee) and Staff 6 (Owner) were informed of the need to ensure the kitchen was kept in good repair. They acknowledged the findings.

1. All issues/findings from recent survery on 5/8/25 are being corrected, scheduled repairs set to begin 5/19/2025 with an expected completion date of 06/06/2025. Approval from FPS is underway. Elderwise was approved to assist with RD requests throughout kitchen repairs. Meals are being served as usual with no changes with the exception of meals being served in the dining room from the temp monitored steam table, and using disposable foodware such as untensils, paper plates, plastic cups, and styrofoam containers for room trays and saved meals. All meals and snacks are being prepared at a foodcart that is 2 mins from the facility and then transported using insulated hot & cold cambro cam go boxes. And held in the hot holding cart and then to the stem table for serving, all cold items are stored in the dining room fridge and are preportioned in disposable portion cups s and transported in insulated cambro cam go box and then held in the fridge for serving. 2. Kitchen maintenance and up keep will be inspected monthly and addressed in facility monthly QA meetings and as needed for up keep and repairs. 3. Monthly, as needed 4. Head cook, kitchen staff, maintenance, asst. Admin, and administrator

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 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:

1. Mt. Scott will comply with c455 by submitting a POC for all tags current an future surveys and if any are denied a new POC will be submitted until an approved POC for each tag is received. 2. All POCS will be submitted and monitored for approved response 3. Per states issuance and requirements 4. Asst. Administrator, Administrator

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure their revisit three kitchen survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 240.

1. Mt. Scott will comply with c455 by submitting a POC for all tags current an future surveys and if any are denied a new POC will be submitted until an approved POC for each tag is received. 2. All POCS will be submitted and monitored for approved response 3. Per states issuance and requirements 4. Asst. Administrator, Administrator

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: