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 the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility kitchen, food storage areas, food preparation and food service on 10/16/24 revealed: * Splatters, spills, drips, and debris noted on: - Counters; - Interior of cupboards; - Interior of the oven; - Interior of drawers; and - Flooring in dry storage/pantry closet. * Damage to the interior of cupboards and the counter to the left of the stove creating porous un-cleanable surfaces. * Packages of open food in dry storage/pantry closet. * Scoops were left in bins of food. * No documented evidence temperatures of cooked food consistently monitored to ensure proper cooking. * Staff observed to not change gloves between tasks, touching ready to eat foods. The food storage concerns and areas in need of cleaning were reviewed with Staff 1 (Administrator) on 10/16/24. She acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule 1) A deep clean of kitchen and pantry will be completed to include all counters, cupboards outer and interior, oven outer and interior, drawers, shelves and floors. Repairs will be completed for cupboards, counters and all un-cleanable surfaces. All packaged foods will be properly stored, sealed and dated. Scoops will be removed from any bulk containers. Food temperatures will be documented accordingly, foods delivered to residents rooms will be covered properly. Retraining with staff on proper food storage, temping of all foods, hand washing techniques, apron use and glove use will be completed. 2) Training and review with staff will be completed on proper kitchen and food sanitation rules including proper storing of foods, temping of foods, apron use, glove use, cleanliness of kitchen and pantry, covering of foods being served to residents apartments, hand hygiene as well as how to document and who to notify if repairs are needed. 3) Food storage, food temps, proper use of aprons and gloves, covering of foods served in apartments, and general cleanliness of kitchen and pantry will be audited daily as well as monthly using the Administrator Quality Assurance audit . 4) The administrator/designee will be responsible to ensure the system has been corrected/monitored, with oversight from the Regional Director of Operations.

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 411-054-0200 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure hot water temperatures in residents' units and common bathrooms were maintained within a range of 110 to 120 degrees Fahrenheit (F). Findings include, but are not limited to: A tour of the facility on 10/16/24, revealed the following: *The common bathrooms water was turned on and noted to be hot to the touch. The water temperature, taken by the surveyor with thte facility thermometer, was 1135 degrees F; *Room 3 resident's bathroom sink hot water was 135.2 degrees F; *Room 8 resident's bathroom sink hot water was 138 degrees F. Review of the facilities water temperature monitoring logs identified water temperatures exceeding 140 degrees F in resident rooms as far back as 5/2024. On 10/16/24, the hot water temperatures were discussed with Staff 2 (Maintenance), he verified the water was too hot. Staff 2 immediately reduced the water temperature. The need to ensure water temperatures were maintained within a range of 110 to 120 degrees F was discussed with Staff 1 (Administrator) on 10/16/24. She acknowledged the findings.

OAR 411-054-0200 (9) Plumbing Systems 1) Maintenance Director has regulated the water temperatures in resident bathrooms and common area bathrooms to be within the required range of 110-120 degrees. 2) Maintenance Director will preform water testing, as well as train staff on how to temp water in resident areas, this will include instruction on immediate notification to Maintenance Director if water temperatures are out of range. 3) Maintenance Director and or designated staff will complete water temperatures 3 times a week for 2 weeks, then twice weekly for 2 weeks, then monthly to ensure water temperatures are maintained in allowable range. 4) The Administrator/designee and Maintenance Director to ensure the corrections are completed/monitored with Regional Director of Operations oversight.

OAR 411-054-0200 (9) Plumbing Systems (9) PLUMBING SYSTEMS. Plumbing systems must conform to the building codes in effect at the time of facility construction.(a) Hot water temperature in residents' units must be maintained within a range of 110 - 120 degrees Fahrenheit.(b) Hot water temperatures serving dietary areas must meet OAR 333-150-0000 (Food Sanitation Rules).(c) An outside area drain and hot and cold water hose bibs must be provided for sanitizing laundry carts, food carts, and garbage cans. This Rule is not met as evidenced by:

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to: Observations on 10/16/24 revealed exit doors did not have an operational alarm or other acceptable system to alert staff when residents exited the building. The alarms on front and back doors of the facility were not alerting staff when the door were opened. Staff turned on the alarm for the back door when questioned by the surveyor. The front entrance to the building lacked a system to alert staff when residents exited the building The need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building was discussed with Staff 1 (Administrator). She acknowledged the findings.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable 1) Maintenance has installed working alarms on exit doors front and back. 2) Exit door alarm checks will be added to staff daily task sheets to ensure proper functioning of alarms. Staff will receive training on reporting non-functioning alarms. 3) The system will be evaluated daily to ensure alarms are operational and alerting staff of when residents and visitors enter/exit the building. 4) The Administrator/designee and Maintenance Director to ensure the corrections are completed/monitored with Regional Director of Operations oversight.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable (11) CALL SYSTEM. A RCF must provide a call system that connects resident units to the care staff center or staff pagers. Wireless call systems are allowed.(a) A manually operated emergency call system must be provided in each toilet and bathing facility used by residents and visitors.(b) EXIT DOOR ALARMS. An exit door alarm or other acceptable system must be provided for security purposes and to alert staff when residents exit the RCF. The door alarm system may be integrated with the call system.(c) Security devices intended to alert staff of an individual resident's potential elopement may include, but not be limited to, electronic pendants, bracelets, pins.(12) TELEPHONES. Adequate telephones must be available for resident, staff, and visitor use, including those individuals who have physical disabilities. If the only telephone is located in a staff area, it must be posted that the telephone is available for normal resident-use at any time and that staff shall ensure the resident's uninterrupted privacy. Staff may provide assistance when necessary or requested.(13) TELEVISION ANTENNA OR CABLE SYSTEM. A RCF must provide a television antenna or cable system with an outlet in each resident unit. This Rule is not met as evidenced by: