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 maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen was reviewed on 11/12/24 from 10:40 am through 3:00pm and memory care unit during lunch service from 11:15pm thru 1:15 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Reach in coolers; * Walk in cooler floor; * Walk in cooler metal racks; * Walk in cooler fan blades/cages and ceiling; * Walk in freezer floor; * Interior of ice machine; * Kitchen drains; * Floors under, behind and between equipment; * Legs and wheels of large equipment; * Interior and exterior of microwaves; * Industrial can opener and housing; * Griddle top and sides; * Interior of cabinet where clean plates were stored; * Ceiling vents above food prep areas; * Floors throughout kitchen in corners and edges; * Walls behind cooking areas; * Walls and floors behind and underneath dish machine; * Top and sides of dish machine; * Interior of metal and wood drawers; * Sprinkler heads; * Utility racks; * Utility carts; * Juice machine; * Counter tops throughout kitchen; * Metal shelving storing spices; * Industrial slicer * Industrial Mixer and table holding mixer; * Memory care unit reach in refrigerator and freezer; * Interior of memory care microwave; b. The following areas were in need of repair: * Caulking by dish machine area with black debris build up. * Multiple sprinkler heads with heavy dust/grease build up. * Area on steam line with green duct tape. * Dish machine with scale build up on sides/top and interior; * Ice machine with significant black debris build up on interior; * Reach in refrigerator in memory care unit with cracks to plastic shelving; c. Multiple food items found in walk in cooler, reach in coolers, walk in freezer and reach in freezer not covered and exposed to potential contamination. Sliced lemon noted in memory care refrigerator not wrapped or covered exposing it to potential contamination. d. Multiple prepared food items found past seven days. Multiple potentially hazardous food items not dated when opened and/or prepared. e. Multiple staff noted to be handling clean dishes and/or preparing/serving food without facial hair restraints as required. f. Staff drinks were observed stored in food preparation areas and did not contain lids/straws/handles to minimize hand/lip contact as required. g. Multiple food items found in dry storage stored open to potential contamination. h. Single service utensils were observed stored open and exposed to potential contamination. i. Multiple potentially hazardous food items found stored in walk in refrigerator stacked on top of each other with visible drippings in a pan. Not all items were of the same meat and were not separately contained as required. j. Person In Charge (PIC) Staff 2 (Director of Dining Services) was interviewed at 12:45pm and was not able to correctly state proper reheat procedures or temperatures needed to ensure food was safely heated to 165 degrees as required. k. In the walk in, several turkeys were observed on sheet pans thawing. They were open to potential contamination. The turkeys did not have any dates as to when those items were pulled to begin their thawing process. l. Multiple staff in memory care were did not done aprons during meal service to protect from potential cross contamination from care tasks and meal service. m. Multiple care staff in memory care until were observed to potentially contaminate gloves during meal service (touching face/hair, or touching handles of drawers/carts/refrigerator then serve drinks, handle utensils for and to residents. On 11/12/24 at 1:15pm Staff 2 (Dining Services Director) was informed of the identified concerns and areas in need of correction. Staff 2 acknowledged areas. At 2:30 pm areas identified were reviewed with staff 1 (LPN of Health and Wellness) who acknowledged areas in need of correction.

A. Kitchen cleanliness 1. Dining employees will maintain a clean and sanitary kitchen by following a regular program of cleaning and will follow a daily, weekly, monthly and deep cleaning schedule. 2.The dining service director is responsible for maintaining the policy, will schedule all kitchen and dining staff to complete cleaning tasks and will provide a weekly checklist to the Administrator after completion. 3. Employees will follow a daily, weekly, monthly and deep cleaning schedule and will be monitored twice weekly by the dining service director as an ongoing task. 4. The dietary staff and Dining service director will complete all cleaning tasks. The Dining Service Director will monitor 2x/week ongoing to ensure all corrections are completed. The Executive Director will oversee all corrections and will monitor for efficiency 1x/week while corrections are taking place and then twice monthly ongoing. B. Kitchen Repair - 1. The Maintenance and Dining Service Director will be involved with all kitchen repairs. All items listed are scheduled to be fixed or have already been fixed. 2. All kitchen/dining employees will follow the food service equipment cleaning policy and procedure and will maintain sanitary surfaces and equipment. 3. The DSD (dining service director) will monitor all areas twice weekly. All employees will be responsible for daily tasks. 4. The DSD will oversee all corrections and will monitor weekly and as needed. The ED will monitor effectiveness and maintenance weekly while corrections are being completed and twice monthly ongoing. C. Potential food contamination, outdated food items, uncovered food, meat storage: 1. Dining employees will maintain food areas in a clean, safe and sanitary manner. All food items in freezer, walk-in, small refrigerator and dry storage will be labeled, dated and covered per policy and procedure. 2.The dining service director is responsible for maintaining the policy and will train all employees in the proper food storage methods. 3. This will be monitored daily by the AM Cook, Evening Cook and Dining service Director while on shift prior to leaving for the day. 4. The Dining Service Director will monitor 2x/week ongoing to ensure all corrections are completed. The Executive Director will oversee all corrections and will monitor for efficiency 1x/week while corrections are taking place and then twice monthly ongoing. D. Hairnets/Facial hair coverings 1. Dining employees will maintain a clean and sanitary kitchen and follow safe personal hygiene practices. 2.The dining service director is responsible for maintaining the policy and will train all employees to wear facial hair coverings and hairnets or another hair covering while working with, preparing, and serving food as well as during clean up. 3. Employees will follow the hygiene policy and will be monitored twice weekly by the dining service director as an ongoing task. 4. The Dining Service Director will monitor 2x/week ongoing to ensure all corrections are completed. The Executive Director will oversee all corrections and will monitor for efficiency 1x/week while corrections are taking place and then twice monthly ongoing. E. Personal Beverages 1. All employees will follow the policy and procedure for safe food handling and keeping beverages in the kitchen. 2. New employee orientation and ongoing in-services will be completed monthly at all-staff meeting for safe food handling and storage of food and personal beverages. 3. The DSD (dining service director) will monitor all areas twice weekly. All employees will be responsible for daily tasks. 4. The DSD will oversee all corrections and will monitor weekly and as needed. The ED will monitor effectiveness twice monthly. F. Single Service Utensils 1. All employees will follow the policy and procedure for safe food handling that lists single storage and the safe storage of utensils and single service utensils. 2. New employee orientation and ongoing in-services will be completed monthly at the all-staff meeting for safe food handling. 3. The DSD (dining service director) will monitor all areas twice weekly. All employees will be responsible for daily tasks. 4. The DSD will oversee all corrections and will monitor weekly and as needed. The ED will monitor effectiveness twice monthly. G. Proper re-heat and thawing procedures and processes 1. Dining employees will follow the policy and procedure for food temperatures and the proper heating and thawing process. 2.The dining service director is responsible for ensuring that food temperatures are taken and recorded and will follow the thawing process from the food handling/safe food handling course. 3. The DSD (dining service director) will monitor all areas twice weekly. All employees will be responsible for daily tasks. 4. The DSD will oversee all corrections and will monitor weekly and as needed. The ED will monitor effectiveness twice monthly ongoing.

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: Z 142: Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Please refer to C240

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: