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, sanitary manner or with required food inventory levels in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include but are not limited to: Observation of the facility kitchen, dining room and activity kitchenette on 12/02/24 from 10:30 a.m. through 1:30 pm revealed the following deficient practices: a. An accumulation of food spills, splatters, food debris build-up, loose food and debris, dust, dirt build-up and/or uncleanable surfaces was visible on the following: Ovens-Interior and Exterior; Windowsill ledge behind large metal rack; Multiple metal racks in kitchen; Racks in Cooler/Freezers-various; Handwashing sink faucet area; Wall poster outside of dry storage; Flooring Corners and edges; Cooler/Freezer bottom shelves; Top of dish machine; Light switch in ware washing area; Knife Rack; b. The following areas needed repair: Caulking in ware washing area with black matter debris build-up Hole in wall below knife rack; Walls with scrapes/dings/peeling-missing paint in various areas; Light switch damaged; Standing/pooling water under dish machine from possible leaking sprayer faucet; Cooler/Freezer racks with missing/peeling coating and rusted areas creating non-cleanable surfaces. c. The following areas needed replacement: Multiple metal racks with non-cleanable surfaces storing food items; Heavily scored sauté pans; Chipped, frayed, or rusty cooking utensils; d. Sanitation in the dishwashing process: Dish machine was run several times by surveyors and Staff 2 (Dining Services Coordinator) and was not able to reach correct sanitation concentration for chlorine levels. Upon investigation, sanitizing chemical was empty. Staff 2 changed out sanitizer, however dish machine continued to not register correct concentration after running another several times. Facility maintenance staff was contacted and was eventually able to get the dish machine sanitation concentration to 200 ppm as required. Facility was not able to determine when the dish machine was last correctly sanitizing dishes. Facility was not able to demonstrate effective monitoring system was in place for the dish machine to ensure dishes were effectively sanitized. Facility chlorine test strips were noted to be expired. e. Food Supply Dry goods, Perishable goods, Freezer goods not at required inventory levels. Staff 2 validated a large order would be placed that day and facility was not typically this low. Staff 2 acknowledged current food on hand did not meet 7 days of dry/staple foods nor 2-3 days of perishables required. Staff 2 did state they could run to store down the street if/when needed. f. Dating, labeling and/or expired food items Various food items observed stored in reach in coolers that were not dated, labeled or past the 7 days allowed per rule. Cakes for a staff party was stored with resident food. g. Miscellaneous areas noted Food equipment not covered/protected from potential contamination when stored (mixer bowl/whisk), coffee filters were stored open to potential contamination, scoop observed stored with handle touching food beverage item, dining room utensils observed pre-set and exposing food contact areas, uncovered food/beverages in dry storage, cooler, and freezer. Staff 2 toured kitchen with surveyors and acknowledged above areas in need of attention. At 1:30 surveyors reviewed with Staff 1 (Administrator) and Staff 2 (Dining Services Manager) the concerns found and they acknowledged the need for correction.

1. Community team began cleaning areas identifed in during survey immedaitely and all areas and/or equipment identified during survey will be cleaned or replaced by 12/31/24. Vendors have been contracted for all areas identified to be in need of repair and repairs will be completed or replaced by 1/20/25. Dry, perishable, and freezer goods have been replenished 2. A comprehensive cleaning list with daily/weekly/monthly tasks was been updated and appropriate staff were educated on its use on or before 12/10/24. Staff were educated on proper labeling, food storage, and equipment storage on or before 12/10/24. This included proper utensil setting when pre-setting the tables. 3. The Executive Director will complete a weekly walk for the next 60 days through to ensure kitchen cleanliness, proper food and equipment storage, and adequate food supply. The Dining Service Coordinator will monitor cleaning checklist complete and complete a weekly audit to ensure proper food and equipment storage, food supply and ktichen cleanliness a minimum of twice weekly as standard operations. 4. The Dining Services Coordinator and the Executive Director are responsible for this plan of correction

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: