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 interviews, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with the Food Sanitation Rules, OAR 333-150-000. include, but are not limited to: Observation of the kitchen on 12/31/24 at 10:45 am through 1:00 pm revealed the following deficiencies: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Flooring/walls and ceiling in freezer room; * Flooring in corners, edges, between and under equipment in main kitchen area; * Floors and walls in dry storage; * Walls, floors, ceiling, and vents; * Drains throughout kitchen; * Industrial can opener and housing; * Interiors of cupboards/cabinets and drawers; * Interior of reach in cooler; * Range top, grill, and interior of ovens; * Steam wells and knobs; * Grill and oven knobs; * Floor between oven and side tables with food debris; * Walls throughout kitchen and food storage areas; * Area behind and under 3 compartment sink; * Minor equipment (blender/food processor); * Metal racks; * Open metal shelving; * Plastic bins/containers storing food; * Coffee makers; * Utility carts; * Fan blades and cages; * Metal racks in reach in cooler; * Hand washing skink and surrounding area; b. The following areas were found in need of repair: * Cabinets under hand washing sink with visible damage; * Section of caulking behind sinks with black matter buildup; * Vents and fire sprinklers with heavy dust/dirt buildup; * Multiple light fixtures in kitchen and dry storage not operational making dark and unsafe conditions. * Holes around electrical conduit by hood and fire suppression system allowing potential entry way to insects and pests. * Facility dishwasher had broken and been removed more than two months prior and had not been replaced or repaired. b. Facility did not have a commercial dishwasher. It was removed in October. Facility was utilizing the 3 compartment sink method to clean and sanitize dishes. Staff 1(Facility Designee) was not aware a commercial dishwasher was required for facilities with census capacity of 17 or more. Staff 1 acknowledged facility had a census capacity of 22 residents. c. Handwashing sink was directly by a food prep or service area and did not have a splash guard to prevent possible contamination of food or area by hand washing. d. Multiple food items observed stored in reach in coolers without open dates. e. Scoops were found stored in multiple bulk food items/bins potentially contaminating food products; f. Seven days of menus were not readily available as required. Staff 2 stated usually week of menus was posted out side of kitchen. Staff 2 stated the printer was broken. Staff 1 indicated the menu system license had expired. f. Food contact surfaces of utensils and to go containers and disposable plates/bowls were found stored uncovered and open to potential contamination. Surveyor toured kitchen areas with Staff 2 (Dining Services Manager) and they acknowledged the identified areas. At 12:30 pm surveyor reviewed items with staff 1 (Facility designee) and they acknowledge areas needing correction.

All deep cleaning of kitchen arear and dining area will be completed 2/5/2025. Maintenance has observed the repairs stated and Equipment required per State regulations.Culinary Director will be providing menus 1 week in advance. Adjusting menu according to resident diet. Community will be undergoing renovations, date TBD. Pots, pans, storage containers and dining ware has been purchased. Anticipating arrival 1/27/2025 Culinary Director is adjusted the snack program introducing “A la Carte” style carte. This will be available during the day and overnight according to resident specific diet. Maintenance Director will order a guard for handwashing station to prevent contamination an install by 3/1/2025, along with repairing hole Around electrical conduit by hood and fire suppression system. Culinary Director and staff will clean vents and fire sprinklers daily. Contracted with Sentas to ensure they are clear and clean of dust or debris routinely( as of 1-24-25 next scheduled cleaning is to be May of 2025) along with repairing hole around electrical conduit by hood and fire suppression system. Task sheets will be checked daily by Culinary Director and address in complete task directly. ED will walk through kitchen, storage and dining room once weekly to ensure all equipment is working and clean. Ensuring cleanliness is within community and state guidelines. ED will provide guidance and support as needed. Interim ED will oversee task sheets daily/weekly, and during one on one with director. Permanent will take over upon hire.

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 (7)(e) Kitchen and Food Storage (e) KITCHEN AND FOOD STORAGE. Kitchen facilities and equipment in residential care facilities with a capacity of 16 or fewer may be of residential type except as required by the building codes. Residential care facilities licensed for a capacity of more than 16, must comply with OAR 333-150-0000 (Food Sanitation Rules). The following are required: (A) Dry storage space, not subject to freezing, for a minimum one-week supply of staple foods. (B) Refrigeration and freezer space at proper temperature to store a minimum two days' supply of perishable foods. (C) Storage for all dishware, utensils, and cooking utensils used by residents must meet OAR 333-150-0000 (Food Sanitation Rules). (D) In facilities licensed to serve 16 or fewer residents, a dishwasher must be provided (may be residential type) with a minimum final rinse temperature of 140 degrees Fahrenheit (160 degrees recommended), unless a chemical disinfectant is used in lieu of the otherwise required water temperature. In facilities of 17 or more capacity, a commercial dishwasher is required meeting OAR 333-150-0000 (Food Sanitation Rules). (E) In residential care facilities with a capacity of 16 or fewer, a two compartment sink or separate food preparation sink and hand wash lavatory must be provided. In residential care facilities with 17 or more capacity, a triple pot wash sink (unless all pots are sanitized in the dishwasher), a food prep sink, and separate hand wash lavatory must be provided. (F) Food preparation and serving areas must have smooth and cleanable counters. (G) Stove and oven equipment for cooking and baking needs. (H) Storage in the food preparation area for garbage must be enclosed and separate from food storage. (I) Storage for a mop and other cleaning tools and supplies used for dietary areas must be separate from those used in toilet rooms, resident rooms, and other support areas. In residential care facilities with a capacity of 17 or more, a separate janitor closet or alcove must be provided with a floor or service sink and storage for cleaning tools and supplies. (J) Storage must be available for cookbooks, diet planning information, and records. (K) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture. This Rule is not met as evidenced by: Based on observation and interview, it was determined that the facility failed to have a commercial dishwasher when census capacity is 17 or greater. During the annual kitchen survey on 12/31/24, it was observed that the facility did not have a commercial dishwasher. Staff 2 (Food Service Director) was interviewed at approximately 11:00am and indicated the dishwasher had been removed in October. Staff 2 verified they were using the Three compartment sink method for cleaning and sanitizing of dishes. Staff 2 had indicated they had inquired several times as to when another dishwasher would be installed and had not been made aware when or if one would be replaced. At approximately 12:45 Staff 1 (facility administration designee) was informed of the need for a commercial dishwasher for facilities with 17 or more capacity. Staff 1 verified capacity was 17 or more and that they did not currently have a commercial dishwasher. They were unaware of a rule that required one. Staff 1 did indicate that the facility had attempted to get one from a sister facility but it did not fit.

Rashall Orr (identified as Facility Designee) has notified RDO, Regional Maintenance for state of Oregon and COO of state regulation and rule regarding community *OAR 411-05400200(7)(e)*. This was confirmed with survey analyst. Regional Maintenance was given approval for purchase. Rashall Orr had reached out to regional to confirm that unit was ordered and pending delivery date. Culinary Director will begin using to ensure proper sanitization. Culinary Director will establish a forum to track temps and sanitization daily and complete weekly trap cleaning. Currently Interim ED will observe and ensure dishwasher is being used to sanitize all dishes and check for completion of temp logs. Permanent will take over upon hire.

OAR 411-054-0200 (7)(e) Kitchen and Food Storage (e) KITCHEN AND FOOD STORAGE. Kitchen facilities and equipment in residential care facilities with a capacity of 16 or fewer may be of residential type except as required by the building codes. Residential care facilities licensed for a capacity of more than 16, must comply with OAR 333-150-0000 (Food Sanitation Rules). The following are required: (A) Dry storage space, not subject to freezing, for a minimum one-week supply of staple foods. (B) Refrigeration and freezer space at proper temperature to store a minimum two days' supply of perishable foods. (C) Storage for all dishware, utensils, and cooking utensils used by residents must meet OAR 333-150-0000 (Food Sanitation Rules). (D) In facilities licensed to serve 16 or fewer residents, a dishwasher must be provided (may be residential type) with a minimum final rinse temperature of 140 degrees Fahrenheit (160 degrees recommended), unless a chemical disinfectant is used in lieu of the otherwise required water temperature. In facilities of 17 or more capacity, a commercial dishwasher is required meeting OAR 333-150-0000 (Food Sanitation Rules). (E) In residential care facilities with a capacity of 16 or fewer, a two compartment sink or separate food preparation sink and hand wash lavatory must be provided. In residential care facilities with 17 or more capacity, a triple pot wash sink (unless all pots are sanitized in the dishwasher), a food prep sink, and separate hand wash lavatory must be provided. (F) Food preparation and serving areas must have smooth and cleanable counters. (G) Stove and oven equipment for cooking and baking needs. (H) Storage in the food preparation area for garbage must be enclosed and separate from food storage. (I) Storage for a mop and other cleaning tools and supplies used for dietary areas must be separate from those used in toilet rooms, resident rooms, and other support areas. In residential care facilities with a capacity of 17 or more, a separate janitor closet or alcove must be provided with a floor or service sink and storage for cleaning tools and supplies. (J) Storage must be available for cookbooks, diet planning information, and records. (K) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture. 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.

As of 1/17/2025, Britney King has taken place as Interim ED until one is hired permanently. Waiver request has been submitted for extension for licensing. When RDO hires permanent ED, Britney King will remain on site to ensure that proper transition of licensee is complete before leaving the community. Until permanent ED has been submitted and approved by Licensing. RDO Marrissa Drinkhouse-Quintana and Interim ED Britney King

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: