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 01/23/25 at 10:50 am, the facility kitchen was observed to need cleaning and repair in the following areas: * Juice machine in service area – rusty stained ledge/drip pan full of “mucky” liquid/drips/spills; * Top and sides of dishwashing machine – debris/drips/spills; * Wall behind spray hose, under counter and behind dishwashing machine – significant build up of black matter; * Lower shelf in dishwashing holding dish washing racks - build up of spills/food debris; * Floor under steamtable, small refrigerator and under and behind cooking equipment – build up of food debris/black matter; * Drains under steamtable and two sink prep counter – build of food debris/black matter/spills; * Ceiling vents above clean dishes/pot and pans storage rack – build up of dust; * Lower shelf of prep counter – food debris/spills/drips; * Food bin lids – food debris: and * Dishwashing machine was not running at appropriate rinse temperature; rinse gauge was non-functional; booster not operating; kitchen staff unaware of proper wash and rinse temperatures; temperature logs were blank since 1/15/25; Staff 4 (Maintenance Director) and Staff 3 (Regional Dining Manager) contacted EcoLabs for immediate assistance with rinse temperature and service for repairing the booster; EcoLabs had recently modified sanitation procedure with bleach although facility had no test strips for checking chlorine level; Staff 3 obtained test strips and determined chlorine level was too low. The facility will use three sink method for cleaning and sanitizing dishes until dishwashing machine is repaired and operating at required temperatures for wash and rinse. Improper food storage concerns: * Ice cream tubs in high traffic area not covered; * Walk in freezer – boxes and tub of ice cream on the floor, open bag of pretzels; * Dry storage – bag of sugar on floor, open bag of dry pasta; and * Pan of cake on prep counter - uncovered. The areas of concern were discussed with Staff 2 (Executive Director) and Staff 3 on 01/23/25. The findings were acknowledged.

PLAN OF CORRECTION: I. KITCHEN CLEANLINESS A. Completed Actions The facility has completed a comprehensive deep cleaning of the kitchen on February 3, 2025, including: • Walls behind spray hose and dishwashing machine • Floor under steam table and cooking equipment • Drains under steam table and prep counter sinks • Lower shelves of prep counters • Dishwashing rack holders • Food bin lids • Ceiling vents (completed January 26, 2025) B. Staff Training Program The Executive Director has implemented mandatory staff training covering: • Cleaning task list requirements • Proper cleaning procedures • Placement of compost bins -All training documentation is maintained in personnel files. C. Monitoring Protocol 1. Daily Monitoring: • Dining Services Manager will review cleaning task lists • Documentation of all cleaning activities will be maintained • Daily kitchen area inspections will be conducted 2. Weekly Monitoring: • Executive Director will conduct audits with Dining Services Manager • Findings will be documented and maintained II. DISHWASHER SANITATION A. Completed Actions • Replaced dishwasher coils (January 23, 2025) • Implemented temperature monitoring system with clips • Purchased chlorine testing strips (January 23, 2025) B. Ongoing Monitoring Protocol 1. Kitchen Staff Responsibilities: • Record temperatures on daily log sheets • Sign off on temperature checks each use • Test and record chlorine levels daily 2. Management Oversight: • Dining Services Manager will review temperature logs daily • Executive Director will conduct weekly audits • All documentation will be maintained III. FOOD STORAGE COMPLIANCE A. Completed Actions The facility has corrected all storage violations including: • Walk-in freezer organization • Dry storage compliance • Ice cream storage procedures B. Ongoing Monitoring 1. Daily Oversight: • Dining Services Manager will conduct storage area audits • Document and correct any compliance issues immediately 2. Weekly Oversight: • Executive Director will conduct comprehensive audits • Review findings with Dining Services Manager • Maintain documentation of all audits IV. QUALITY ASSURANCE MEASURES A. Weekly Review Process Executive Director and Dining Services Manager will review: • Cleaning task list completion • Temperature logs • Storage compliance reports • Staff training needs B. Ongoing Compliance • All documentation maintained for state review • Monthly food forums (last held January 7, 2025) • Quarterly oversight visits by Regional Dining Services Director

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: Based on observation and interview, 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.

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: