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 02/04/25 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas: * Ceiling vent and area around vent above the service line – build up of dust; * Dishwashing area – wall and caulking behind sink and spray hose – significant build up of black matter, exterior of garbage disposal and power box – significant drips/spills; * Flooring under and behind steam jacketed kettles, hot box, convection oven, stove, and grill – significant build up of food debris/spills/drips/grease; * Wall behind stove/grill/deep fat fryer – build up drips/spills/grease; * Shelf below grill – significant build up of food debris/grease; * Deep fat fryer, side/front – drips of grease: * Refrigerator on service line, interior bottom shelf - food debris; and * Sides between refrigerator on service line and well containing ice – drips/spills. The areas of concern were observed and discussed with Staff 1 (Food Service Manager) and discussed with Staff 2 (Associate Executive Director) on 02/04/25. The findings were acknowledged.

SOD ID PREFIX TAG: C0240 Q1. What Actions will be taken to correct the rule Violation? The team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Daily cleaning according to the policy has been implemented. a. An after hour deep cleaning of the kitchen, appliances and dishwashing area was scheduled and completed on 2/9/2025 to ensure the kitchen is in compliance. b. A back of the house all-staff meeting was scheduled 2/9/2025, to re-educate a staff on compliance policies and procedure. c. Cleaning logs were updated, and were included in the all -staff training to ensure all staff are informed on compliance standards for cleaning of the kitchen. d. All caulking behind sink and spray hose has been replaced on 2/14/2025; repair of garbage disposal and power box completed to prevent further occurrences of drippage. Completed on 2/14/2025. Q2. How the system will be corrected so this violation will not happen again? The Food and Beverage Director is accountable to all Dining Department policies and procedures as well as The Oregon Administrative Rules. The Food and Beverage Director will ensure compliance utilizing all available resources. The team will receive ongoing and adequate support to ensure sustainable compliance. The Director, Sous Chefs, lead cooks will review the prior day logs and perform visual inspection to confirm compliance and take corrective action immediately if found to not be in compliance. a. All Cleaning schedules and assignments have been posted for the kitchen. Each item needing to be cleaned and the frequency of cleaning are included in the cleaning schedule. b. Monthly in-service meetings for Dining room staff and back of house staff have been scheduled and attendance is mandatory. Q3. How often will the area needing correction will be evaluated and who has been assigned to evaluate efforts? Daily, per policy for the areas and equipment being evaluated. Those assigned to evaluate efforts are the Food & Beverage Director, Sous Chef Adminstraot, and Executive Director. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? Food and Beverage Director, Sous Chefs and Dining room supervisor. Executive Director, Associate Executive Director to support Food and Beverage department when leadership is absent. Q5. Date Faculty Alleges compliance: 2/28/2025

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.

SOD PREFIX TAG: Z0142 Z0142 Corresponds with the above C240. The Plan of Correction above for C240 will be implemented for the purposes of bringing Z142 into compliance.

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: