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 02/25/24 at 10:35 am, the facility kitchen was observed to need cleaning in the following areas: * Spice container holders – food debris build up; * Oven doors and sides – drips/spills; * Prep counter next to the stove/oven – debris/spills; * Single door refrigerator exterior door & interior bottom shelf – smears/drips/spills; * Commercial can opener – blade finish worn off/black matter around housing; * Ceiling area around vents between cooking equipment and steamtable – accumulation of dust build up; * Ceiling and wall above entrance door near dishwashing area – accumulation of dust build up; * Ceiling and sprinkler head between lights in dishwashing area – accumulation of dust build up; * Exterior of dishwasher – spills/drips; * Exterior of garbage disposal – spills/drips; and * Exterior of toaster on shelf above steam table – drips/spills. The areas of concern were observed and discussed with Staff 1 (Culinary Manager) and Staff 3 (Corporate Culinary Director) and discussed with Staff 2 (Executive Director) on 02/25/25. The findings were acknowledged.

All identified areas were cleaned by the Culinary Services Director Specialist (CSDS) and the Culinary Services Director (CSD) by 2/27/2025. CSD was educated by the CSDS and National Director of Culinary Services on 2/27/2025 about daily, weekly and monthly cleaning schedules. The CSD/CSDS will educate Culinary staff on cleaning expectations and schedules. Daily, weekly and monthly cleaning schedules are posted in the kitchen for staff to follow. CSD will audit cleaning schedules/cleanliness at least 3 days/week. Executive Director (ED) will audit kitchen cleaning and schedules weekly x 4 weeks, bi-weekly x 4 weeks, and then randomly 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: 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.

The Executive Director will educate all leadership staff on this Plan of Correction. The ED will do audits of the kitchen cleanliness and cleaning schedules weekly x 4 weeks, and then bi-weekly x 4 weeks and then randomly ongoing.

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: