OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by: Based on observations, interviews, and record review, it was determined, the facility failed to ensure there was an effective method in place to respond and resolve resident complaints related to food/meal service. Findings include but are not limited to: On 03/04/25 at 9:30 am, food complaints and resident council minutes were requested and reviewed. The following was identified: * In January’s meeting the minutes documented “food warmer carts?”, “better presentation,” “warm food up without the bun,” There was no documentation under the “final resolution column. * The February meeting minutes documented, “Grove Menu do not like”, “Filling out menus/reading menus”, along with many other items. No resolution was documented for those identified items. *On 02/16/25 residents noted lunch was “cold” and of poor quality. At 11:00 am, Staff 1 (Administrator) and Staff 2 (Food Service Director), were interviewed regarding the council minutes. Staff 1 acknowledged the minutes did not contain descriptive information about the topics/concerns nor listed resolutions. When asked why food warmer carts were on there, they verified it was because residents were concerned and complained about cold food. Staff 1 indicated the facility used to use insulated carts for room tray delivery but those had gone away some time back and the residents had wanted them back. When asked what the resident’s didn’t like about the Menus they confirmed they mentioned things like “too fancy” and that some resident’s didn’t like the couscous. Staff 2 stated the facility would start using the insulated carts again. On 03/04/25 lunch meal was observed. 12 residents were observed eating in the dining room and were interviewed regarding the food. Nine of the 12 indicated they felt the meals are cold most of the time. Multiple of those residents felt that the meat is often tough and dry. Many of these residents voiced dislike of the “Grove” menus. The surveyor asked all residents if they felt they were involved in menu choices and most of them said they did not feel they had much if any input into menu choices. During the lunch observation, surveyor ordered a test tray and found the main entrée (Chicken Tacos) were not palatable at 101 degrees. The cold side item of black bean and tomato salad was noted at 57 degrees not at 41 required for cold food items. Surveyor tested the temperatures for food items sent to the room for room delivery and the taco was at 103 degrees and tasted cold. The bean salad was at 67 degrees. This observation confirmed facility was not serving residents hot food hot and cold food cold confirming continued temperature palatability issues. On 03/04/24 at 2:30 pm, Staff 1(Administrator) Staff 2, and Staff 3 (Executive Director) acknowledged they were aware of voiced food concerns by residents that included cold food temperatures and dislike of some menu items. Residents interviewed during kitchen survey continue to feel the food service at facility was not adequate. Residents voiced they had raised concerns to facility multiple times and that facility was not adequately addressing concerns. Residents feel they do not have adequate input into the menus. Observations during meal service validated unpalatable temperatures for hot and cold food items. The facility has not effectively addressed residents voiced concerns/complaints regarding meal services.

Moving forward all resident counsel minutes will be updated and results posted with resolution prior to next meeting. This will be monitored and checked by Adminstrator. A separate food service meeting implemented to ensure feedback on quality of meals, temperture, accuracy of orders, menu input and any other resident's needs monthly. Minutes will be posted within 72 hours of meeting. Resident "Cusine Survey " has been given to all residents for input of food likes, dislikes and suggestions. Administrator and Culinary Director responsible for corrections and monitoring.

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by:

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, in a sanitary manner, served meals at palatable temperatures, and residents have input into menus as in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the Main kitchen and North kitchenette and dining room on 03/04/25 from 9:30 am thru 2;30 pm revealed the following: 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: Main Kitchen area * Floors corners, edges * Floors in walk in cooler under metal racks * Racks in dry storage * Metal can rack * Microwave * Walls/floors under dish washing area * Industrial can opener and housing North Unit Kitchenette *Floors *Microwave b. The following areas were in need of repair: * Cabinets/cupboards in north kitchenette with areas of exposed porous wood. * Bakery prep area table pulling away from wall. * Walk in cooler floor peeling/chipping c. Facility prepared food items found in walk in cooler past 7 days. d. Care staff observed to heat up a can of soup and did not check the temperature of the food item before service to resident to ensure it was at appropriate service temperature. e. Staff member preparing food was observed to not have facial hair restrained as required. f. Cold salad of black beans, tomatoes and avocado was not stored on ice to ensure it remained cold during food service and to the point of delivery. Temperature noted on dining room tray was 57 degrees. Temperature on room delivery tray was 67 degrees. g. Multiple residents during meal observations complained that often hot entrée food temperatures seemed cold. Surveyor ordered a test tray and multiple meal items were noted at unpalatable temperatures for hot food items. Chicken tacos were found at 101 degrees and tasted cold. Bean salad at 57 degrees (cold item) did not taste cold and was very bland needing salt. Cup of soup was warm, but pieces of vegetables (potato and whole baby carrot) were unusually large and didn’t fit on spoon.) This would have been difficult for a resident needing cut up food to eat. h. During lunch meal dining observations on 03/04/25, multiple residents voiced dislike of current menus and felt they had little to no input on menu choices. Staff 2 Food Service Director, and Staff 3 (Executive director) toured areas with surveyor and acknowledged the areas identified. On 03/04/25 at 2:00 pm, surveyor discussed dining observation and test tray findings with staff 2, staff 1 and staff 3 who acknowledged the identified issues.

Updated cleaning schedule has been put in place for daily, weekly, monthly tasking with Dietary Manager evaluating daily task sheets. North unit kitchenette cleaning schedules has been updated and posted by Dietary manger to evaluate daily. All kitchen staff will be trained on checklist to ensure proper completion and accurancy. Work orders have been submitted to Maintence for all repair areas noted in statement of deficencys. Reporting of maitenance issues have been added to daily task sheets. Food items will be put on a rotating cycle and open labels to be checked on daily basis by Culinary Director or designee. Procedure in place for proper warming of food cooked in microwave, posted at each microwave. Beard nets will be worn by a staff with beards, ensure proper uniform be monitored by Culinary Director and Administrator. Temps audit 3x weekly on temperature of food upon being served to resident. Food warming cart has been put into place for delivery of room trays. Mindy's Corner created for food services input monthly meeting. Resident "Cusine Survey" has been given to each resident for likes, dislikes and suggestions. Audit to be completed weekly of all areas, completed by Administrator, Culinary Director or their designee.

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: