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 and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Facility also failed to ensure residents were served correct textured diets. Findings include, but are not limited to: Observation of the 2 cottage kitchens (A and B) occurred on 04/08/25 at 11:15 am through 2:15 pm and 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: * Interior of cabinets and drawers for both houses. * Window screen in kitchen (B) where food is prepared. * Ceiling in main kitchen (B). b. The following areas were found in need of repair: * Caulking behind both sinks in Kitchen of House (B) missing or with black debris b. Resident food and beverages were transported from kitchen to the resident’s room and was not covered/protected from potential contamination as required. c. Cook did not check food temperatures of meal items prior to service to residents to ensure they were appropriate cooked to temperatures. d. A bowl of fajita vegetables was reheated for a resident and the cook did not check the temperature of the reheated food to ensure it was at safe and palatable temperatures. e. Facility did not have a system in place to ensure hot or cold food items were held at appropriate temperatures during service to ensure hot food was served hot (135 degrees or greater) or cold food served cold (41 or below). The meal consisted of refried beans, Mexican rice, steak fajitas and fresh fruit salad. Food was prepared in House B and placed on the countertop or stove top during plating. No burners were on, and food was not fully covered. Once all residents were served in house B, food was placed in hotel pans, covered with foil, and transported on an open cart to house A. Once in house A the pans were placed on the counter for service. The fruit salad was in a large bowl that was removed from the refrigerator at approximately 11:50 am it was not placed on ice during service. At the end of service after the last plate was served all hot food items were noted less than 135 degrees. The steak fajitas were 103 degrees, the rice was 97 degrees and the beans were 119 degrees. These are not palatable temperatures for “hot” food items. f. The facility did not have a system in place to ensure dishes were effectively sanitized. The cook, facility care staff and the maintenance staff were interviewed and neither were able to identify the rinse temperature of the dishwashers being used. The cook and care staff both indicated that at times the quick wash was used to ensure adequate dishes were clean for the next meal. Neither the cook, care staff nor maintenance staff knew which cycle to use on either house dishwasher to ensure effective sanitation for dishes. Maintenance staff acknowledged that they did not test/validate any rinse or cycle temperatures for either dishwasher. g. There were two residents identified by the facility as needing altered texture food items and one that needed thickened liquids for house A. All residents were provided with thin liquids for the lunch meal service. All residents received regular textured meal/food items for the lunch meal. Care staff was interviewed after meal service and was not aware that one of the residents was on a Minced and Moist texture modification diet. The care staff did not know what minced and moist texture was. Care staff acknowledged all residents were served regular textures. At approximately 1:00 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Administrator) who acknowledged the areas. Staff 1 was also asked regarding textured diets. Staff 1 was unaware of any residents on thickened liquids or modified textures. Staff 1 reviewed the resident with minced and moist indicated on the Posted “Resident Allergy/Info Chart”. Staff 1 reviewed the resident’s chart and verified the current diet order was Minced and Moist/Honey Thick Liquids. Staff 1 acknowledged the resident did not receive the correct diet texture for the observed meal. Staff 1 was not aware of the cycle temperatures for the dishwashers used in House A and B and if they met sanitization requirements.

C240 A and B 1. Kitchen will be deep cleaned by kitchen personnel to address food spills and ceiling, inside of cabinets, screens will be cleaned or replaced kitchen caulking to be redone by maintenance. 2.Modify kitchen cleaning chores list to include inside of cabinets, screens and ceiling fan. Kitchen personnel to retake food saftey training on O.C.P. 3. Audit to kitchen cleaning check off sheet weekly with visual inspection. X4 every 2 weeks, x1 month, monthly there after. 4. Admin/RCC/LN C240 C 1.Resuable plate and cup covers will be used for all room food delivieries. 2.Kitchen personnel to retrain via O.C.P. 3. Weekly x's 4, every 2 weeks x 1 4. Admin/RCC/LN C240 D and E 1. Food temp will be checked prior to serving residents with a food grade thermometer. 2. Kitchen personnel retrained via O.C.P. Additional thermometer purchased. 3.Daily x 7 via audit tool. Weekly x 4 Bi weekly X 1 4. LN/RCC. C240 F. 1. Food warmer purchased to transport food from B building to A building to keep hot food hot. Ice tray will be added to keep cold foods cold. Temps will be monitored to be in compliance with kitchen standards. 2. Admin/Kitchen to retrain via O.C.P. for kitchen standards. 3. Weekly x 4 Bi weekly x 2 Monthly there after. 4. LN/RCC C240 G. 1. Dishwasher will be checked and confirmed to be adequate for sanitation by maintenance. 2. Kitchen personnel to monitor temps as part of regular check off list. 3. Weekly x 4 Bi weekly X 2 Monthly there after. 4. Kitchen Personnel and Maintenance. C240 H. 1.Food textures list reviewed with kitchen personnel on admission and any diet order changes via diet book. Signature page added requiring kitchen staff confirm knowledge of textures and changes. 2. Retrain kitchen staff to proper diet texture with speech therapist through Home Health agency. Texture definition sheets in Kitchen for review. 3. Daily x's 7 days Weekly x's 1 month Bi monthly. 4. LN/RCC.

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 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.

See POC for 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: