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 04//30/25 at 10:35 am, the facility kitchen was observed to need cleaning and repair in the following areas: * Commercial can opener – blade with food debris/housing with black matter build up; * Lower shelves throughout the entire kitchen – food debris/spills/drips; * Two door refrigerator: door handles sticky, exterior food smears, interior spills/drips bottom shelf; * Ice maker interior – black/pink matter build up; * Stainless steel underneath counter around the service line – drips/spills; * Stainless steel drawer fronts on service line – spills/drips; * Stove oven doors and sides – grease/drips/spills; * Grill top and surround – heavy build up of grease (black); * Counter with toaster/microwave – drawer fronts with drips/spills; * Food bin lids and exterior – food debris/splatters; * Counter/prep area next to grill – drawers exterior and interior – food debris/spills/drips; * Walk in refrigerator – fans with heavy build up of black matter, housing around fans and ceiling with build up of black matter, floor with black ;matter build up, rusty metal shelf * Cabinet doors in service area of dining room – drips/spills; * Flooring throughout the entire kitchen, including underneath prep areas, sinks, service area dishwashing area and behind cooking equipment – build up of black matter, food debris, spills; * Screen in clean dishwashing area – significant build up of dust (window was open); * Window screen not secure, potential for pests to enter; * Walk in freezer – significant build up of ice on the floor, ceiling pulling apart; and * Commercial stand mixer – finish worn off, per staff unusable. Improper food storage: * Food stored in two door refrigerator lacked labels, dates and/or not covered. * Scoops in flour, panko crumbs and brown sugar. * Flooring under racks in dry storage had food items such as sugar packet, tea bag and creamer containers. * Service area off dining room – soup well uncovered. Other concerns: * White cutting board on service line – stained and scored; and * Colored cutting boards – worn and very scored. * Staff not always washing hands between glove changes. * Lack of using beards restraints. The areas of concern were observed and discussed with Staff 1 (Dining Services Director) and discussed with Staff 2 (Executive Director) on 04/30/25. The findings were acknowledged.

1. All identified areas in the kitchen have been deep cleaned, and all repairs have been completed. 2. Routine cleaning schedules for kitchen have been updated to include areas that were missing. Dining Director will be reviewing cleaning schedules weekly, at a minimum, and will follow up as needed. Dining Director will complete a monthly kitchen sanitation audit, to include repair work needed, and ensure any deficencies will be corrected timely. 3. New cutting boards were immediately purcahsed. 4. Window screen has been secured 5. Infection control training provided to all dining staff reminding and instructing on proper hand hygeine and importance of hair and beard nets. Visual instructions have also been posted throughout kitchen and servery. 6. System will be evaluated monthly as part of the Quality Assurance Performance Improvement process to include a review of the monthly kitchen sanitation audits. 7. Executive Director, Maintenance Director and Dining Director will be responsible for maintaining this system

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: Observations of the facility kitchen, food storage areas, and food preparation on 06/06/2025 at 11:00 am revealed splatters, spills, drips, and/or debris on: * Lower shelves throughout the entire kitchen; * Stainless steel underneath counter around the service line; * Stainless steel drawer fronts on the service line; * Stove oven doors and sides; * Grill top had a heavy build-up of grease; * Counter with toaster and microwave and drawer fronts beneath it; * Counter/prep area next to grill – interior and exterior drawers; * Cabinet doors in service area of dining room; * Interior of ice machine; * Windows along the length of the kitchen were observed to be open and the window screens had a significant build-up of dust on the surfaces; * Walk-in refrigerator had fans with a heavy build-up of black matter on the blades, housing around fans and ceiling, and housed a rusty metal shelf; and * Flooring throughout the entire kitchen, including in the walk-in refrigerator, underneath prep areas, sinks, service area dishwashing area, behind cooking equipment and underneath dry storage racks had build-up of black matter, food debris and spills; b. Improper food storage: * Food stored in two-door refrigerator and walk-in refrigerator lacked labels, dates, and/or was not covered. c. The following equipment was observed not in good repair. * White cutting board on service line was stained and scored; and * Walk-in freezer had a significant build-up of ice on the floor and the ceiling was pulled apart. The areas of concern were observed and discussed with Staff 1 (Dining Services Director) and Staff 3 (Interim Administrator) on 06/06/25 at 11:45 am. They acknowledged the findings.

1. All identified areas in the kitchen have been cleaned and all identified repairs have been completed. 2. Routine cleaning schedules for kitchen have been updated to include areas that were missing. Dining Director will be reviewing cleaning schedules weekly, at a minimum, and will follow up as needed. Dining Director will complete a monthly kitchen sanitation audit, to include repair work needed, and ensure any deficencies will be corrected timely. 3. New cutting board was immediately purchased. 4. Infection control training provided to all dining staff reminding and instructing on proper hand hygeine and importance of hair and beard nets. Visual instructions have also been posted throughout kitchen and servery. 5. Monthly kitchen sanitation audits will be completed by the Dining Director and this system will be evaluated quarterly as part of the Quality Assurance Performance Improvement process. 6. Executive Director and Dining Director will be responsible for maintaining this system.

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 411-054-0030 (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 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

1. Dining Director and Executive Director will meet weekly to review the weekly cleaning schedule and monthly kitchen sanitation audit (if applicable) to ensure completion and compliance. 2. Executive Director will be responsible for submitting weekly cleaning schedule reviews and monthly kitchen sanitation audit (if applicable) to District Director of Operations on a weekly basis to ensure that plan of correction is being followed and we are remaining on track to meet our alleged compliance date.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: