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 in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main kitchen and dining room kitchenette areas on 05/16/25 from 10:30 am through 1:00pm 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: * Interior of ice machine; * Kitchen drains; * Exterior/handles of reach in coolers; * Interior of microwaves in dining rooms; * Interior of ovens; * Interior of reach in freezer * On/in and around light fixtures; * Interior of reach in refrigerator in dining room * Interior of activities oven in dining room * Industrial can opener blade * Walls behind and under dishwashing area * Carpet just outside the kitchen door with multiple stains/dark areas b. The following areas were in need of repair: * Area where pipes inter walls just below ceiling with open areas and not sealed allowing potential entry for pests. * Section of wall directly behind steamer with damage * Caulking behind hand washing sink missing, damaged or with black debris accumulation * Section of wall corner with drywall chipped/cracked and metal corner exposed * Section of grout missing near PIC desk area. * Black 3 tier utility cart with heavy damage yielding unsmooth and non-cleanable surface. c. Dining assistant observed handling personal phone and touched glasses/face and did not wash hands. Cook observed to leave line to open reach in refrigerator, leave and handles dirty dishes and return to line and did not remove gloves, did not wash hands and handled ready to eat breadsticks. Cook was observed to leave the kitchen and when returning did not clean hands. Cook was observed to handle sanitizer rag to clean thermometer/knives and did not change gloves. They were observed to handle ready to eat foods after handling sanitizer rag. d. Multiple items (beverages, dessert, soup, salad) for resident room tray service were not covered and protected from contamination when delivered to rooms. e. Cook was using latex gloves for food service. Latex gloves use is prohibited according to food sanitation rules. f. A large drink container of coffee for kitchen staff was observed right next to food preparation area. It did not have a lid or a straw and posed contamination risk. g. The facility did not have pasteurized shell eggs. Kitchen staff confirmed they prepare and served eggs cooked to order with those eggs including over easy and over medium. Staff 2 (Dietary Services Manager) they were aware of the need to use pasteurized eggs for eggs that were not “fully cooked” and indicated they had not been able to get pasteurized shell eggs from their vendor. h. Multiple rags for surface cleaning/sanitation were observed stored out of the sanitation buckets on random counters/areas throughout the kitchen. i. Staff 2 was not aware of the chemical or concentration of the chemical they were using for their surface sanitation. The test strips on the wall was a quat based test strip which was not for the current chemical used. Staff 2 verified they facility did not have any strips to test the effectiveness of the chemical used for surface sanitation. Staff 1 (Executive Director) verified the vendor recently switched the chemical used for sanitizing surfaces in the kitchen and that the facility did not know the current chemical used nor the effective sanitation PPM (parts per million) Staff 1 indicated they would contact their vendor right away to have the correct strips to validate effective sanitation. j. The facility did not have a copy of the Oregon Food Sanitation rules as required for every food establishment. Surveyor provided guidance on where to locate the electronic copy. k. Salad dressings observed without open or use by dates. Container of raw shell eggs observed stored in a metal container with multiple eggs cracked uncovered and with egg product leaking over other eggs. Other food items observed without open or preparation dates. Staff 2 Dining Services Manager, toured kitchen with surveyor and acknowledged the areas identified. At approximately 1pm, the surveyor and Staff 1 (Executive Director) reviewed areas of concern. Staff 1 acknowledged the above areas needed to be cleaned and repaired and practices that needed addressed.

A. The kitchen has been thoroughly cleaned. Task sheets were created and each shift will use task sheet to ensure proper cleanliness. Task Sheets will be turned into DSD to assess and verify cleanliness. DSD will audit daily x 1 week. Weekly x 3 weeks, then monthly x 2 months. B. The hole in the ceiling around pipe has been sealed with fire caulk. The wall behind steamer has been repaired. The hand washing sink has been caulked. The wall with metal showing on the corner has been repaired. The missing grout on the kitchen floor has been regrouted. The cart that was damaged was thrown away. DSD and Maintenance will do a kitchen walk through monthly to assess and address reapairs. C. Staff have been educated on hand hygiene and proper glove usage. Continuing education and audits to take place on hand hygiene by DSD daily x 1 week, weekly x 3 weeks, monthly x 2 months. D. Staff have been educated on covering all food and beverages for tray delivery. DSD will audit daily x 1 week. Weekly x 3 weeks, monthly x 2 months. E. All Latex gloves were removed from kitchen. Staff educated on the prohibition of latex gloves. DSD will ensure latex gloves are not used by auditing daily x 1 week. Weekly x 3 weeks and monthly x 2 months. F. Staff educated on the prohibition of personal food and beverage items on the cook line and to use deisgnated break areas for such items. DSD to audit daily x 1 week, weekly x 3 weeks, monthly x 2 months. G. Staff educated that pasteurized eggs cannot be cooked to order, they must be thoroughly cooked. DSD to audit daily x 1 week, weekly x 3 weeks, monthly x 2 months. H. Staff educated on sanitizer rags "living" in the sanitizer bucket and not lying all over counters. DSD to audit daily x 1 week, weekly x 3 weeks, monthly x 2 months. I. DSD educated on Chemical Concentration for surface sanitation, and use of test trips. DSD to audit Chemical concentration daily x 1 week, weekly x 3 weeks, monthly x 1 month. J. DSD printed out Oregon Food Sanitation Rules and Posted in Kitchen. DSD to educate staff on Rules and location for referance. DSD to audit it is in place daily x 1 week, weekly x 3 weeks, monthly x 2 months. K. Staff educated on the process of covering and dating all opened items. DSD to audit daily x 1 week, weekly x 3 weeks, monthly x 2 months.

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: