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. Facility also failed to ensure menus were predominately displayed for residents with altered texture diets were served meals in a palatable manor and in accordance with the menus. Findings include, but are not limited to: Observation of the main kitchen and individual house kitchens were reviewed on 05/30/25from 10:30 am through 2:00pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Walk in cooler fan grates * Exterior of Ninja blender * Interior of plastic bins storing measuring cups, spoons and scoops * Hinge of portable tray line shelf b. The following areas needed repair: * Screen door in the main kitchen area left a 1 ½ inch gap at the bottom of the door when in the closed position leaving space for insects/pests to enter. Main door was observed open the majority of survey with this gap allowing potential pest entry to kitchen * Knobs to one of the portable steam lines where broken off. c. Surface sanitizer buckets were tested upon entry to the main kitchen area. No parts per million (PPM) of sanitizer registered on the strips. The buckets were changed by staff and a fresh one was mad that also registered 0 ppm. The chemical was not observed flowing thru the hose to the mixing valve until ran for several seconds. Mixture was then tested and was registering 100ppm. Facility staff including staff 2 (Executive Chef) were not able to verbalize the correct concentration for the sanitizing solution used. Logs were reviewed and it was documented the staff documented the sanitizing solution earlier that day at 125 ppm. The facility was utilizing quaternary ammonia for surface sanitation which needs to be between 200 and 400 ppm for effective sanitation. Facility was unsure how long the dispenser of surface sanitizer was not dispensing the correct sanitation amounts. Surveyor brought this to the attention of Staff 2 who discussed the correct concentration needs to staff members. d. Multiple food items were found stored in the walk-in cooler that did not have a date opened or prepared and/or past the seven days as required. One item was found multiple days past the manufactures use by dates. e. A cook was observed to touch multiple servings of ready to eat Salmon for lunch with their bare hands while transferring from the baking pan to the tray line pan. f. Care staff members in multiple houses were observed serving and/or assisting residents with their meals without protective barriers to prevent cross contamination from care giving duties with meal service tasks. g. Kitchen staff drinking/beverage cups were not off the approved style making hand contact to lip surfaces of the cup likely which is prohibited per rule. h. Food and beverage items were not appropriately covered and protected from potential contamination when delivered to resident rooms. i. Menus were not predominately posted in the houses for residents/visitors to review. j. A resident in house E was observed to be served all pureed food items in 1 dish all mixed together. It did not look appetizing. Caregiver was asked why they were doing it that way and they said they had just always done it that way. Staff 2 acknowledged this was not an appropriate way to present the food products for palatability and provided education to the staff member. k. Multiple prepared pureed meals were observed in the walk in cooler. Staff 2 was interviewed and indicated the facility’s practice was to puree the days meal for meal service the next day. This meant that residents receiving the pureed meal were a day behind the rest of the residents and that the residents were always getting reheated “leftovers” from the day before. Staff 2 verified the residents on puree diets were not served freshly cooked food like the other residents. This practice was related to allowing staff the ability to serve puree residents before other residents related to assistance needed with meals. This practice was not related to resident request or choice. At 1:30 pm, surveyor reviewed above areas with staff 2 and staff 1 (Facility Designee) who acknowledged areas in need of attention.

A) Cleaning checklist has been updated to include items found to be deficient: fan in walk in cooler, blender, bins, and portable tray B) Screen door and knobs on steam lines will be replaced by 6/17/25 C) On 6/5/25 all kitchen staff were properly trained on different chemical strips, submersion time for each strip, and frequency. Administrator will routinely have kitchen staff demonstrate procedure at least weekly D) Administrator will check stored and shelved food for dates, prepared within 7 days, and properly stored E) Staff training provided on cleanliness, proper use of gloves, and hand hygiene. Administrator to ensure individuals are following best practices F) Training and routine monitoring starting 5/31/25 to ensure staff are wearing full aprons and following best practices G) On date indicated, staff to be prohibited from keeping drinks in main kitchen H) Training and routine monitoring starting 5/31/25 to ensure staff are properly covering food and drinks when delivering trays I) Menus will continue to be emailed to families weekly, resident’s input during resident council meetings, and will be displayed on the refrigerator J) Puree food will be served in divided plates, staff will be trained on not mixing pureed food unless this is resident’s preference and will be care planned, and dining will use menu items of the day for puree foods

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.

Z0142) Community will follow proposed POC to ensure compliance of this rule

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: