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 kitchens clean and 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: The main kitchen and the kitchenettes in Cottages 1 through 8 were toured on 06/04/25 at 9:28 am. Staff 2 (Food and Beverage Director) stated the caregivers prepared the breakfast meal in the kitchenette of each Cottage and the main kitchen prepared lunch and dinner. The following was identified: a. Main kitchen: * Sanitation levels for the Quaternary based surface sanitizer was observed to be over 400 parts per million (ppm). b. Food Storage: * The refrigerators in Cottages 1,2,3,4,5,7 and 8 were observed to have torn and/or damaged door gaskets and internal temperatures over 41; * Cottage 8 had expired food in the refrigerator; and * Multiple Cottage refrigerators for resident use were being used by staff to store their personal food items. c. Garbage compost bins in 6 of 8 Cottages had missing lids. d. Leftover food items were improperly stored, labeled, dated and/or lacked a cover. e. Multiple cottages had improperly stored cooking equipment inside the ovens. f. Cottage 4 needed repair in the following areas: * Refrigerator crisper was broken/missing; * Handwash sink didn’t operate; * Multiple drawer pulls were damaged; and * Wood veneer by the sink was damaged rendering the surface uncleanable. g. Cottage 7 needed repair in the following areas: * The wood cabinet beneath the sink had dry rot and damaged wood and the front of the cabinet was pulling away from the base of the cabinet; * Quarter round baseboard joining the floor to the sink cabinet was damaged and separated from the floor. h. Cottage 8 needed repair in the following areas: * Corner cabinet between the sink and the stove had a broken door hinge preventing the cabinet from opening and closing correctly. The need to ensure the facility had a system in place to ensure the kitchens were clean and in good repair and maintained in a sanitary manner in accordance with Food Sanitation Rules was discussed with Staff 1 (ED) and Staff 2 (Food and Beverage Director) on 06/04/25 at 1:05 pm. They acknowledged the findings.

Cottages Senior Living will maintain cottage kitchen areas to be clean, in good repair and in a sanitary manner. Main kitchen sanitation levels for the quaternary based surface sanitizer will be at desired level. Cottage refridgerator gaskets will be in good repair to maintain proper internal temperature. During inspection food items that were susceptible to rapid bacterial growth were removed from refridgerators and discarded. Cottage refridgerators will be used for resident use only, team members will not store their personal food items in refridgerators. During inspection personal food items were discarded. Cottage food scrap bins will have lids. During inspection, all food scrap bins in cottage kitchens were replaced with bins with lids. Leftover resident food items will be properly stored, labeled, dated and covered. During inspection leftover resident food items were discarded. Cottage ovens will be free of improperly stored cooking equipment. Cottage 4's refridgerator crisper will be in good repair. Cottage 4's handwash sink will be in good repair. Cottage 4's drawer pulls will be in good repair. Cottage 4's wood veneer by sink will be in good repair. Cottage 7's wood cabinet beneath sink will be in good repair. Cottage 7's baseboard joining floor to sink cabinet will be in good repair. Cottage 8's corner cabinet between sink and stove will be in good repair. Bi-weekly audits will be completed by Executive Director (ED), Dining Services Director (DSD), Maintenance Director (MD), and Resident Services Director (RSD) or Designee to assure compliance. Audits will be reviewed during Monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance. All staff meeting held on June 10, 2025; training topics included cottage kitchens need to be clean, in good repair and in a sanitary manner. Future all staff meetings will be held July 10, 2025 and August 8, 2025; topics will include the above. Leadership meeting held on June 11, 2025 to discuss inspection findings and plan of correction. Daily Standup meetings were held with team members from all departments to discuss inspection findings and plan of correction. Weekly memos posted in team breakroom to alert team members of plan of correction and compliance. ED, DSD, MD and RSD will be responsible.

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 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on interview and record review, the facility failed to establish and maintain infection prevention and control protocols to prevent the development and transmission of communicable disease per OAR 333-150-0000. Findings include, but are not limited to: During the entrance conference for the annual kitchen inspection, the facility provided a copy of their “Employee Illness Policy”. The policy lacked the following required exclusions for food employees: *Jaundice; * Lesions that are open and draining on the hands, wrists or exposed arms; and * Exclusion due to confirmed or presumptive with Hepatitis A virus, Shigella, E. coli or Salmonella. The need to ensure the facility established and maintained infection prevention protocols for all food employees was discussed with Staff 1 (ED), Staff 2 (Food and Beverage Director) on 06/04/25 at 1:05 pm. They acknowledged the findings.

Cottage Senior Living will maintain a Employee Illness Policy that meets the requirement to include exclusions and restrictions for food team members. All staff meeting held on June 10, 2025: training included Employee Illness Policy that needs to include exclusions and restrictions for food team members. Leadership meeting held on June 11, 2025 to discuss inspection findings and plan of correction. ED will be responsible.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by:

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all poisons, chemicals, rodenticides, and other toxic materials were secured in locked storage. Findings include, but are not limited to: During the tour of the kitchenette in Cottage 7 on 06/04/25 with Staff 2 (Food and Beverage Director) the following was identified: Multiple dishwasher pods and two chemical disinfectant spray bottles were observed in unlocked cabinets. The door leading into the kitchenette was unlocked and the door was open. The need to ensure all toxic chemicals were secured in locked storage was discussed with Staff 1 (ED) and Staff 2 on 06/04/25 at 1:05 pm. They acknowledged the findings.

Cottages Senior Living will ensure all toxic chemicals are secured in locked storage. During inspection, dishwasher pods and chemical spray bottles were removed from cottage. Bi-weekly audits will be completed by ED, DSD, MD and RSD or Designee to assure compliance. Audits will be reviewed during monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internl system to keep in compliance. All staff meeting held on June 10, 2025; training topic included toxic chemicals need to be secured in locked storage. Future all staff meetings will be held on July 10, 2025 and August 8, 2025; topics will include the above. Leadership meeting held on June 11, 2025 to discuss inspection findings and plan of correction. Daily standup meetings were held with team members from all departments to discuss inspection findings and plan of correction. Weekly memos posted in team breakroom to alert teawm members of plan of correction and compliance. ED, DSD, MD and RSD will be responsible.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. 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 observation, interview and record review 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: C 240, C 295, and C 510

Cottages Senior Living will follow licensing rules for Memory Care Community Rules. Please see plan of corrections under tags C0295, C0240 and C0510.

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: