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 observations and interviews, it was determined the facility failed to maintain the kitchen in a sanitary manner and serve food at palatable temperatures and appropriate textures in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the kitchen on 06/05/25 at 10:45 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, around or underneath the following: * Kitchen drains * Industrial mixer and slicer * Industrial can opener * Metal large can rack * Metal shelf above cooking area * Interior of stainless-steel drawers * Juice machine * Lids of bulk bins * Popcorn maker * Stainless-steel shelving b. The following areas were in need of repair: * Light switch cover cracked * Area around floor electrical outlet in Dining room with gap in caulking. c. Both surface sanitizer buckets were found not a proper concentration (Parts Per Million) for effective sanitizing. Facility’s test strips did not turn any color indicating zero active sanitizing chemical available in the red buckets meant for sanitizing surfaces. Facility made fresh buckets and were found at appropriate PPM for sanitizer concentration. d. Multiple food items were found not dated when opened. e. Multiple containers of bulk dry goods had cups or scoops stored in them with the handles or hand contact surfaces touching the food product potentially contaminating the items. f. The small memory care refrigerator was noted at 48 degrees. The facility was not able to demonstrate an effective process for monitoring the mini fridge temperatures for cold food storage. Multiple resident food items were observed stored in that refrigerator. g. Some items in reach in freezers were observed not fully covered/protected from potential contamination. h. Two residents on minced and moist diet textures were served minced meat but with bbq sauce poured on top. For this diet type mixed textures are not permitted and must be thoroughly mixed into the product yielding one texture. The temperature of the BBQ pork was also noted to be at 118 degrees Fahrenheit and was about to be served to the residents at that lower temperature. Surveyor interviewed and instructed that food must be hot held and leave the kitchen at 135 degrees or hotter. Staff 2 (Dining Services Director) acknowledged the food was not hot enough and was going to be served at unpalatable temperatures. Food was reheated to a higher and more palatable temperature before served to residents. i. Caregiving staff in memory care unit that were assisting residents with their meals did not have aprons/protective barriers on to prevent possible contamination from their clothing during meals. j. Industrial slicer was observed uncovered and not protected from potential contamination when stored/not in use. At 12:45 pm, the surveyor reviewed above identified areas with both Staff 1 (Executive Director) and Staff 2 who acknowledged the of areas in need of correction.

1. The following areas have received a deep clan and the kitchen cleaning schedule has been reviewed/updated to ensure all below items are on the routine cleaning schedule: kitchen drains, mixer and slicer, can opener, can rack, stainless shelving, interior of drawers, juice machine, popcorn maker. The following areas have been repaired: light switch cover and gap in caulking around floor electrical outlet. 2. The Dining Services staff will receive additional training on food temperatures and diet cards, preparing and testing sanatizing buckets, covering and labeling/dating food items, proper scoop storage for bulk dry goods, refrigerator temperature logs. Direct Care staff will receive additional training on use of aprons. 3/4. The QA - Dining Services Review Schedule will be completed weekly by the DSD and reviewed by the ED who is responsible for ensuring compliance.

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, interview, and record review, it was determined the facility failed to maintain the kitchen and handle and serve food items in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observation of the kitchen on 06/05/25 at 10:45 am through 1:00pm revealed the following: a. The following area was in need of repair: * Floor electrical outlet in the Assisted Living dining room with gap in caulking. b. The surface sanitizer buckets were found not at a proper concentration (parts per million) for effective sanitizing. The solution tested at 100 parts per million. Staff 2 (Dietary Services Manager) stated that he believed the solution should be 150 ppm and showed documentation of daily sanitizing bucket checks throughout 08/2025 where the solution was noted to be 150 ppm. The facility utilized QT-10 strips for quaternary ammonia which requires the solution to test at 200 parts per million for effective sanitizing. Staff 2 remade the sanitizing solution, which continued to read at 100 ppm. The facility was unable to demonstrate a system for creating a sanitizing solution of an effective concentration for sanitizing. c. A container of bulk dry goods had a cup stored in it with the hand contact surfaces touching the food product, potentially contaminating the item. d. A box of hamburger patties in the reach in freezer was observed not fully covered to protect from potential contamination. e. At 12:16 pm, a hamburger patty was observed being removed from the hot hold area to be served to a resident. The hamburger was tested to be 92 degrees F. Surveyor reviewed that hot food must be 135 degrees F or greater when removed from hot holding temperature control. Staff 2 stated that there was no current system for testing food temperatures when removed from the hot holding area to ensure hot items are at least 135 degrees F. f. Caregiving staff in MCC unit who were assisting residents with their meals did not have aprons/protective barriers on to prevent possible contamination from their clothing during meals. The need to ensure the kitchen was maintained and food served in accordance with the Food Sanitation Rules was reviewed with Staff 1 (Executive Director) and Staff 2 on 08/26/25 at 12:50 pm. They acknowledged the findings.

1. The floor electrical outlet has been repaired, the sanitizing solution has been corrected, potentially contaminated product has been disposed of. 2. The Dining Services Staff will receive additional training on the QA - Food Temperature Log (Set-Up, Service, Holding) and the QA - Storage and Sanitation Audit (proper food storage and sanitation solution). The Dining Services Staff and Direct Care Staff will receive additional training on the use of aprons when assisting with meal service. 3. The Dining Services Director will review the areas of concern daily per the QA - Dining Services Review Schededule. The Executive Director will review the results of the QA audits weekly. 4. The Executive Director will be responsible for ensuring compliance.

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, interview, and record review, it was determined the facility failed to ensure the plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to: C240.

Refer to C 240.

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:

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.

Refer to 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: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to: C240.

Refer to C 240.

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: