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: The facility's kitchen was toured on 06/09/25 at 9:52 am. a. An accumulation of food spills, splatters, loose food debris, grease, dirt, dust, garbage, or black matter was observed on, in or underneath the following: * Baseboards and flooring throughout the kitchen; * Walls throughout the kitchen; * Counters throughout the kitchen; * Lighting fixtures throughout the kitchen; * Open shelving under drink stations; * Microwaves; * Toaster; * Sandwich press; * Interior casing of can opener; * Shelving under steam table; * Sides of grill and equipment surrounding grill; * Interior of drawers; * Baker's racks; * Flooring of walk-in refrigerator; * Exhaust fan grates and ceiling in walk-in refrigerator; and * Warewasher, including plumbing and mechanics. b. The following kitchen items required repair or replacement: * Coffee station shelving had cracks, gouges and bare wood exposed; * Exposed area in baseboard under coffee station; * Tea and cocoa station shelving was missing laminate with bare wood exposed; * Microwave interior had peeling enamel; * Green cutting board had gouges and scrapes; * Sandwich press had peeling enamel; * Corner drywall near freezer was gouged with metal corner guard exposed; and * Tile near warewasher was gouged. c. Observation of the facility's refrigerators and dry storage revealed multiple food items were not covered, dated, and/or labeled appropriately. d. Poor infection control practices observed, but not limited to: * Plastic cups, used as scoops, were stored in the containers with the food products; * Stand mixer and mixing bowl were left uncovered when not in use; * Sanitizing buckets had cold water, and kitchen staff were not using chemical testing strips; * Rotten potatoes, moldy blackberries, and wilted greens were observed stored in fresh produce; * Kitchen staff failed to perform hand hygiene consistently between dirty and clean tasks; and * The warewasher was not reaching the required temperature of 120 degrees F. Concerns regarding the warewasher not reaching the minimum temperature for sanitation were discussed with Staff 1 (ED) on 06/09/25 at 11:47 am. The temperature was immediately adjusted and was re-tested at 123 degrees F. A kitchen walkthrough was completed with Staff 1 and Staff 2 (Cook/Dishwasher) on 06/09/25 at 1:51 pm. The areas that did not meet the rules, were discussed with Staff 1 and Staff 2. They acknowledged the findings.

1.All identified areas in the kitchen were thoroughly cleaned in the days following the inspection. This included removal of food debris, spills, grease, and dust from the following areas: • Baseboards and flooring throughout the kitchen • Walls throughout the kitchen • Counters throughout the kitchen • Lighting fixtures throughout the kitchen • Open shelving under drink stations • Microwaves • Toaster • Sandwich press • Interior casing of can opener • Shelving under steam table • Sides of grill and equipment surrounding grill • Interior of drawers • Baker’s racks • Flooring of walk-in refrigerator • Exhaust fan grates and ceiling in walk-in refrigerator The microwave and sandwich press were removed and replaced with new equipment. Damaged cutting boards were discarded and replaced. The drink station, which includes shelving with cracks, gouges, and exposed wood, is currently pending replacement and a vendor quote is being obtained. Other damaged areas, including gouged tile and drywall, are being assessed for appropriate repair or resurfacing. All improperly stored, uncovered, or unlabeled food items were discarded at the time of the inspection. Plastic cups that had been used as scoops were immediately removed and discarded. Staff were re-educated on infection control expectations, including proper hand hygiene when transitioning between dirty and clean tasks. The stand mixer now has a cover in place, and staff were instructed to keep it covered at all times when not in use. Sanitizing buckets were found to be filled with cold water and not tested for chemical strength. Staff were re-educated on correct sanitizing procedures, including maintaining temperature and testing with chemical strips, which were available but not being utilized. Spoiled produce—including blackberries, potatoes, and wilted greens—was discarded. The warewasher was found to be operating below the required sanitation temperature; the water heater was adjusted during the inspection and the warewasher was confirmed to be reaching 120°F. 2. A full inspection of the kitchen and food service areas will be completed prior to the plan of correction compliance date to ensure no other deficient practices exist beyond those identified during the survey. Any additional findings will be addressed and corrected at that time. Although no other staff were cited for infection control concerns, a monthly kitchen staff meeting has been scheduled on an ongoing basis to review sanitation expectations, address any concerns, and reinforce key food safety and infection control policies. As an added layer of oversight, the facility has updated its cleaning checklists and implemented a structured walkthrough schedule: daily walkthroughs by the cook on duty, weekly walkthroughs by the lead cook/dining services coordinator/designee, and monthly walkthroughs by the Executive Director/designee—or more often if concerns arise. 3. Daily, weekly, monthly and as needed for concerns. 4. Cooks, Lead Cook, Dining Services Coordinator, Executive Director, or Designees

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. This is a repeat citation. Findings include, but are not limited to: The facility's kitchen was toured on 08/20/25 at 9:00 am. a. An accumulation of food spills, splatters, loose food debris, grease, dirt, dust, garbage, or black matter was observed on, in, or underneath the following: * Tile flooring/grout lines/cove base at kitchen entrance and throughout the kitchen; * Metal edge of hand wash sink and white half wall adjacent to coffee area; * Caulking behind hand wash sink; * Floor drain near ice machine; * Multiple walls throughout the kitchen; * Open shelving and bins under drink stations; * Microwave at tea/cocoa station; * Shelving under steam table; * Sides of grill and equipment surrounding grill; * Baker's racks; * Flooring of walk-in refrigerator; * Exhaust fan grates and ceiling in walk-in refrigerator; and * Caulking and wall underneath dish machine. b. The following kitchen items required repair or replacement: * Baseboard under coffee station; * Tea and cocoa station shelving had laminate taped to the edge; * Corner drywall near freezer was gouged, with metal corner guard exposed; * Tile near dish machine was gouged; * Paint on entry/exit doors was scratched; and * Scraped/gouged wall behind food bins. c. Two kitchen staff did not have facial hair contained/covered. A kitchen walk-through was completed with Staff 1 (Executive Director) on 08/20/25 at 10:15 am. She acknowledged the findings.

1. The kitchen flooring, including tile, grout lines, cove base, and walk-in refrigerator floors, was steam cleaned and power washed, with regular steaming added to the cleaning schedule. The metal edge of the hand wash sink and adjacent half wall were thoroughly cleaned. Caulking behind the hand wash sink was cleaned, and sections that could not be adequately sanitized were replaced. Floor drains near the ice machine were fully cleaned. All walls, open shelving, bins, the microwave, shelving under the steam table, grill sides and surrounding equipment, and baker’s racks were cleaned and sanitized. Exhaust fan grates and the ceiling in the walk-in refrigerator were dusted and cleaned. The caulking and wall underneath the dish machine were cleaned, with replacement performed where cleaning was not sufficient. The coffee, tea, and cocoa station was scheduled to be resurfaced, and the area underneath was enclosed to ensure smooth and cleanable surfaces. Drywall near the freezer was patched and repainted, restoring the integrity of the wall. Gouged tile near the dish machine was repaired. Scratched paint on the entry and exit doors was touched up, and scraped walls behind the food bins were patched and painted to create intact and easily sanitized surfaces. Beard nets were purchased and distributed to all kitchen staff, and all staff received immediate re-education on personal hygiene requirements and food sanitation standards. Supervisory spot checks were initiated to verify compliance with facial hair covering at the beginning of each shift. 2. To correct the system and prevent future violations, the facility has implemented comprehensive cleaning checklists that address each specific area cited, including floors, grout, drains, walls, shelving, equipment surfaces, and refrigeration units. These checklists are divided into daily, weekly, and monthly tasks to ensure consistent attention to both high-use and hard-to-reach areas. All cleaning is logged by staff and reviewed by supervisory personnel for accountability. In addition, a preventive maintenance program has been established to identify and promptly repair damaged or uncleanable surfaces such as drywall, tile, paint, and shelving. Staff hygiene compliance is now monitored through mandatory beard net use, reinforced by staff education, updated dress code policy, and supervisory spot checks at the start of each shift. These system corrections create multiple layers of oversight to maintain sanitation, ensure repairs are completed in a timely manner, and sustain compliance with food sanitation rules. 3. The Executive Director, Dining Services Coorintator, or designee will complete a kitchen walk-through each week to verify that cleaning, maintenance, and staff compliance are sustained. 4. Executive Director, Dining Services Coordinator, or Designee

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 2 of 3 staff (#s 2 and 4) who prepared food had active food handler's certificates. Findings include, but are not limited to: On 06/09/25, employee records were requested and reviewed to ensure staff had active food handler's cards. The food handler's cards for Staff 2 (Cook/Dishwasher) and Staff 4 (Cook/Dishwasher) were dated as obtained the day of survey. On 06/09/25 at 2:31 pm, the surveyor requested to review Staff 2 and Staff 4’s previous food handler's cards. Staff 1 (ED) reported she “couldn’t track them down.” The need to ensure staff who prepared food had active food handler’s certificates was discussed with Staff 1 on 06/09/25 at 2:31 pm. She acknowledged the findings.

1. All food service employees have obtained current food handler certifications. The Business Office Coordinator (BOC) is now responsible for tracking food handler card documentation and monitoring expiration dates. Staff will be notified in advance of any upcoming expirations to ensure continuous compliance. Certification records will be stored in the Training Binders located in the business office. Moving forward, food handler certification will be required as part of the onboarding process for all new food service employees. The BOC will review the training tracker at least twice per month to confirm that all required documentation remains up to date. 2. To ensure that no additional staff were out of compliance, a full audit of employee files was completed, and all food service staff were confirmed to have valid food handler certifications. All current documentation is now stored centrally in the Training Binders and monitored by the Business Office Coordinator to prevent future lapses. 3. Twice monthly review of the Training Tracker for food handler's cards expiring and as needed for new hires by Business Office Coordinator. Executive Director will verify at least quarterly to ensure tracker is up-to-date and compliant. 4. Business Office Coordinator and Executive Director

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable 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 kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

1. The facility immediately conducted a full kitchen deep cleaning and verified that all previously cited areas were corrected. Staff were re-educated on their responsibilities under the plan of correction, and updated cleaning and maintenance checklists were implemented. A new plan of correction was written to address all cited issues and ensure regulatory compliance. 2.The facility re-educated staff to ensure the kitchen plan of correction is fully implemented and maintained. Cleaning and maintenance tasks from the POC have been built into daily, weekly, and monthly checklists, with documentation reviewed by the Dining Services Manager and oversight by the Executive Director. 3. The Executive Director, Dining Services Coorintator, or designee will complete a kitchen walk-through each week to verify that cleaning, maintenance, and staff compliance are sustained. 4. Executive Director