OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs. This Rule is not met as evidenced by: Z 142: 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 and C 295

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 a sanitary manner, and to ensure meals were served at appropriate temperatures, in accordance with the Food Sanitation Rules, OAR 333-150-000. Facility also failed to ensure menus for residents were complete, varied and nutritious and changes/substitutions to menus were communicated to residents timely. Findings include, but are not limited to: Observation of the memory care kitchen area as well as the food storage building on 07/08/25 at 10:45 pm through 1:45 pm revealed the following deficiencies: 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: * Sponge/blue scratch pad used to clean dishes; * Interior of drawer storing food service equipment b. Multiple containers holding meal leftovers were observed with out dates when prepared or contained labels identifying food items. Multiple food or beverage items were found opened without opened dates as required. c. Staff 2 (Person In Charge) was noted to touch drawer handles, refrigerator handle, cupboard handles with gloved hands. The staff was then observed to handle ready to eat (RTE) food with her potentially contaminated gloves. Staff 2 was not observed to use single use gloves correctly using for multiple tasks. d. Staff were observed to wash hands in a sink that had dishes in the sink. Kitchen must have a dedicated sink for handwashing that is not used of other purposes during all food preparation and service times. e. Staff 2 was observed to take a container of left overs from the refrigerator and place in the microwave for 30 seconds then take out and serve to a resident. The staff did not stir the product and did not check the temperature of the food to ensure it was safely reheated per food code requirements. f. Staff 2 was not able to correctly demonstrate proper cooling processes or temperature requirements. Staff 2 indicated in interview that the facility was not checking temperatures of leftovers to ensure they were reaching the needed temperatures in the necessary time frames directed in food code. Staff 2 was not able to state correct reheat temperatures required to ensure food was reheated safely per code. g. Staff drink was observed stored in resident refrigerator. There was not a separate place to store staff food or beverages intermixing resident food with staff items. h. A staff drink was observed open on the counter next to the kitchen sink. The drink container was not of the correct/approved style as outlined in food code to limit/prevent staff handling of lip contact surfaces causing potential cross contamination. i. Menus were reviewed and were found to include multiple repetitive items such as Chili, Lentil soup, tuna salad sandwiches often only 1 day apart. Menus often listed incomplete items leaving out fruit or juice for multiple breakfasts. Multiple breakfasts not having a protein component. Multiple meals did not list a vegetable component or just listed soup or a sandwich. One week had 4 of 7 diner meals as soup the other 3 meals were sandwiches. The menu did not demonstrate adequate variety or complete nutritive value. The menus did not have a nutritional breakdown to verify the residents were served meals that met nutritional requirements. The menu for the meal at time of survey listed residents were to receive Chili and cornbread. Residents were served chicken wraps. The facility did not notify residents of the menu/meal change. The facility did not have a system in place for notifying residents of meal/menu changes. k. Dishwashing cleaning device was noted to be dirty and with pilling and in poor repair along with being unapproved materials for effective cleaning (sponge). Surveyor reviewed above areas with Staff 1 (Administrator) and they acknowledged the identified areas needing correction.

1. Cello Memory Care hired a new Activities Director as of 7/18/25. This person has excellent qualifications to be a Kitchen Lead and is also preparing food Menus an preparing meals. August food Menu is attached. White board in dining room will be used to note meal changes. Staff also communicate with residents when there is a meall change.Monthly meal plan will continue to be posted in dining room. In-service and educational material on proper use of gloves during meal preparation and while serving meals, educational materials provided. All employees were assigned the "Keeping Food Safe and Nourishing for Older Adults" Deep cleaning of Kitchen and dining room will be scheduled in August and every 3-6 months thereafter. Staff will clean surfaces/floor, appliances, dishes daily per policy. Leftover meal containers will be dated and monitored daily by Kitchen lead of the day, educational materials provided on datekeeping and available in the kitchen. Sponge for dishwashing replaced with fiber sponge that can be placed in the dishwasher. Staff now have a designated separate plastic container to store their drinks in kitchen refrigerator. Appropriate beverage containers to prevent spread of foodborne illness described to staff. Kitchen Lead will monitor daily. Administrator will do weekly walk through in kitchen area and will monitor completion of classes by due date

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 record review and staff interview, it was determined the facility failed to ensure appropriate policy and procedures were developed and in place to prevent the potential spread of communicable disease including but not limited to food borne outbreaks. Findings include but are not limited to: This rule indicates 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 including possible food borne outbreaks and gastrointestinal outbreaks including but not limited to Noro Virus. This also includes having a food worker sick policy for exclusion as outlined in Oregon Food Sanitation Rules. On 07/08/25 at 10:45 am during a kitchen survey, the facility was asked to provide a copy of their policy for food worker exclusion. This policy per food code should identify the symptoms and illnesses that staff who work with food should be excluded from work to prevent the potential spread of disease. The facility was not able to provide a policy that met this requirement. Staff 1 acknowledged their policy did not address the symptoms or illnesses listed/identified in food code. At the time of the kitchen survey the facility was also asked to provide their gastrointestinal illness (GI) outbreak policy and procedure. The facility was not able to provide any policy addressing potential GI/Noro/Food borne illness outbreaks. Staff 1 (Administrator) indicated in an interview at 1:30 pm that they were working on their policies with their consultant company and acknowledged they did not currently have a policy addressing communicable disease outbreaks that included potential food borne disease outbreaks.

1. In- service with employees on 7/30/25. Discussed Kitchen survey, reviewed the Employee Illness Policy and provided a copy via email to all. See attached. Revised Food Safety Policy and provided education both written and verbal to employees. See attached. Revised Infection Control policy. See attached. 2. Will continue to update policies as required and continue to incorporate classes/education and in- services to review infection control policies and procedures quarterly. All employees were assigned the "Keeping Food Safe and Nourinshing for Older Adults" class 3. Designated infection control specialist completed the "Infection Control Specialist Training for CBC" through Oregon Care Partners on 3/6/2025. 4. Our lead kitchen worker is on site 5 days a week and will be responsible for specific food service/kitchen monitoring as per our employee illness policy, food safety policy, and infection control policy. She will report to Infection Control Specialist or to Administrator any areas that need corrections immediately.

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 411-057-0140(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 and C295

Please refer to POC under C240 and C295

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: