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 ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to: Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to: On 07/15/25 and 07/16/25, observations of the facility's kitchen identified the following: a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following: * Reach-in refrigerators and freezer shelving, doors, flooring, and ceiling; * Ice machine, including the vent had a white substance build-up throughout; * A build-up of brown and gray matter on the light switch in the dry storage; * Ceiling vents in the dry storage and above the pots and pans; * Inside of the ovens; * Flour bins in the dry storage; * Walls and ceiling throughout the kitchen, most notably at the dish washing station; * Can opener blade had debris, including metal shavings; * Stand mixer; * Interior of microwave; * Walls and floors of the janitorial closet; * The top of the ware washing machine; * Drains throughout the kitchen; and * Interior and exterior of multiple cabinets and drawers. b. Food Storage * There were open brownie, cake mixes, and marshmallow packages opened and not dated; * Multiple condiments were open and not dated. c. Food preparation: * A container of butter that contained milk product was stored next to the stove and not maintained below 41 degrees F; and * There were no pasteurized eggs available for soft-cooked entrees. During an interview on 07/15/25 at 11:00 am, Staff 2 (Interim Dietary Services Manager) stated eggs were prepared to order, including over easy and over medium. d. Sanitation and Equipment: there were testing strips available to check sanitizers for the staff, but staff were not using them. e. Cleaning and Repair * There was an exposed electrical outlet outside of the pantry; * The face of the soap dispenser at the hand washing sink was in disrepair; and * There were multiple small holes in the walls by the coffee pot, oven, and ware washing areas. f. Infection Control and Cleanliness: * Clean silverware was not stored in an inverted position * Kitchen staff failed to consistently perform hand hygiene and change gloves between tasks during plating; and * Trash cans lacked covers when not in use. g. The refrigerator temperature ranged between 42 and 44 degrees Fahrenheit during lunch observation on 07/15/25. There was a temperature log for that refrigerator to validate temperatures were being monitored, however, the temperature was not recorded for the last four days. It consistently listed the temperature at 38 degrees F. During an interview on 07/15/25 at 11:30 am, Staff 2 reported the refrigerator typically ran between 37 and 38 degrees F but did increase during meal service secondary to opening and closing doors. The surveyor returned to the kitchen with Staff 1 (Administrator, Regional Director of Operations) on 07/15/25 at 2:45 pm, and temperature was observed to be 46 degrees F. Staff 1 reported the facility had ordered an internal thermometer to validate the temperature, and it should arrive within an hour. Surveyor directed that non shelf stable food items should not be used prior to validation, and Staff 1 agreed. On 07/16/26 at 8:40 am, Staff 1 and surveyor checked the internal temperature of the refrigerator, which was 51 degrees F. All non-shelf stable food items were discarded. Staff 1 stated they would be purchasing a refrigerator to use in the interim for non-shelf stable food items. The kitchen was toured, and the above areas were discussed with Staff 1 on 07/16/25 at 8:40 am. The findings were acknowledged.

A.) 1. Dorian's kitchen will be clean, free of food spills, dust, splatters, debris. All fridges, shelves, walls, drains, light switches, ceiling vents, oven, stand mixer, can opener, microwave, walls and floors, drains, cabinets and drawer will be cleaned on a regular daily, weekly and monthly basis to ensure that the kitchen continues to be clean and sanitary. 2. Dorian will begin a cleaning scheduled and sign off for staff with tasks. 3. This will be checked during daily community walk throughs, weekly with the dietary team and during Quality Assurance meetings 4. The executive director will be responsbile for oversight and ensuring the kitchen is clean, free of food spills and debris. B). 1. Food boxes and packages will be closed, sealed, dated and stored properly 2. All open foods has been thrown out if the date could not be verfied. All new food purchased will be dated once opened 3. This will be verfied during daily walk throughs and weekly with kitchen team meeting 4. The executive director will be responsible for oversight and ensuring the kitchen food is sealed, dated and stored properly C. 1. Food prep will be in compliance per OAR 411-054-0030. Food will be stored at the appropriate temps and non pasturized eggs will not be served to residents 2. The community will purchase pasturized eggs to serve residents who request to ordered eggs, liquid pasturized eggs will be used in soft cooked entrees and all butter products will be stored below 41 degrees. 3. This will be verfied during daily walk throughs and with weekly kitchen meeting 4. The executive director will be responsible for oversight of the kitchen to ensure that all food is purchased and stored correctly. D. 1. Sanitation solution and strips will be used in the kitchen to ensure that the kitchen is being cleaned properly. 2. Staff will be training on properly using the sanitation solution provided and will use it daily. 3. This will be verified during daily walk through and during weekly kitchen meeting. 4. The executive director will be responsible for oversight of the kitchen to ensure that the sanitizer is being used correctly E. 1. The kitchen will be in good repair, including all electrical outlets will be covered, the soap face will be repaired, all holes repaired and painted over. 2. The maintenance team will address all repair tickets including fixing holes and applying paint to create a clean surface. 3. This will be verfied during the quality assurance meetings 4. The executive director will be responsible for oversight of the kitchen and that all repairs are made in a timely manner. F. 1. All infection control concerns will be addressed including storing of silverware, proper hand hygiene and gloves, and trash cans with lids when not in use. 2. All silverware will be stored inverted, staff will be educated on hand hygiene, and trash can lids will be ordered and put into use. 3. This will be verfied during daily walk throughs of the kitchen, weekly observation of meals being prepared and quality assurance meetings. 4. The executive director will be responsible for oversight of the kitchen and ensuring that all infection contol tasks are being completed. G. 1. The community will ensure that all food is stored at a proper tempurature and that the fridge temps are recorded accurately. 2. The community destroyed all food that was stored out of temp range and purchased secondary fridges until the main commercial one was repaired. The commercial fridge was repaired on 7/21 and has maintained a temp of 38 degrees. 3. Proper temp recording and temp ranges will be verified during daily walk through and during quality assurance meetings. 4. The executive director will be responsbile for kitchen oversight and that all fridges are functioning properly.

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 ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. This is a repeat citation. Findings include, but are not limited to: On 10/22/25 from 3:54 pm through 5:27 pm, observations of the facility's kitchen identified the following: a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following: * A build-up of brown and gray matter on the light switch in the dry storage; * Ceiling vents in the dry storage and above the pots and pans; * Flour and sugar bins; * Walls and ceiling throughout the kitchen, most notably at the dish washing station; * Can opener blade had debris, including metal shavings; * Stand mixer; * Interior of microwave, most notably the plate; * Walls and floors of the janitorial closet; * Drains throughout the kitchen; * Exterior of multiple cabinets and drawers; * Exterior of the heating/cooling unit in the dry storage area; * Two box fans in the kitchen; and * A tan footstool underneath the coffee area. b. Cleaning and Repair: there were multiple small holes in the walls by the coffee pot, oven, and ware washing areas. c. Infection Control and Cleanliness: * Clean silverware was not stored in an inverted position; and * Trash can in the dish pit lacked cover when not in use. The kitchen was toured, and the above areas were discussed with Staff 4 (Administrator) on 10/22/2025 at 5:30 pm. The findings were acknowledged.

C0240 OAR 411-054-0030(1)(a) Resident Services Meals, Food Sanitation Rule 1a) All food spills, splatters, debris, dirt, and/or black matter will be cleaned immediately. * The light switch in the dry storage area will be clean and free of brown and gray matter build up. * The ceiling vents in the dry storage and above the pots and pans will be free of dust and debris. * The flour and sugar bins will be clean and free of food spills and dust. * The walls and ceiling throughout the kitchen, most notably at the dish washing station will be clean and free of food spills and splatters. * The can opener blade will be replaced and maintained. It will be kept clean and free of food spills. * The stand mixer will be clean and free of food spills and splatters. * The interior of microwave, most notably the plate will be clean and free of food spills and splatters. * The walls and floors of the janitorial closet will be clean and free of debris and dirt. * Drains throughout the kitchen will be free of food spills and debris. *Exterior of cabinets and drawers will be clean and free of food spills and splatters. * Exterior of the heating/cooling unit in the dry storage area will be clean and free of dust and debris. * The box fans will be clean and free of dust and debris. * The foot stools will be clean and free of food spills, splatters and debris. 1b) Repair and cleaning will be completed. * Holes in the walls by coffee pot, oven, and ware washing station will be repaired and walls will be smooth and a cleanable surface. 1c) Infection control and cleanliness will be addressed. * Clean silverware will be stored in an invertated position. * Trash cans will have covers placed when not in use and will be clean and free of food splatters and debris. 2) The system will be corrected by adding cleaning tasks to be done daily, weekly, and monthly to ensure violation will not happen again. 3) The kitchen will be evaluated daily and weekly. 4) The head cook will be responsible for daily evaluations. ED will conduct weekly evaluations.

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 and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

C0455 OAR 411-054-0105(2-4) Inspections and Investigations Insp Interval 1) Facility will ensure the re-licensure survey plan of correction is implemented and satisfies the Department. 2) Facility will follow plan of correction and OAR 411-054-0030(1)(a) to ensure violation does not happen again. 3) Weekly evaluations will be done. 4) ED will be responsible to see that the corrections are completed/monitored.

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: