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 in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen was completed 07/14/25 from 10:20 am through 11:45 am and the following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease and/or black matter was visible on or underneath the following: * Juice machine * Hand washing sink edges/corners * Floors under equipment/counters in beverage service area * Interior of ice machine * Edges of flooring in dry storage * Flooring and walls under and around dish machine area * Kitchen drains * Floors under steam table * Flooring under and in between large equipment and behind oven/range/grill * Stainless steel shelving holding clean dishes by service line * Knobs of ranges/ovens/grill and steam table * Flooring in under and around dishwashing area * Walk in freezer floor * Can rack in dry storage * Metal racks storing clean dishes * Stainless steal service area on tray line b. The following areas were in need of repair: * Small gap in ceiling by sprinkler c. Multiple food items found in walk in cooler without proper labels and/or prepared/opened or use by dates as required. Multiple food packages found open in walk in exposing food products to potential contamination. Multiple items found open/uncovered and without proper labels/dates in deli cooler. Multiple items found in walk in cooler that were past 7 days from prepared date and should have been discarded. d. Facility did not have test strips to verify/validate surface sanitizing chemicals were at appropriate levels for sanitizing as required. Staff 2 (Dining Services Manger) was not aware of the type of chemical dispensing from the wall for 3 compartment sink and surface sanitizer buckets needed different test strips. The chemical contained lactic acid and the facility had quaternary ammonia strips. The facility did not have a system to regularly test the concentration of that solution to ensure at appropriate sanitizing levels. e. Multiple kitchen staff observed without hair or beard/facial hair restraints. f. Reach in cooler for beverages including items that were potentially hazardous/protein rich did not have a thermometer to ensure items were stored at appropriate temperatures for cold holding. Staff 2 verified they could not locate a thermometer. At 11:30 am the above items were reviewed with Staff 2 who acknowledged areas needing correction. On 07/15/25 at 2:00 pm, identified areas were reviewed with Staff 1 (Executive Director) and Staff 2 who acknowledged the areas of concern.

1. a. accumulation of all food splatter, dirt, and grease has been thoroughly cleaned from literally every surface in the kitchen, drink stations, floors, walls, dish machine, ice machine, ranges, ovens, and steam table. b. repairs for the small gap in the ceiling sprinkler has been repaired on 7/24. c. ALL food items have been properly covered and dated. All staff have been re-educated about proper food handling/storage. Dietary Manager following up and managing staff to ensure consistency. d. all the correct test strips have been purchased and all staff have been trained on how to utilize test strips, when to change out the sanitation bucket, and which strips are used for what purpose. e. all staff have been reminded about hair restraints and instructed that if they show up for their shift without their hair properly restrained, they'll be sent home. f. there is now a working thermometer in the reach-in cooler, and all staff are aware of where it is and what the purpose is for. There is also a checklist to document temps. 2. a. daily cleaning task list will be completed, signed and turned in to the Dietary Manager who will audit for cleanliness and efficiency. b. maintenance have on their schedule to inspect and clean sprinkler heads and vents once a month, unless there is a need before. c. Dietary Manager will audit food inventory throughout the day to ensure all food items and beverages are properly covered and dated. Staff will be closely managed to ensure they are remembering to properly dated and covered. If staff continue to go against policy, they will receive a written warning and be required to retake the Food Handler's course. d. Dietary Manager will do daily audits of all sanitizing buckets throughout the day to ensure proper use and testing system is in place, in addition to staff documenting each time they do testing and changing out bucket. e. all staff have signed hair restraint policy and will be held accountable if they do not comply. f. confirming presence and accuracy of thermometer will be added to daily checklist. 3. a. a detailed daily cleaning task list, weekly deep cleaning task list, monthly "cleaning party" to be scheduled, managed, and documented. Dietary Manager will follow up to ensure quality and effiency. b. monthly maintenance checklist for cleanliness and/or repair of sprinkler heads and vents. Dietary Manager will alert maintenance if it needs attention sooner. c. daily audit to ensure all food items are always covered and dated. d. daily audit of sanitation testing checklist to ensure it is being completed according to schedule. e. daily observation of staff to ensure hair is restrained. f. daily audit to ensure thermometer has been checked off and signed that it is present and accurate. 4. a. Dietary Manager and Executive Director b. Dietary Manager, Executive Director and Maintenance c. Dietary Manager and Executive Director d. Dietary Manager e. Dietary Manager and Executive Director f. Dietary Manager

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 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 facility main kitchen was completed on 09/24/25. The following was identified: An accumulation of food spills, splatters, loose food debris, dirt, dust, grease, and/or black residue was observed on and/or underneath the following: * Hand washing sink edges/corners; * Floors under equipment/counters in beverage service areas; * Edges of flooring in dry storage; * Flooring and walls under and around dish machine area; * Floor drains; * Floors under steam table; * Flooring under and in between large equipment and behind oven/range/grill; * Stainless steel shelving holding clean dishes by service line; * Knobs of ranges/ovens/grill and steam table; * Flooring in, under, and around dishwashing area; * Metal racks storing clean dishes; * Stainless steel service area on tray line; * Interior of drawers; and * Wall behind trash can. The need to ensure the kitchen was kept clean was discussed with Staff 1 (Executive Director) and Staff 2 (Dining Services Manager) on 09/24/25. They acknowledged the findings.

1. accumulation of all food splatter, dirt, and grease has been thoroughly cleaned from literally every surface in the kitchen, including but not limited to floors, walls, ranges, ovens, steam table, surface areas, racks, walk-in cooler and freezer, dry storage, drink stations, ice machine, and dishwashing station. 2. detailed cleaning task list will be completed, signed, and turned in to Dietary Manager on a consistent basis. Dietary Manager will audit for cleanliness and efficiency. Task lists will be divided and assigned to staff #1, 2, 3 to prevent any confusion on who is responsible for what tasks. This will also assist management in holding staff accountable and/or provide further training opportunities. 3. daily, weekly, monthly. 4. Dietary Manager, Assistant Executive Director, Executive Director.

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 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 facility main kitchen was completed on 12/31/25 from 10:00 am through 11:15 am. The following was identified: An accumulation of food spills, splatters, loose food debris, dirt, dust, grease, and/or black residue was observed on and/or underneath the following: * Hand washing sink edges/corners in beverage area; * Floors under equipment/counters in beverage service areas; * Flooring and walls under and around dish machine area; * Floor drains in beverage area, under steam table, under dish machine and under back prep sink; * Interior of bottom cabinet under steam table; * Floors under steam table; * Stainless steel shelving holding clean dishes by service line; * Stainless steel shelving above baking prep area; * Knobs hand handles of ranges/ovens/grill and steam table; * Range top spiders and area under; * Removable drip pan under stove top; * Interior and exterior of convection oven; * Flooring in, under, and around dishwashing area; * Metal racks storing clean dishes; * Interior of drawers holding clean utensils; and At 11:00 am, the need to ensure the kitchen was kept clean was discussed with Staff 1 (Executive Director) and Staff 2 (Executive Chef) on 12/31/25. They acknowledged the findings.

1. ALL areas of kitchen, beverage service areas and dishwashing area have been thoroughly deep cleaned of all food splatters, loose food debris, dirt, dust, grease, and/or black residue including but not limited to: hand washing sinks, floors under equipment and counters, all beverage service areas, all drains, floors, walls, steam tables, cabinets, shelving, knobs and handles of range/oven, drip pan, and all metal racks. 2. A detailed cleaning check list has been updated which includes daily, weekly, and monthly duties to ensure cleanliness is being maintained on a consistent basis. ALL kitchen staff have been in-serviced about cleaning expectations and accountibility if not completed. Executive Chef will audit kitchen and cleaning lists daily to ensure compliance is up to par and maintainted. Executive Director and Executive Chef will meet weekly to review task lists, audits, and discuss any changes/modifications needed. 3. Cleaning will be done and audited on a daily basis. 4. Executive Director and Executive Chef will be responsible to see that corrections are being implemented and monitored.

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 kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240.

1. PLEASE REFER TO C240 2. PLEASE REFER TO C240 3. PLEASE REFER TO C240 4. PLEASE REFER TO C240

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 interview, observation and review of records, 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. PLEASE REFER TO C240 2. PLEASE REFER TO C240 3. PLEASE REFER TO C240 4. PLEASE REFER TO C240

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: