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 kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 07/15/25 at 10:50 am, the facility kitchen was observed to need cleaning the following areas: * Ceiling vents at entrance to kitchen – heavy layer of dust; * Front of dishwashing machine – drips/spills; * Wall above splash guard behind spray hose – caulking with black matter build up; * Exterior of garbage disposal – build up of food spills/drips; * Hood above dishwashing machine – build up of dust; * Microwave interior and exterior – food splatters/handle sticky; * Commercial can opener – blade finish worn off/housing with significant build up of black matter; * Waffle iron exterior – build up of dried food batter; and * Walk in refrigerator fan – build up of dust. Other areas of concern included: * Clean flatware stored with eating portion up creating potential for cross contamination; * Dishwashing machine leaking – tub below catching water from piping; * Two small refrigerators on counter in service line area without interior thermometers; and * Lack of facial hair restraints. The areas of concern were observed and discussed with Staff 1 (Dietary Serviced Director) and discussed with Staff 2 (Executive Administrator) on 07/15/25. The findings were acknowledged.

The facility acknowledges the cited deficiencies and is committed to correcting and maintaining compliance with all health and safety standards. A comprehensive action plan is outlined below. 1) Deep Cleaning and Maintenance - Completed on 7/20/2025 The following areas have been thoroughly cleaned and sanitized: • Ceiling vents at kitchen entrance • Front and hood of dishwashing machine • Wall above splash guard and caulking behind spray hose • Exterior of garbage disposal • Microwave (interior and exterior) • Commercial can opener (cleaned; replacement blade ordered) • Waffle iron disposed of and replaced • Walk-in refrigerator fan a) Clean Flatware Storage - Corrected by 07/16/25 *Flatware is now stored with eating portions down to prevent contamination. b) Dishwashing Machine Leak *Leak was assessed by maintenance and is in process of being repaired.To be monitored daily for signs of recurring leaks. c) Refrigerators Missing Thermometers - Corrected on 07/17/25 *Interior thermometers have been installed in both small refrigerators. d) Facial Hair Restraints - Implemented on 07/16/25 *All dietary staff with facial hair have been reminded to wear appropriate facial hair restraints while on duty. Supplies provided and staff re-trained. 2) The Dietary Services Manager (DSM) is responsible for overseeing the daily operations of the Dietary Services department, ensuring that all kitchen practices and protocols comply with the Food Sanitation Rules (OAR 333-150-0000), under the supervision of the Administrator. The DSM ensures that all cleaning tasks are completed, checklists are signed, and records are properly documented in the daily logs. The Administrator or their designee conducts daily check-ins with the DSM to discuss departmental needs, set goals, and provide oversight. During these check-ins, the Administrator verifies that the DSM is reviewing cleaning checklists and ensuring proper documentation. a) DSM is responsible for visual inspections during each meal service. b) Maintenance Director is responsible for maintenance log and follow-up inspection and continued monitoring. c) DSM verifies thermometers logged and checked twice daily. d) Administrator verifies staff grooming compliance checks added to kitchen audits. 3. The DSM, Maintenance Director, and Administrator are responsible for overseeing these processes on a daily basis. 4. The DSM and Maintenance Director ensures the above processes are occurring, with oversight from the Administrator.

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: