OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation and interview it was determined the licensee failed to ensure adequate administrative oversight of facility operations for food services. Findings include, but are not limited to: During the second revisit of the kitchen inspection of 07/23/25, conducted 12/16/25, administrative oversight to ensure adequate food services rendered in the facility was found to be ineffective based on failure to implement plan of correction and ensure adequate oversight to correct deficiencies. Refer to deficiencies in the report.

1. Adminstrator or designee will ensure POC is implemented effecitively with dietary staff 2. Adminstrator or designee will ensure that dietary staff are inserviced on proper protocol and will have dietary compentencies reviewed yearly 3. Areas needing correction will be monitored daily until compliance met and tracked through QAPI 4. Adminstrator or designee

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by:

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. Findings include, but are not limited to: On 07/23/25, 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: * Walk-in refrigerators and freezer shelving, doors, flooring, and ceiling; * Fan and fan cages of the walk-in refrigerator; * Ceiling vent near the bulletin board; * Four bins containing flour, sugar, oats, and semolina flour; * Walls, floors, and ceiling throughout the kitchen; * Hood vents; * Can opener blade; * Stand mixer; * Toaster; * Caulking behind iced tea machine and ware washer; * 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, including free standing utensil bins. b. Food Storage * Multiple items in dry storage, walk-in refrigerator, and walk-in freezer were opened and not dated; * Multiple boxes in dry storage containing food items were stored directly on the floor; * A bag of split peas was open and stored directly on the floor; * A box of yams and potatoes were stored in a carboard box near a sink; * There was a small bowl stored directly in the sugar bin; * A box of bacon was stored directly over bread items in the walk-in freezer; and * Multiple boxes were stored on the floor of the walk-in freezer, including boxes of apple juice were stored directly on top of a box containing raw beef. c. Food preparation: * There were no pasteurized eggs available for soft-cooked entrees. During an interview on 07/23/25 at 11:00 am, Staff 2 (Kitchen Services Manager) stated he had started as interim this week and was unsure why there were no pasteurized eggs available. d. Sanitation and Equipment: testing strips were not available to ensure the sanitizing solution was at the correct ratio. Sanitizer towels were not submerged in the sanitizing solution. e. Cleaning and Repair * There was a burned-out light above the janitorial closet; * A brown cutting board had deep gouges rendering it uncleanable; * Multiple shelves throughout the kitchen had chipped laminate; * The wire racks of the walk-in refrigerator were chipped and corroded; * The wooden door to the janitorial closet had multiple gouges and black marks; * Walk-in freezer door was in need of repair and unable to close door completely due to build-up of ice and seal was in disrepair; * The reach-in refrigerator and ice machine were in disrepair and not in use; and * There were multiple small holes in the walls by the coffee pots and ware washing areas. f. Infection Control and Cleanliness: * Clean forks were not stored in an inverted position; * Beard restraints were not available for staff use; and * Tables in the dining area were set with cutlery with food surface contact areas exposed to potential contamination. The kitchen was toured, and the above areas were discussed with Staff 1 (Administrator) and Staff 2 on 07/23/25 at 12:20 pm. The findings were acknowledged.

1a. all identified areas (refrigerator, fans, ceiling vent, floor bins, walls, floors, ceiling, hood vents, can opener, stand mixer, toaster, microwave, dishwashing area and dishwasher, drains, and cabinets will be cleaned and sanitized daily b. all food items opened will be labeled with date at the time of opening. all food storage will be off the floor and on shelving units in the refrigerator or dry storage area Freezer and refrigerator will have designated areas for meat, produce, bread, and milk items c. pasteurized eggs will be available daily for residents soft cooked entrées. d. sanitations buckets will be available with towels daily for cleaning surfaces test strips for sanitation will be ordered and used daily e. replace lights that are burnt out in kitchen, remove and replace cutting board, audit all cabinets, shelves and doors for any chips and corrosion and repair, remove wooden door from closet due to disrepair, replace seal on freezer door, replace ice machine and reach-in refrigerator, fill in and paint hole in the walls in the kitchen f. place all cleaned utensils in a container that facilitates them in an inverted position, cover stand mixer when not in use, all staff with beards will wear a beard restraint when preparing and serving food, cutlery to be covered with a napkin prior to meal service and setting table. 2a. Staff inservicing regarding cleaning of kitchen surfaces and sanitation rules. Cleaning schedule created and posted with daily task sheets for the staff to maintain compliance b.Inservice staff on dates for all food items opened and provide labels for containers c.dietary manager to order appropriate amount of pasturized eggs to meet needs of residents weekly d. inservice staff on sanitation regulations and provide test strips and log for recording of sanitizing ratio daily and as needed e. inservice staff on how to notify maintenance when items in the kitchen need repair. Provide log for them to document issues. Maintenance department to check log twice a day f. Inservice staff on infection control in the kitchen. provide utensil holder to store utensils inverted, provide cover for stand mixer, provide beard restraints, roll silverware in napkins prior to placing on tables 3. kitchen will be observed for cleanliness. Task sheets and kitchen logs will be reviewed daily until compliance met and then weekly. 4. Dietary manager or designee

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:

1a. all identified areas (refrigerator, fans, ceiling vent, floor bins, walls, floors, ceiling, hood vents, can opener, stand mixer, toaster, microwave, dishwashing area and dishwasher, drains, and cabinets will be cleaned and sanitized daily b. all food items opened will be labeled with date at the time of opening. all food storage will be off the floor and on shelving units in the refrigerator or dry storage area c. sanitations buckets will be available with towels daily for cleaning surfaces sanitation solution will be tested per regulation and be at or above 300 ppm e. replace lights that are burnt out in kitchen, remove and replace cutting board, audit all cabinets, shelves and doors for any chips and corrosion and repair, seal on freezer door has been replaced by Sunglow on 11.2.2025 f. place all cleaned utensils in a container that facilitates them in an inverted position, cover stand mixer when not in use, cutlery to be covered with a napkin prior to meal service and setting table. 2a. Staff inservicing regarding cleaning of kitchen surfaces and sanitation rules. Cleaning schedule created and posted with daily task sheets for the staff to maintain compliance b.Inservice staff on dates for all food items opened and provide labels for containers c.dietary manager to order appropriate amount of pasturized eggs to meet needs of residents weekly d. inservice staff on sanitation regulations and provide test strips and log for recording of sanitizing ratio daily and as needed e. inservice staff on how to notify maintenance when items in the kitchen need repair. Provide log for them to document issues. Maintenance department to check log twice a day f. Inservice staff on infection control in the kitchen. provide utensil holder to store utensils inverted, provide cover for stand mixer, provide beard restraints, roll silverware in napkins prior to placing on tables 3. kitchen will be observed for cleanliness. Task sheets and kitchen logs will be reviewed daily until compliance met and then weekly. 4. Dietary manager or designee

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: a. Food spills, splatters, debris, dirt, and/or black matter was observed on or underneath the following: * Walk-in refrigerators and freezer shelving; * Fan and fan cages of the walk-in refrigerator; * Four bins containing flour, sugar, oats, and semolina flour; * Wall behind knife rack; * Stand mixer; * Metal rack storing bread; * Drains throughout the kitchen; and * Interior and handles of multiple cabinets and drawers, including open utensil bins. b. Food Storage: * A bin of rice in the dry storage area lacked a lid. c. Repair: * The wire racks of the walk-in refrigerator were chipped and corroded; and * The walk-in freezer door lacked a full seal, leading to a build-up of ice around the door, on the floor of the freezer, and on food bags. The kitchen was toured with Staff 4 (Assistant Administrator) on 12/16/25 at 11:15 am. He acknowledged the findings.

1a. all identified areas (refrigerator/freezer, fans, ceiling vent, walls, floors, stand mixer, containers/bins, bread racks, utensil bins, dishwashing area and dishwasher, drains, and cabinets will be cleaned and sanitized daily 1b. all dry storage items will be identified and have lids as appropriate 1.c. Refrigerator racks to be replace or repaired as indicated, freezer door seal will be assessed for proper seal by refridgeration company 2a. Staff inservicing regarding cleaning of kitchen surfaces and sanitation rules. Cleaning schedule created and posted with daily task sheets for the staff to maintain compliance 2b. staff inservicing regarding ensuring that all bins with lids are securely placed to protect food safety and sanitation 2c. staff inserviced on ensuring freezer door is closed and when to notify maintenance of any sealing issues 3. kitchen will be observed for food safety and sanitaion. Task sheets and kitchen logs will be reviewed daily until compliance met and then weekly. 4. Dietary manager or designee

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, record review, 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 limed to: Refer to C 240

1. Culinary manager will ensure POC is implemented effecitively with dietary staff 2. Dietary staff will be inserviced on proper protocol and will have dietary compentencies reviewed yearly 3. Areas needing correction will be monitored daily until compliance met and tracked through QAPI 4. Culinary manager

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 C240.

1. Culinary manager will ensure POC is implemented effecitively with dietary staff 2. Dietary staff will be inserviced on proper protocol and will have dietary compentencies reviewed yearly 3. Areas needing correction will be monitored daily until compliance met and tracked through QAPI 4. Culinary manager

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: