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 the Food Sanitation Rules, OAR 333-150-000. Facility also failed to ensure residents receiving puree textures meals were nutritious and menus were followed. Findings include, but are not limited to: 1. Observation of the main food prep kitchen and individual house kitchens on 07/22/25 at 11:15 am through 3:00 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: Main Food Prep Kitchen (960) * Walls * Removable hood vents * Kitchen drains * Floors under/behind equipment * Industrial Can opener and housing * Shelving in dry storage area * Ceiling vent above food preparation areas House 950 * Ceiling vents * Industrial can opener and housing * Industrial mixer * Removable hood vents * Ovens * Windowsill House 940 * Industrial can opener * Removable hood vents * Reach in refrigerator House 920 * Reach in refrigerator * Walls/Ceiling with dust and dirt build up * Stainless steel shelving * Drain *Windowsills/windows House 910 * Reach in refrigerator * Windowsill Food storage area in House 960 * Carpet with dirt and heaving staining b. The following was observed needing to be repaired. *Caulking around hand washing sink was cracked/missing or had black substance build up. * House 960 dry storage area with wood shelving with damage to shelving exposing porous wood areas * Reach-in refrigerators/coolers in house 960 with seals off/damaged/needing repair * Large hole in house 950 in dry storage area in back entry way. Hole was directly above dishes/utensils/equipment that was stored. * Hand washing sink pulling away from wall leaving large gap * Multiple metal worktables bottom shelves were found/observed worn with metal rusting/corroding * Utility sink faucet in house 950 observed with a leak spraying water onto the windowsill c. Staff food item was observed stored with resident food. d. Ice machine in house 910 was observed with lid open exposing ice to potential contamination. Ice machine was located next to a window which was open and screens and windowsills were very dirty. e. Staff 2 was designated person in charge and was not able to effectively demonstrate knowledge in potential illnesses that would be excludable and reportable as per food code. Staff 2 was also not able to demonstrate appropriate knowledge in required reheating temperatures or cooling time and temperature guidelines. f. Residents who received puree textures were not provided a vegetable for the meal observed. The posted menu stated mixed vegetables should be served along with the chicken and potatoes. The residents receiving puree texture were not provided an appropriate alternative to ensure similar nutritional value of meal served. Staff 2 was interviewed and acknowledged residents receiving puree textures were not prepared or served vegetables that meal and stated their blender (robo coupe) didn’t puree certain vegetables well to get a good puree texture. Staff 2 acknowledged an alternative vegetable was not served. g. Puree meal included puree chicken and mashed potatoes. Both items were white/colorless and looked similar. No garnishes were used and no color contrasts were served to distinguish one food item from the other. Puree meals were served in separate bowls and not on a plate like other diet types. Staff 2 was interviewed and indicated they have just always served puree in separate bowls. Staff 1 (Executive director) was interviewed and verified the residents receiving puree did not have any service planned needs or instructions for serving foods in separate bowls. Neither Staff 1 or Staff 2 was able to state a clinical reason for serving food in separate dishes to residents with puree textures. Staff 1 and Staff 2 acknowledged the meal served during survey was not visually appealing and was served differently than other residents without appropriate indication or resident request to do so. h. Multiple buildings/houses kitchen areas had a restroom in the kitchen area that were observed to have the door to the restroom open including during meal service Times. Food code requires rest room doors to be kept closed except when cleaning. i. Kitchens did not have dedicated hand washing sinks as required. Kitchens were using a utility sink for hand washing. These sinks were also used for dish washing and other purposes. Food code requires a dedicated hand washing sink. Multiple houses the traditional hand washing sink was noted to be dirty/damaged or not operational or did not have appropriate supplies. House 920 sink had dirty dishes observed in sink where staff were observed to wash their hands on top of the dishes. j. Main food prep kitchen (house 960) observed with door to outside propped open. No screen or netting observed to prevent potential insects or pests from entry to kitchen area. k. Multiple house kitchens were observed with recyclables not stored in appropriate containers that were lined, washable and covered to prevent potential accumulation or attraction of pests as outlined in Food Sanitation rules. l. Dishes/equipment were not stored covered or inverted and protected from potential contamination. m. Multiple sauté pans in house 950 were worn, chipped, scrapped or observed with cooked on brown/black carbon debris on food contact surface. n. Multiple trays of food were observed served to residents without food or beverages covered and protected from potential contamination in houses 920 and 910. o. Sanitizing solution for 3 compartment sink was tested in house 910 chemical was a Quaternary ammonia (QUAT) solution distributed from a wall unit. When tested using facility provided and surveyor test strips 0 parts per million (PPM) was noted. Staff 1 validated no PPM on strips and investigated the wall dispensing unit and discovered the lid was not attached properly. Staff in kitchen area were unsure how long the chemical was not dispensing correctly. Facility did not have a system in place to ensure chemical concentration was tested frequently to ensure operating correctly. At approximately 2:30 pm surveyor reviewed above areas with Staff 1 who acknowledged identified areas.

1. Culinary Services Director (CSD) and culinary services staff will be educated by the Executive Director (ED) or designee on the following by: a. Daily, weekly, and monthly cleaning schedules b. Foodborne illnesses and reporting c. Reheating and Cooling guidelines for food safety. d. Pureed/altered diets procedures; menu spreadsheets for altering textures; and visually appealing plating techniques. e. Infection control practices to include handwashing and restroom door closure; storage of dishes and food delivery practices to prevent contamination. f. Sanitizing test strip usage and logs. 2. All staff will be educated by the ED/CSD on food delivery practices to prevent contamination. 3. The identified areas were cleaned and/or repaired by the Culinary Services Team and designees by 9/20/25. 4. The ED or designee will perform a weekly CBC kitchen walkthrough x 2 months, and then monthly x 3 months. 5. The CSD or designee will audit the cleaning schedules at least 3 times per week x 1 month, weekly x 1 month, and then monthly x 2 months to maintain compliance.

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 411-057-0140(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.

1. Culinary Services Director (CSD) and culinary services staff will be educated by the Executive Director (ED) or designee on the following by: a. Daily, weekly, and monthly cleaning schedules b. Foodborne illnesses and reporting c. Reheating and Cooling guidelines for food safety. d. Pureed/altered diets procedures; menu spreadsheets for altering textures; and visually appealing plating techniques. e. Infection control practices to include handwashing and restroom door closure; storage of dishes and food delivery practices to prevent contamination. f. Sanitizing test strip usage and logs. 2. All staff will be educated by the ED/CSD on food delivery practices to prevent contamination. 3. The identified areas were cleaned and/or repaired by the Culinary Services Team and designees by 9/20/25. 4. The ED or designee will perform a weekly CBC kitchen walkthrough x 2 months, and then monthly x 3 months. 5. The CSD or designee will audit the cleaning schedules at least 3 times per week x 1 month, weekly x 1 month, and then monthly x 2 months to maintain compliance.

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: