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. Findings include, but are not limited to: Observation of the facility main kitchen area, and memory care kitchenette were reviewed on 08/04/25 from 10:45 am through 2:30 pm and found the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Kitchen drains * Floors in walk-in cooler under racks * Walk in cooler fan cages * Ceiling vents * Walk in freezer floors * Plastic racks in freezer * Ceiling vents * Interior of microwaves (main and Kitchenette) * Industrial can opener and housing * Interior of combo steamer/convection oven * Flooring under and around tables in dining room * Juice machine * Stainless steal open shelving holding clean equipment * Flooring corners and edges behind/under/between equipment * lip/edge of base coving in multiple sections/areas of kitchen * Blender base in kitchenette * Interior of toaster in memory care kitchenette * Interior of cabinets storing clean dishes in kitchenette * Interior and exterior of insulated meal/food delivery carts b. The following areas were in need of repair: * Cracked tile in cove base by threshold between service area and dish washing area * Corner of wall near kitchenette door with large gouge exposing dry wall. c. Kitchen staff was observed to not have hair effectively restrained where their very long pony tail was observed to drag across multiple clean and sanitized dishes/surfaces potentially contaminating the dishes/surfaces. d. Multiple food items were observed in cold and dry food storage spaces in the main kitchen and memory care kitchenette open to potential contamination. e. Multiple kitchen staff were observed to touch/handle their masks without washing or sanitizing hands and then touch food contact surfaces and/or ready to eat foods or cleaned and sanitized areas. The facility was under a covid 19 outbreak protocol. f. Staff member washing dishes was observed to enter the kitchen area without cleaning or sanitizing hands. They were then observed to touch their face, clothing, glasses without washing or sanitizing hands as required. They were also observed to handle dirty dishes and the sprayer in the dirty area and proceed to handling/putting away cleaned and sanitized dishes/cooking equipment with the potentially contaminated hands. g. Multiple food items were observed stored without date prepared or date opened as required. h. Large metal soup pans/kettles were observed in the walk-in with soup in them. Staff were interviewed regarding cooling practices. Staff were not able to discuss the appropriate cooling methods and time temperature guidelines to ensure food reached appropriate/safe temperatures within acceptable time frames. Staff 2 (Food Service Director) was also not able to demonstrate appropriate knowledge on proper cooling times/thresholds. i. Staff member was observed with long, painted/decorated nails. The staff member was observed to dish out salad and soups and did not have gloves on as required to protect food from potential contamination. j. Box containing empty/dirty drink cans were stored in main kitchen without a tight-fitting lid/closed as required to prevent pest attraction/accumulation. Trash can in memory care kitchenette observed with food debris from previous meal and was uncovered. Staff 2 verified neither receptacle had a lid. k. Multiple staff were observed to handle clean and sanitized dishes excessively touching the food contact surface during handling, transport. At approximately 1:00 pm, surveyor reviewed above areas with staff 2 (Food Service Director) who acknowledged the items in need of correction. At approximately 1:45pm Staff 2 (Acting Administrator) and Staff 3 (Regional Director) were informed of the compliance concerns and they acknowledged the identified areas.

1.) Executive Chef/Designee addressed cleaning deficiences listed in SOD (Drains, walk ins, racks, microwave, can opener, flooring, juice machine, open shelving). Executive Chef/Designee will host two cleaning trainings to ensure all kitchen staff are aware of expectations. RDO/Designee to get vendor out to repair cracking in tiles. Executive Chef/Designee to in-service staff on proper trash can coverage/lids required in kitchen. Executive Chef/Designee to in-service all kitchen staff on proper hair restraints, head coverings, appropraite hair-dos while in kitchen. Executive Chef/Designee to in-service all kitchen staff on fake nails and the need for glove usage when preparing foods. Executive Chef/Designee to in-service all kitchen staff on proper food storage in cold and dry storage. Proper food dating and time restraint to use the foods. In addition to proper soup cooling procedures. Executive Chef/Designee to in-service all kitchen staff on proper hand washing procedures. 2.) Executive Chef/Designee to complete two cleaning training parties by 8/31/2025 to address and correct all concerns. 3.) Executive Chef/Designee to monitor weekly and as needed. 4.) Executive Chef/Designee/RDO.

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: Observations of the main facility kitchen and memory care kitchenette were completed on 10/31/25, from 10:45 am through 1:00 pm, and the following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Walk-in cooler fan cages; * Ceiling vents; * Plastic racks in walk-in cooler; * Industrial can opener and housing; * Interior of cupboards and drawers in kitchenette; * Interior of microwave in kitchenette; * Exterior of blender base in kitchenette; and * Interior and exterior of insulated food transportation/storage cart. b. Multiple kitchen staff handling food and/or clean equipment were not using effective hair restraints. c. Staff 2 (Food Service Director) was not able to demonstrate appropriate knowledge on proper cooling times/thresholds. d. Two whole pies that were for resident’s desserts for the lunch meal were observed on top of the food transportation cart. The pies were not covered or protected from potential contamination during transport to the memory care unit. e. The cook in main kitchen was observed to handle ready-to-eat foods with bare hands while serving on the tray line for the lunch meal. At approximately 12:45 pm, the surveyor reviewed the above areas with Staff 2 (Executive Chef), who acknowledged the items in need of correction. At approximately 1:00 pm, Staff 1 (Executive Director) and Staff 3 (Regional Director) were informed of the compliance concerns, and they acknowledged the identified areas.

c0240- a. Kitchenette infractions have been addressed with staff, cleaned and Memory Care Director is overseeing daily/weekly task sheets to include cleaning tasks on the expectations. a. Main kitchen updated cleaning task lists to include additional daily/weekly monitoring and cleaning of walk in plastic racks, ceiling vents, insulated food cart, can opener. Executive Chef audits and oversees the completion of these task lists. b. Inservice completed in both Memory Care and Main Kitchen to immediately enforce hair/beard nets. Memory Care Director and Executive chef are responsible for holding staff accountable for wearing the nets and adherign to policy. c. Executive Chef was educated at time of revisit. Soup log is now in effect and Executive Chef conducted inservice with kitchen staff on proper cooling methods 11/13/25. Executive chef will continue to train new staff to these standards and audit logs for consistant use and adherance. d. inservice was made for safe food practices while transporting throughout the community. Executive Chef, Memory Care Director and Executive Director to ensure this policy is trained with new staff and adhered ongoing for daily food transportation. e. Inservice was conducted for all kitchen staff on safe ready to eat foods practices while on the line. Executive chef to train and ensure ongoing safe practices are met with new staff and observe during meal service and expo to ensure this safe practive continues.

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 interview, and observation, 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.

z01420-Memory Care Director is auditing cleaning task lists, ensuring weekly audits are done on overall unit to include kitchen standards, with Executive Director continuing to monitor these QA audits.

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:

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.

Refer to plan of correction for C240.

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.

c0455- New administration and Executive Chef has committed to improving and following current plan of correction. Executive Director is meeting with Executive chef weekly to ensure best practices are in place and Executive Chef is conducting weekly QA audits on temp logs, cleanliness, uniform and hygeince practices are being upheld.

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: