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 main kitchen, memory care prep kitchen, and unit kitchenetts on 08/13/25, from 10:00 am through 2:00 pm, revealed the following: 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 Kitchen * Cabinets under steam table area * Interior of cabinets storing clean dishes * Interior of ovens * Handles, knobs of stove, oven, grill top * Grill top * Industrial mixer * Industrial can opener housing * Flooring in corners/edges/behind and under equipment * Walls throughout kitchen area * Ceiling vents * Small fan near kitchen entry blades and cage * Walk in cooler fan cage * Walk in cooler ceiling * Grout spaces in floor between steam table and ovens * Steam table areas around plate warmer and metal pieces * Spice shelf * Flooring and walls behind/under dish machine * Carpet area back of kitchen storing chemicals and dishes * Kitchen drains * Coco machine * Sprayer by dish machine handle and sprayer * Walls near entry and exit of kitchen of dining room Prep Kitchen * Black utility carts * Bottom cabinet next to dish machine b. The following areas were in need of repair: Main Kitchen * Build-up of black debris in caulking in dirty side of dish machine area; * Missing/low grout between steam line and ovens where large amounts of food/dirt debris accumulation * Multiple areas missing covering on counter/cabinet under steam table that was exposing wood areas yielding non-smooth surfaces. * Dish machine spraying water/detergent on wall/floor during cycles yielding accumulation of water/mineral/chemical buildup on floors/walls behind/under dish machine. Prep Kitchen * Bottom cabinet next to dishwasher door * Reach-in refrigerator not cooling at required cold food storage temperatures Unit Kitchenettes * Reach-in freezers with heavy ice accumulation/build up c. Kitchen staff was observed handling dirty dishes and then touching clean dishes without washing their hands. d. Kitchen staff was observed using single use gloves for multiple uses/tasks and not changing when necessary to prevent possible cross contamination. The one observation of a glove change, the staff did not wash/sanitize hands before donning new pair of gloves. e. In Main kitchen, clean and sanitized dishes were not stored covered or inverted exposing them to potential contamination. Single service cups and clean dishes were observed with food debris/splatter/contaminants in/on the food contact and non-food contact surfaces. f. Reach in cooler in memory care prep kitchen was noted to be at elevated temperatures out of approved ranges for cold food storage. Thermometer stored in fridge was noted to be at 48 degrees Fahrenheit multiple times during the survey process. At 1:02 pm, yogurt stored in the door of the refrigerator was noted to be at 48 degrees Fahrenheit. Records were reviewed and there were multiple missing documentations for that reach in refrigerator. Staff 1 (Executive director) verified 48 degrees was not acceptable for cold food storage and indicated food that was temping out of range would be discarded and that the refrigerator would be evaluated to ensure operating correctly. g. Dishes for memory care residents are washed and sanitized in the Prep kitchen. There is a commercial dishwasher that utilizes chemicals for sanitation step. Staff working in prep kitchen was not able to demonstrate knowledge for what chemical was used for sanitation. Staff was not able to produce test strips for chemical to ensure machine was operating correctly and that dishes were sanitizing effectively. Staff verified the facility did not currently have a system to frequently(daily) check effectiveness of dishwasher sanitizing. Staff indicated Eco Lab vendor comes monthly to check on the machine. Surveyor had chlorine test strips and was able to validate machine was at the correct sanitizing parts per million. h. Facility was using Ecolab rapid Multi surface disinfectant cleaner to “sanitize” surfaces. Staff in the memory care prep kitchen was not able to verbalize understanding/effective use of the chemical for sanitizing. Staff was not aware of the needed contact time and if it needed to be wiped off after contact time. Staff also was not aware if it could be used on food contact surfaces. i. Staff in the memory care prep kitchen was not observed to sanitize thermometer before or between use when checking temperatures for lunch service. There was no food contact surface sanitizer available for use. On 08/14/24, at 1:00 pm, the identified areas were reviewed with Staff 2 (Person In Charge) who acknowledged the areas. At approximately 1:45pm the surveyor reviewed areas needing attention/correction with Staff 1 (Executive Director) who acknowledged the findings.

1. The identified cleaning deficiencies are addressed and enhanced cleaning continues; food spills, splatters, ceiling vents, fan blades and cage, lights cleaned, loose food, trash debris, dirt, dust, black matter, and grease has been cleaned and are in compliance. This includes the walk in cooler walls and ceiling, microwave, industrial can opener and mixer, interior/exteriors of the cabinets, floors, walls, and interior/exterior of the ranges and ovens. The sides of the steam table, plate warmer, spice shelf, Hot Coco machine, dirty dish sprayer and around the same area, (cleaned), complete hood cleaning (completed), walls and ceiling (cleaned), coffee prep areas (cleaned), maintenance required items, flooring, grout, edging with exposed wood, dish machine repairs, cooking utensils have been evaluated for the need to be replaced (items ordered). The kitchen back hallway and carpet clean and kitchen use only vacuum purchassed. The reach in refriderator in the prep kitchen to be replaced. Single use containers to be stored differently to reduce collection of debris. Staff training also inludes hand washing and sanitizing between tasks, including donning and doffing gloves. Sanitizing strip order andin place. Staff instructed and trained on proper use and documentation. Ecolab training on the use of kitchen products scheduled. Thermometer sanitizing process reviewed and corrected. 2. Onboarding and ongoing training of all staff. All kitchen and meal areas will be monitored for compliance. New Kitchen Cleaning Task sheets has been developed to ensure the focus of proper cleaning pratices. 3. Daily by staff, weekly by the supervisors, and monthly by the Director during the QAPI process. 4. The Dining Services Director and 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 ensure food service areas were kept clean and in good repair and dishes sanitized in accordance with the Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observation of the main kitchen, memory care prep kitchen, and unit kitchenettes on 10/29/25, from 11:45 am through 1:15 pm, revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and black matter in the bottom cabinet next to the dish machine in the Memory Care prep kitchen. Staff member in the prep kitchen stated they had a very difficult time keeping that cabinet clean and in good repair. b. Memory care unit prep kitchen did not contain any test strips to validate effective sanitation of the dish machine for the resident dishes and utensils. Kitchen staff member stated they had been asking for test strips since last survey but had yet to receive them. Kitchen staff member acknowledged the facility was not routinely checking/validating effective sanitation of the residents’ dishes. Surveyor reviewed the chemical used and used their own test strips to test for effective parts per million (PPM) of the chlorine for sanitation. Multiple attempts were made and no effective PPM were noted, indicating dishes were not being sanitized effectively. On 10/29/25 at 1:00 pm, Staff 1 (Campus Executive Director) was interviewed and stated he was unaware the prep kitchen did not have test strips available. Staff 1 verified the facility was not documenting sanitation levels of the prep kitchen dish machine. Staff 1 produced a document from Eco Lab indicating the last time the sanitation was validated was on 09/22/25 by the vendor. Staff 1 was unsure how long the resident dishes were not being effectively sanitized and acknowledged the facility needed to ensure dishes for residents were sanitized and the sanitation system monitored. Staff 1 acknowledged the cabinet that needed cleaning.

1. The memory care prep kitchen and both MC wing sub kitchens, have been cleaned of any food spills, loose food, splatters, trash debris, dirt, dust and black matter. The MC kitchen has been provided the proper and valid tests strip for the dish machine that is in use. The required log to document the results of the tests is in place and being used daily. Ecolab was called to perform required maintenance to ensure the dish machine is working properly. 2. Kitchen task sheets have been updated for cleaning and expectations. Weekly inspections of the prep kitchen and sub kitchens will be completed by the administrator. Dish machine test logs will be comeplted daily and reviewed by administrator weekly. 3. Daily cleaning review and weekly review by the administrator to ensure the tests logs are being completed and are within normal ranges. Administrator will also complete weekly inspections as a follow up to ensure kitchen are clean and free of filth. 4. The MC administrator will be responsible for montioring these corrections.

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, 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. I appoligize, there was a misunderstanding. The plan of correction is now complete and has been sent. 2. Monitor timelines correctly and meet or exceed those timelines. 3. Each time there is a survey. 4. The administrator of the campus.

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.

Please reference C240 for the plan of correction

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.

Please refer to C240 plan of correction

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: