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 a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Facility did not ensure residents with modified textured diets received correct textures. Findings include, but are not limited to: Observation of the main facility kitchen and the unit kitchenettes were reviewed on 08/20/25 from 11:15 am through 1:45 pm and revealed the following deficient practices: 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: * Kitchen drain under ice machine * Ceiling vents above steam table area * Open shelving in prep area; * Sides of fryer and grill top; * Metal racks storing clean dishes and service supplies; * Walk in freezer floor; * Dry storage floor * Metal rack in walk in * Large can rack in dry storage * Cedar unit kitchenette oven * Cedar unit cupboards and drawers * Aspen unit kitchenette reach in freezer * Walk in ceiling. b. Multiple food items/packages/containers found in walk in not dated when opened. Item found past manufactures use by date. c. Facility was using a quaternary ammonia surface sanitizer but did not have the appropriate chemical testing strips to validate correct concentration for chemicals to effectively sanitize surfaces. d. Multiple staff beverages and food items were observed stored in walk in cooler next to and above/on food designated for resident use causing potential contamination issues. e. Kitchen staff was observed to serve multiple residents with “soft and bite size” diet orders items that were not bite size. Staff was not able to demonstrate appropriate knowledge of appropriate items and/or size for standardized bite size diets. Staff did not know bread items typically not appropriate for this diet type unless approved by SLP (speech therapist) and those items would need to be bite size. Staff was observed to served multiple residents with large vegetable pieces including broccoli stems and/or large broccoli florets. Staff served multiple residents on soft and bite size diets whole roles. Staff was not aware of appropriate validating/testing measures for minced and moist and puree textures to ensure they met those diet texture specifications. Staff acknowledged very limited training on these diets were provided. f. Meal service single use disposable items were noted stored uncovered with the food contact surfaces exposed/not protected from contamination. g. Multiple scoop plates were observed heavily stained/scored and in need of replacement. At 1:30 pm Staff 1 (Executive Director) was informed of above areas in need of correction, and they acknowledged the identified areas.

• Dinning Services Manager Immediately re-trained all kitchen staff on IDDSI (International Dysphagia Diet Standardisation Initiative) guidelines, including proper texture modifications, approved food items, and portion sizing for bite-sized diets. • Removed inappropriate bread items from texture-modified diet line-up unless approved by a speech therapist. • RN to consult with Speech therapist to review and update dietary guidelines for residents requiring texture modification. • All kitchen staff will receive annual and ongoing quarterly training on IDDSI guidelines. • DSM will provide Visual guides and portion reference posters in the kitchen and dietary prep areas. • Dietary Manager/designee will conduct weekly meal audits to verify proper food textures and resident diet compliance. • DSM and kitchen staff will preform a full deep-clean of all kitchen areas, neighborhood kitchenettes, shelving, vents, drains, and appliances was completed immediately following the survey. • All expired food items were removed and discarded. • Implemented a written daily, weekly, and monthly cleaning schedule with assigned staff responsibilities and supervisory sign-off. • Kitchenettes in memory care neighborhoods will be placed on the same cleaning and inspection schedule as the main kitchen. • Dietary Manager and Environmental Services Supervisor will perform weekly sanitation audits using a standardized checklist. • Monthly unannounced kitchen inspections will be completed by the Executive Director/designee. • All undated or expired items were discarded immediately. • Staff were re-educated on the requirement that all opened items must be labeled and dated. Weekly audits of food storage areas by Dietary Manager. • Proper quaternary ammonia test strips were obtained immediately. • Staff trained on proper testing technique and acceptable sanitizer ranges. • All staff food/beverages were removed from resident food areas immediately. • Staff re-educated that personal food and drink must be kept in designated breakroom refrigerators only.

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 a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000, and failed to ensure meals were served according to established menus. This is a repeat citation. Findings include, but are not limited to: Observations of the main facility kitchen and the unit kitchenettes were completed on 12/02/25 from 10:30 am through 2:00 pm and revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, white billowy matter, and grease was visible on or underneath the following: * Kitchen drains under ice machine, steam line, and prep area; * Open shelving storing spices; * Plastic “shelf liners” on metal racks storing clean dishes and service supplies; * Walk-in freezer floor; * Metal racks in walk-in; * Fan cage in walk-in cooler; * Large can rack in dry storage; * Movable baking rack stored in walk-in; * Metal water hose and spigots near stove; * Countertop mixer; * Cedar unit kitchenette oven; * Cedar unit cupboards and drawers; * Cedar unit reach-in refrigerator; and * Aspen unit kitchenette oven interior. b. Food items/packages/containers found in walk-in not were not dated when opened. Items found past manufacturer’s use by date. A rotting head of iceberg lettuce was cut and wrapped in foodservice plastic without a date. Hot dogs were observed in a pan dated 11/20, past the use by date for the opened product. c. During the meal observation, the menu items were from the day before according to the week-at-a-glance menu provided to residents and families. No notification of the menu change was provided to the residents. Staff 2 (Dining Services Manager) acknowledged she did not know the process for finding and generating daily menus yet and was due to receive training soon in this area. The lunch menu items posted at the table stated that the vegetable was to be carrots; however, the vegetable served was corn. Staff 2 stated typically items that were changed would be communicated to residents but did not believe the vegetable change had been communicated for that meal. Staff 2 acknowledged the substitution was not of similar nutritional value and was not aware that this was a requirement. e. Spent/used cooking oil was observed stored in empty uncovered cans under the hand washing sink with potential to attract insects and pests. At 1:30 pm Staff 1 (Executive Director) and Staff 2 (Dining Services Manager) were informed of above the areas in need of correction, and they acknowledged the identified areas.

A. All open shelving, metal racks, plastic shelf liners, and storage surfaces were scrubbed, sanitized, and reorganized to prevent debris accumulation. Walk-in freezer floor and metal racks were deep-cleaned, and sanitized. Walk-in cooler fan cage was fully cleaned to remove dust accumulation. Large dry-storage can rack and movable baking rack were removed, cleaned, sanitized. Metal water hose and spigots near the stove were cleaned and sanitized to remove grease buildup. Countertop mixer was fully disassembled, cleaned, and sanitized. Cedar unit kitchenette oven, cupboards, drawers, and reach-in refrigerator were cleaned to remove spills, stains, dust, and debris. Aspen unit kitchenette oven interior was fully cleaned and degreased. Stephanie Morton Dinning Services Manager/cooks/dietary aides. a weekly deep-clean checklist that includes all racks, shelving, fan guards, equipment surfaces, and unit kitchenettes. Stephanie Morton, Cooks,and Dietary Aides. B.Food items/packages/containers in walk-in were all dated and any expired foods were thrown away. Dietary aides now have a task list to check through walk-in daily to ensure all open dates are in place as well as checking for expired food items. Dietary Aides, DSM, Cooks C. when Substitutions are needed for meal changes, Cooks/dietary aides will write on menu to notify family, residents and staff. Dietary aides, RA's, Cooks E. Grease/oil that was uncovered was immedietly covered. Grease/oil will be kept in a closed container to prevent insects/pests. Stephanie Morton

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, and Z142.

A. All open shelving, metal racks, plastic shelf liners, and storage surfaces were scrubbed, sanitized, and reorganized to prevent debris accumulation. Walk-in freezer floor and metal racks were deep-cleaned, and sanitized. Walk-in cooler fan cage was fully cleaned to remove dust accumulation. Large dry-storage can rack and movable baking rack were removed, cleaned, sanitized. Metal water hose and spigots near the stove were cleaned and sanitized to remove grease buildup. Countertop mixer was fully disassembled, cleaned, and sanitized. Cedar unit kitchenette oven, cupboards, drawers, and reach-in refrigerator were cleaned to remove spills, stains, dust, and debris. Aspen unit kitchenette oven interior was fully cleaned and degreased. Stephanie Morton Dinning Services Manager/cooks/dietary aides. a weekly deep-clean checklist that includes all racks, shelving, fan guards, equipment surfaces, and unit kitchenettes. Stephanie Morton, Cooks,and Dietary Aides. B.Food items/packages/containers in walk-in were all dated and any expired foods were thrown away. Dietary aides now have a task list to check through walk-in daily to ensure all open dates are in place as well as checking for expired food items. Dietary Aides, DSM, Cooks C. when Substitutions are needed for meal changes, Cooks/dietary aides will write on menu to notify family, residents and staff. 12/2/25 Dietary aides, RA's, Cooks E. Grease/oil that was uncovered was immedietly covered. Grease/oil will be kept in a closed container to prevent insects/pests. 12/2/25 Stephanie Morton

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.

• Dinning Services Manager Immediately re-trained all kitchen staff on IDDSI (International Dysphagia Diet Standardisation Initiative) guidelines, including proper texture modifications, approved food items, and portion sizing for bite-sized diets. • Removed inappropriate bread items from texture-modified diet line-up unless approved by a speech therapist. • RN to consult with Speech therapist to review and update dietary guidelines for residents requiring texture modification immedietly following survey. • All kitchen staff will receive annual and ongoing quarterly training from DSM on IDDSI guidelines. • Visual guides and portion reference posters are now posted in the kitchen and dietary prep areas. • Dietary Manager/designee will conduct weekly meal audits to verify proper food textures and resident diet compliance. • DSM and all kitchen staff will preform a full deep-clean of all kitchen areas, neighborhood kitchenettes, shelving, vents, drains, and appliances immediately following the survey. • All expired food items were removed and discarded. • DSM will Implement a written daily, weekly, and monthly cleaning schedule with assigned staff responsibilities and supervisory sign-off. • DSM will ensure that Kitchenettes in memory care neighborhoods will be placed on the same cleaning and inspection schedule as the main kitchen. • Dietary Manager will perform weekly sanitation audits using a standardized checklist which will be turned into Executive director for sign off. • Monthly unannounced kitchen inspections will be completed by the Executive Director/designee. • All undated or expired items were discarded immediately. • Staff were re-educated on the requirement that all opened items must be labeled and dated. Weekly audits of food storage areas by Dietary Manager. Open date stickers we provided and will be in a designated area so that they are available at all times. • Proper quaternary ammonia test strips were obtained immediately. • DSM trained Staff on proper testing technique and acceptable sanitizer ranges. • All staff food/beverages were removed from resident food areas immediately. Signage placed of refridgerator door that states "no staff food or drink". • DSM/Executive Director re-educated that personal food and drink must be kept in designated breakroom refrigerators only.

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. This is a repeat citation. Findings include, but are not limited to: Refer to C240 and C455

A. All open shelving, metal racks, plastic shelf liners, and storage surfaces were scrubbed, sanitized, and reorganized to prevent debris accumulation. Walk-in freezer floor and metal racks were deep-cleaned, and sanitized. Walk-in cooler fan cage was fully cleaned to remove dust accumulation. Large dry-storage can rack and movable baking rack were removed, cleaned, sanitized. Metal water hose and spigots near the stove were cleaned and sanitized to remove grease buildup. Countertop mixer was fully disassembled, cleaned, and sanitized. Cedar unit kitchenette oven, cupboards, drawers, and reach-in refrigerator were cleaned to remove spills, stains, dust, and debris. Aspen unit kitchenette oven interior was fully cleaned and degreased. Stephanie Morton Dinning Services Manager/cooks/dietary aides. a weekly deep-clean checklist that includes all racks, shelving, fan guards, equipment surfaces, and unit kitchenettes. Stephanie Morton, Cooks,and Dietary Aides. B.Food items/packages/containers in walk-in were all dated and any expired foods were thrown away. Dietary aides now have a task list to check through walk-in daily to ensure all open dates are in place as well as checking for expired food items. Dietary Aides, DSM, Cooks C. when Substitutions are needed for meal changes, Cooks/dietary aides will write on menu to notify family, residents and staff. Dietary aides, RA's, Cooks E. Grease/oil that was uncovered was immedietly covered. Grease/oil will be kept in a closed container to prevent insects/pests. Stephanie Morton

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: