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 kitchen was reviewed on 09/03/25 from 10:45 am through 2:00 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: * Walls beside dishwashing area near ceiling * Mirror above the corner of dishwashing area * Fan blades and cage in dry storage * Interior fan in reach in cooler storing resident beverages * Industrial can opener and housing * Interior and exterior of blender base * Spice shelving * Air conditioner unit in window with heavy dust/dirt build up * Side of stove * Stove top * Interior of white cabinet under built in steam table * Interior of cabinets/drawers storing equipment * Exterior of crockpot * Floors (corners/edges) and underneath metal shelving in dry storage (pantry) * Exterior of counter top mixer * Counter top behind prep sink where cutting boards stored * Top of interior of popcorn machine located in activity space b. The following areas/items were noted in need of repair * Opening or gaps around piping entering dry storage area near the ceiling. * Wood shelf where kitchen dishwashing racks were stored with porous wood exposed * Metal rack in reach in cooler noted with protective coating worn and rusted metal exposed c. Silverware was observed set prior to meals service with food contact surfaces exposed. Dining room was open to residents, visitors and other potential sources of contamination. Staff 2 (Cook/Person In Charge) verified that tables were preset directly after a meal for the following meal and acknowledged this left the silverware open to potential contamination between meals. d. Care staff member was observed in the kitchen area preparing residents drinks and or handling clean equipment without an effective hair restraint. e. Multiple food service equipment was noted to be heavily worn and in need of replacement. Multiple cooking utensils noted with chips/gouges and other areas yielding them unsmooth. Multiple cutting boards noted with heavy scoring and deep gouges. A white/light tan utility cart was observed with damaged surfaces yielding an unsmooth surface. Baking equipment (muffin pans) were noted with baked on food debris and large amount of blackened carbon residue. f. Staff items were noted stored in the kitchen reach in cooler where resident food/beverages were stored. Staff 2 and Staff 1 (Director) acknowledged staff had dedicated areas for food/personal item storage and should not be stored with resident items. g. Table-top mixer food contact equipment was observed stored uncovered/protected from potential contamination. Single use spoons were observed stored in the dining room beverage area with food contact surfaces up exposing them to potential contamination. h. Hand washing sink did not contain splash guard to protect from potential splash contamination. Multiple coffee pots were located directly beside hand washing sink. Food prep sink by the window was observed with clean cutting board stored directly behind the sink exposing the food contact surfaces of these items to potential splash contamination from the prep sink. i. Clean dish racks were observed with multiple dishes stacked on top of other dishes overlapping and partially or fully obstructing other items. All items must have a clear and unobstructed access to dishwashing sanitizing spray. Multiple items that were stored as “clean” were observed with food debris that was missed during dishwashing step. j. Care giving staff observed to enter into kitchen area thru the side door and did not wash or sanitize hands and was observed to touch food item (banana) and food equipment (countertop) before exiting kitchen. Multiple care staff were observed to help prepare resident drinks for room trays and other prep tasks inside the kitchen without donning a protective barrier to prevent/minimize potential cross contamination from care giving tasks. Kitchen staff was observed to touch glasses and face mask multiple times without changing gloves. At approximately 1:15, surveyor reviewed above items with staff 2 who acknowledged the areas needing attention. At approximately 1:30 pm Staff 2 (Director) was informed of the identified areas needing attention and they acknowledged the areas.

Following the survey conducted on September 3, 2025, a formal meeting was held between the Executive Director, Kitchen Manager, and Maintenance Director to review the citation and develop a corrective strategy. The team collaboratively identified immediate actions and long-term systems to ensure full compliance. A1. The accumulation of food spills, splatters, loose food and trash debris, dirt, dust and/other black matter was thoroughly cleaned and sanitized on 9/19/2025; which included; walls beside dishwashing area near ceiling, mirror above the corner of dishwashing area, fan blades and cage in dry storage, interior fan in reach in cooler storing resident beverage, industrial can opener and housing, interior and exterior of blender base, spice shelving, air conditioner unit in window with heave dust/dirt build up, side of stove, stove top, interior of white cabinet under build in stem table, interior of cabinets/drawers storing equipment, exterior of crockpot, floors (corners/edges) and underneath metal shelving in dry storage, exterior of counter top mixer, Counter top behind prep sink where cutting boards stored, top of interior of popcorn machine located in activity space. A1. The ED or designee audited kitchen for sanitary condition, addressing concerns identified. A2. The ED or designee re-educated the kitchen manager on the requirement to keep the kitchen in sanitary condition. A3. A weekly kitchen cleaning checklist has been implemented for kitchen aids, detailing specific tasks and surfaces to be maintained. A4. Check list to be monitored by Kitchen Manager, who ensures consistent compliance and documents completion. B1. The cited items were repaired 9/19/2025; opening / gaps around piping entering dry storage area near the ceiling, wood shelf where kitchen dishwasher racks were stored with porous wood exposed, metal rack in reach in cooler noted with protective coating worn and rusted metal exposed. B1. The ED reviewed kitchen for good repair, addressing concerns identified. B1. The ED or Designee audited kitchen for good repair, addressing concerns identified. B2. The ED or Designee re-educated the kitchen manager and the maintenance director on the requirement to keep the kitchen in good repair. B3. Kitchen manager or designee will conduct a monthly visual inspection to ensure the kitchen remains in good repair and any new issues are promptly addressed. B4. Kitchen Manager is responsible. C1. Silverware cited was removed from dining room and cleaned 9/3/2025 C1. ED audited serve area / process silverware, addressing concerns identified C2. ED or Designee re-educated the Kitchen Manager that preset silverware w/food contact surfaces exposed has potential for contamination. C3. Kitchen Manager has initiated new process that silverware is placed with plated meals at time of service. Staff have been trained on new process. C4. Kitchen Manager is responsible. D1. ED or Designee conducted kitchen observation for hair net compliance, addressing concerns identified D2. ED or Designee re-educated Kitchen Manager and kitchen staff on the requirement to wear hair restraint when working with unpackaged food, preparing drinks, and/or clean equipment. D3. Kitchen Manager or Designee will do random audits for hair restraint compliance weekly x 3 weeks then monthly x 2 months. D4. Kitchen Manager is responsible. E1. The multiple food service equipment noted was discarded to include cooking utensils with chips/gouges, cutting boards with heavy scoring/gouges, utility cart, muffin pans w/residue. E1. The ED or Designee audited kitchen equipment for food service equipment concerns, addressing concerns identified. E2. The ED or Designee re-educated the Kitchen manager on the requirement to keep food service equipment in good repair, discard and replace items that become heavily worn, unsmooth/uncleanable surface. E2. Kitchen Manager or Designee re-educated the dietary staff that if a utensil or piece of equipment appears questionable—such as showing signs of damage, residue buildup, or surface deterioration—they are to immediately notify the Cook or Kitchen Manager for evaluation and disposal if necessary. E3. Kitchen manager or Designee will perform monthly reviews of food service equipment to ensure all items are safe, sanitary and in working condition. E4. Kitchen Manager is responsible. F1. Staff items stored in reach in cooler were removed. F1. Ed or Designee audited kitchen for staff items, addressing concerns identified. F2. Kitchen Manager or Designee Re-educated staff on the requirement not to store staff items where resident food/beverages are stored. F3. Kitchen Manager or Designee will do random audits for staff item storage compliance weekly x 3 weeks then monthly x 2 months. F4. Kitchen Manager is responsible. G1. Table-top mixer was cleaned and covered; single use spoons were removed from dining room beverage area and cleaned. G2. ED or Designee re-educated Kitchen Manager and Dietary staff that tabletop mixer and other food contact equipment are stored covered and sanitized between use. Single use spoons are no longer stored in dining room beverage area. G3. Kitchen Manager or Designee will do random audits on table-top mixer and food contact equipment compliance weekly x 3 weeks then monthly x 2 months. G4. Kitchen Manager is responsible. H1. Splash guard was installed on handwash sink, cutting board stored behind food prep sink was removed and cleaned H2. ED or Designee re-educated the Kitchen Manager and staff on the requirement to minimize potential splash contamination. H3. Kitchen Manager or Designee will do random audits for splash contamination compliance weekly x 3 weeks then monthly x 2 months. H4. Kitchen Manager is responsible. I1. Dishes cited were rerun through dishwasher correctly 9/3/2025. I2. ED or Designee re-educated the Kitchen manager and dietary staff on the requirement that dishes are cleaned thoroughly and placed in dishwasher ensuring all items have a clear and unobstructed access to dishwashing and sanitizing spray. I3. Kitchen Manager or Designee will do random audits for dishwashing compliance weekly x 3 weeks then monthly x 2 months. I4. Kitchen Manager is responsible. J1. Kitchen was thoroughly cleaned J2. Kitchen Manager or Designee re-educated care staff on requirement to wash or sanitize hands upon entering kitchen, don protective barrier to prevent/minimize potential cross contamination from care giver tasks prior to preparing resident drinks/food/kitchen tasks. J2. Kitchen Manager or Designee re-educated kitchen staff on the requirement that gloves need to be changed after touching face masks/glasses. J3. Kitchen Manager will conduct random audits on cross contamination compliance weekly x 3 weeks then monthly x 2 months. J4. Kitchen Manager is responsible.

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: