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: Observations of the facility’s main kitchen and kitchen on the second floor were made on 09/25/25 from 10:15 pm through 2:16 pm. The following areas were not kept in a sanitary manner in accordance with Food Sanitation Rules: 1. Main kitchen on the first floor - 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: * Exterior of cooking appliances, multiple refrigerators, and freezer shelving throughout the kitchen; * Fans in walk-in refrigerator; * Floors in walk-in refrigerator and freezer; * Broken sheet pan in the walk-in refrigerator; * Brown matter soiled on a sheet pan in the walk -in refrigerator; * Interior and exterior of the ice machine, including the filters; * The gasket on the ice machine was deteriorating and had an accumulation of green matter; * Busing bin underneath the Hobart mixer, which stored cooking utensils, had dust, dirt, and food debris; * Can opener housing was visibly dirty and the blade was worn, with an accumulation of food matter; * Trash cans throughout the kitchen did not have lids during non-prep times; and * Paper towel dispenser was located over the sink causing the paper towels to drop into the sink when dispensed which created the potential for cross contamination. b. Food Storage - * Walk-in freezer had multiple food items (hamburgers, sausage, ice cream) that were not stored properly to prevent freezer burn and the potential for cross contamination; * There were paper scoops in the flour and sugar bins; and * There was less than a one-week supply of dry food staples. c. Food Sanitation and employee infection control- * During an interview on 09/25/25 at 12:45 pm, Staff 4 (Dishwasher) reported the facility had test strips for the sanitation buckets used for sanitizing surface areas; however, Staff 4 stated, “Oh, I don’t know [the proper sanitation level], they have not trained me how to use them.” * Staff 2 (Assistant Kitchen Manager/Cook) lacked documented evidence the Oregon Food Handlers certification was completed. 2. Facility kitchen on the second floor - a. An accumulation of food spills, splatters, loose food, dirt, and dust was visible on or underneath the following: * Reach-in refrigerator interior shelving; and * Ceiling vent near the door entrance to the dining room and the ceiling vent near the refrigerators had an accumulation of dust and debris. b. Food Storage - * Open cereal packages were not stored properly; * Reach-in refrigerator lacked an internal thermometer; * Paper towel dispenser was located over the sink, causing the paper towels to drop into the sink when dispensed, which created the potential for cross contamination; and * Trash cans throughout the kitchen did not have lids during non-prep times. On 09/25/25 at 2:00pm, the areas above were shown to and discussed with Staff 1 (ED) and Staff 2 (Assistant Kitchen Manager). They acknowledged the findings.

1. Main Kitchen – Sanitation and Maintenance Deficiency Identified: Accumulation of food spills, debris, dirt, and soiled surfaces throughout the main kitchen area (including appliances, floors, refrigerator/freezer, ice machine, and utensils). Corrective Action: - All kitchen areas were deep cleaned on 10/1/25 by dietary staff under supervision of the Kitchen Manager. - Damaged or soiled items (broken sheet pan, deteriorated gasket, etc.) were replaced. - A cleaning schedule and checklist was implemented effective 9/26/25, requiring daily cleaning of high-touch and food-contact surfaces, and weekly deep cleaning. - Environmental Services and Culinary Director will conduct weekly sanitation audits and document completion. Prevention/Monitoring: - Ongoing cleaning logs will be reviewed by the Culinary Director and Administrator weekly. - Retraining provided to all dietary staff on sanitation standards and cleaning procedures. 2. Main Kitchen – Food Storage Deficiency Identified: Improper food storage in the walk-in freezer; paper scoops in dry food bins; less than one-week supply of dry goods. Corrective Action: - Improperly stored items were discarded or repackaged . - Approved plastic scoops with handles were placed in all dry food bins. - Food inventory was reviewed and adjusted to maintain a minimum one-week supply of dry goods. Prevention/Monitoring: - Culinary Director to perform weekly food storage inspections and maintain inventory logs. 3. Main Kitchen – Food Sanitation & Staff Training Deficiency Identified: Lack of knowledge and training regarding sanitation bucket testing; missing Oregon Food Handler certification for Staff 2. Corrective Action: - All dietary staff were retrained on proper sanitation procedures, including use of test strips. - Staff 2 completed Oregon Food Handler certification on documentation placed in personnel file. Prevention/Monitoring: - New staff will complete training within their first week of employment. - Culinary Director will verify Food Handler certifications quarterly. 4. Second Floor Kitchen – Sanitation and Maintenance Deficiency Identified: Visible food spills, dirt, and dust on surfaces, shelving, and vents. Corrective Action: - Area was deep cleaned by dietary staff. - Maintenance staff cleaned and replaced air filters in ceiling vents. Prevention/Monitoring: - Weekly cleaning and monthly deep cleaning schedule implemented. - Sanitation logs maintained and reviewed by Kitchen Manager. 5. Second Floor Kitchen – Food Storage and Equipment Deficiency Identified: Improperly stored open food, lack of refrigerator thermometer, improper paper towel dispenser placement, and unlidded trash cans. Corrective Action: - All open food items were placed in sealed, labeled containers. - Internal refrigerator thermometers installed. - Paper towel dispenser relocated to prevent cross contamination. - Lids for trash can placed on cans Prevention/Monitoring: - Kitchen staff to perform daily checks of food storage and equipment. - Culinary Director to perform weekly compliance inspections.