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 the Food Sanitation Rules, OAR 333-150-000. Facility did not provide accurate textures for residents requiring puree. Findings include, but are not limited to: Observations were made of the main kitchen, dry food and paper product storage area, memory care unit kitchenette, and the RCF unit dining room kitchenettes on 10/13/25, between 10:00 am and 2:00 pm. The following areas were identified: 1. Main kitchen area a) An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following: * Wall above metal rack storing clean dishes; * Floor between wall and prep tables; * Floor under metal racks in dry storage; * Floor sink in janitor closet; * Top of hot food storage cart; * Industrial slicer; * Table holding slicer; * Bottom shelf of prep table holding slicer under rack storing cutting boards * Portable metal baker’s rack; * Convection ovens; * Range top; * Exterior of garbage cans; * Wall behind range/fryer/conventional oven; * Flooring between, under, behind equipment; * Interior of deli cooler; * Juice machine; * Fan cages, ceiling and light fixture of walk in cooler; * Drain under service line/steam table area; and * Ceiling tiles, vents, smoke detector in/near dishwashing room. b. The following areas needed were found needing repair; * Caulking around hand washing sink * Caulking around industrial ware washing machine c. Multiple cutting boards were found heavily scored, stained, and/or missing chunks, deep grooves, and needed to be replaced. d. Cook noted to repeatedly handle RTE (ready to eat) food items with potentially contaminated gloves during tray line service. e. Multiple kitchen staff observed handling food or clean equipment without hair restraints. f. Multiple items potentially hazardous food items found without opened/prepared dates. g. Multiple food items were observed stored uncovered/protected from potential contamination in both walk in cooler and freezer. h. Food contact surfaces of commercial slicer and single service utensils were stored uncovered/protected from potential contamination. Multiple clean/sanitized dishes and food contact surfaces of equipment were not being stored inverted as required. i. Multiple staff drink containers were observed in food preparation and/or storage areas that were not of approved styles yielding potential contamination of lip contact surfaces. Staff drinks were observed stored with resident food items. j. Facility did not have a system to ensure cold food items were at proper temperatures prior to meal service. Facility served a variety of cold items each meal from their deli cooler (tuna salad, deli sandwiches, egg salad, fruit and or vegetable items, etc) and did not ensure the items were at 41 degrees or below when served. Staff 2 was interviewed and confirmed the facility was not checking cold food meal service items prior to service as they were assuming the temperatures were the same as the temperature of the cooler they were stored in. k. Facility had two residents identified as having puree textures as part of their diets. Observations during meal service found the textures to be served to those residents that was too thin as it flowed through the tines of the fork. This does not meet the criteria of puree. 2. Memory Care kitchenette. a) An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following: * Interior of reach in refrigerator; * Countertop mixer; * Interior of oven; * Interior of bottom cabinet next to oven; * Interior of reach in drawers; and * Black utility carts. b) Food and/or beverage items found in the reach in refrigerator observed uncovered/protected from potential contamination 3. Dining room kitchenette a) An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following: * Interior of microwave * Interior of drawer storing clean towels * Exterior/top of small ice machine b. Reach in cooler and/or freezer door seals were observed damaged/cracked and in need of replacement. c. Containers of bulk food items were observed with spoons stored inside the container with the handle touching food items causing potential contamination of the food products. At approximately 1:45pm, the above findings were shared with the Staff 1, Staff 2, and Staff 3 (Director of Dining & Culinary Services), who acknowledged the areas in need of correction.

C0240: 1. a) Action has been taken by refining our cleaning focus to delegate who and when the above-mentioned discrepancies will be cleaned. All tasks will be done by AM or PM kitchen staff. This cleaning focus will be checked daily by leads or designee. Weekly, a checklist with all state required regulations will be used by managers or designee. See attached cleaning focus (1.0 and 1.2). b) Work orders and repairs are in progress. Monthly, a walk through will be done by a lead or designee. In the event repair is needed, said lead/designee will place a work order for that repair. c) New cutting boards have been ordered to comply with regulations. See invoice (1.3). During the monthly walk though done by a lead or designee, cutting boards will be checked to maintain regulations. See checklist (1.0) d) Training has been done on proper glove usage for RTE foods on 10/25/2025. See document (1.4). e) Hair restraint policy has been updated to meet regulations. See attached policy (1.5). f) All kitchen and dining staff have been informed and trained on proper item-dating procedures. This training took place on 10/25/2025. See attached document (1.4). g) Daily, a walk-through will be done by a lead or designee to ensure that all food items are properly stored and covered. See checklist (1.0). h) Training procedures has been conducted. A walk-through will be done by lead or designee to ensure dishes and equipment are stored properly. i) All staff have been informed on personal drink usage and storage. See document (1.4). j) A system has been put in place to ensure safe food temperatures before service. Before each meal, a lead or designee will check the temperatures of all above mentioned areas and food items. k) Training process is in place with RDN and CDM on proper food textures, including purees, consistent with IDDSI standards. This training will take place on 11/20/2025. See attached document (1.8). 2. a & b) Proper training has been conducted with all staff utilizing the Memory Care kitchenette. This training includes proper sanitation and cleaning. A walk-through will be done before and after each usage by a lead or designee to ensure that area has been cleaned properly and that expired food/drink items are thrown out. See document (1.6). 3. a) Weekly cleaning tasks have been updated to assure that above listed areas are meeting regulations. These tasks will be signed off by a lead or designee on the day assigned. See attached task sheet (1.7). b) Work orders have been submitted. Items are in the process of being replaced. Walk-throughs will be done to ensure equipment is up to standard. c) Staff have been informed about proper food storage and utensil usage. A daily walkthrough will be done to ensure food in stored properly. See attachment (1.4).

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 a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the kitchen on 12/18/25, from 10:15 am through approximately 1:00 pm, showed the following areas needed cleaning or repair: 1. Main kitchen area a) An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following: * Floor between wall and prep tables; * Floor under metal racks in dry storage; * Industrial slicer; * Behind table holding slicer; * Convection ovens; * Wall behind range/fryer/conventional oven; * Flooring between, under, and behind equipment; * Interior of deli cooler; * Juice machine; * Drain under coffee service area; and * Ceiling tiles and smoke detector in/near dishwashing room. b. The following areas were found needing repair; * Multiple cutting boards were found heavily scored or deeply stained and needed to be replaced. c. Multiple kitchen staff observed handling food or clean equipment without facial hair restraints. d. Multiple items of potentially hazardous food items found without opened/prepared dates. e. Potentially hazardous food items were found past manufacturer’s use-by date. A container of salad dressing was noted three months past the open date. There was no manufacturer’s use-by date and no note of the facility’s desired use-by date. There was visible green and white velvety biological debris found growing near the lip and lid of the container. 2. Memory Care kitchenette a) An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following: * Countertop mixer; and * Interior of reach-in drawers. 3. Dining room kitchenette a) An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following: * Coffee dripping from coffee machine on countertop into interior of drawer storing dry cereal packages. At approximately 12:30 pm, the above findings were reviewed with Staff 1 (Administrator), Staff 2 (Dining Services Manager), and Staff 3 (Dining and Culinary Director) who acknowledged the findings.

1. Main Kitchen Areas a) A compliance specialist role has been designated where the mentioned areas will be cleaned deeply and thoroughly on a weekly or bi-weekly basis. This role will audit, clean, and document work in these areas. Walk-throughs will be done by a lead daily to ensure these areas are thoroughly attended to. See document (1.1). Ceiling tiles and smoke detectors are currently on an 120 day schedule to be cleaned. In addition, Maintenance team will clean every 30 days. b) New cutting boards have been ordered. See invoice (1.2). Additionally, leads and Compliance Specialist will check the integrity of our cutting boards weekly to ensure that new ones are replaced when needed. c) Our hair restraint policy has been updated to better accommodate safe food handling practices. All employees are required to sign off on this updated policy. See document (1.3). d) Staff training is in progress on proper dating and shelf-life for proper food safety compliance. See document (1.4). Leads and Compliance Specialist will be responsible for checking food storage areas daily. which is posted in the walk-in dry storage, fridge, and freezer. e) As stated above, a document stating the shelf life of our products has been posted for staff easy access. All food storage areas will be thoroughly checked daily by a lead or Compliance Specialist to ensure no potentially hazardous items are kept. 2) a). Memory Care kitchenette Life Enrichment staff will be responsible for keeping the kitchenette clean since they use it the most. A checklist and sign off sheet has been created to give staff something to go by and help keep them accountable. They will be turning the sign off sheet to the Administrator This will be evaluated daily by using the check off list and will be audited weekly by the Administrator or designee . See document (1.5) 3. Dining Room Kitchenette a) Our system has been updated to ensure these areas get deep-cleaned weekly and checked by a lead or designee daily. In addition, all items previously stored in drawers beneath the coffee machine have been moved to other designated locations. Additionally, repairs are in progress (work order placed12/30/25) to improve the integrity of our drawers.

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.

Refer Plan Of Correction to addendum C 240

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: 142: 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.

Z142: The above information includes Memory Care.

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.

Z0142: All above corrections apply to Memory Care.

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: