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. Findings include, but are not limited to: Observations of the kitchen and activities areas occurred on 10/14/25 at 10:15 am through 2:30 pm revealed the following areas: 1. Main kitchen and food storage area a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and/or grease was visible on or underneath the following: * Juice machine under by nozzles; * Metal racks storing spices next to ovens/range; * Removable hood vents; * Sprinklers in hood area; * Piping and wall by hood * Interior of reach in coolers; * Industrial mixer; * Ceiling vent above prep table; * Reach in cooler door seals; * Knobs for oven/griddle; * Exterior/knobs for industrial toaster; * Interior of industrial toaster; b. The following areas were found in need of repair: * White metal racks in reach in freezer with exposed rusted areas. * Metal rack in dry storage with corrosion and severe ware yielding unsmooth and cleanable surfaces and in need of replacement. * Black utility cart had visible burn rings on the top yielding rough/bubbled areas which were not smooth and cleanable. c. Multiple potentially hazardous food items were found stored in the refrigerator without dates opened or prepared. d. Multiple potentially hazardous food items were found past their manufactures use by dates or past 7 days from preparation date. One container of cottage cheese was found well past its use by date and the lid was found to be bulging indicating potential microorganism growth. e. Multiple kitchen staff were observed to prepare foods or handle clean equipment without effective hair restraints. f. Staff member was observed to potentially contaminate their gloves by touching surfaces of unclean carts, counter tops, resident meal tickets, pen and other items then proceed to touch ready to eat items. Staff was observed to grab ready to eat items such as lettuce and tomatoes with contaminated gloves instead of appropriate utensils to minimize risk for contamination. g. Facility was observed to preset tables with table ware and their food contact surfaces exposed well in advance of meal service. Multiple residents were observed unsupervised in the dining room during this time, exposing preset silverware to potential contamination. h. Clean dishes (pots/pans utensils, etc.) were observed stored directly under storage of cleaning chemicals exposing them to potential contamination. i. A staff drink were observed without appropriate style (covered with lid and straw) to protect from potential contamination. These drinks were not stored in a dedicated area to help minimize risk of v potential contamination. j. Multiple leftovers were observed stored in reach in coolers. Staff 2 (Director of Dining Services) was not able to effectively demonstrate knowledge of appropriate cooling practices to ensure left over foods were cooled appropriately. k. Multiple racks of dishes for dishwashing were observed overloaded and overlapping so that not all surfaces of dishes were in direct contact of cleaning/sanitizing agents to ensure effective sanitation of dishes. l. Facility did not have a three compartment sink as required. 2. Activities Space a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and/or grease was visible on or underneath the following: * Interior of reach in refrigerator and freezer; * Interior of oven; * Interior of microwave; * Interior of cabinets/drawers storing food/snack items; b. Staff food items stored in refrigerator where resident food and beverages were stored. c. Reach in refrigerator did not contain a thermometer to monitor cold food storage temperatures. d. A large container of recyclable cans and bottles was found stored without a lid to prevent/protect accumulation of insects/pests. Staff 2 toured kitchen areas with surveyors and acknowledged findings. At 2:00 pm, surveyors reviewed findings with staff 1 (Wellness Director) and again with staff 2 who acknowledged areas in need of correction.

1. Main kitchen and food storage area: A. Daily, weekly and monthly cleaning schedules. Executive Director or designee will audit the cleaning schedules 3 times weekly x1 month, weekly x1month thereafter to maintain compliance. B. Will replace mental racks in reach in freezer and dry storage area. Black utility cart will be replaced. C. Dining Service Director (DSD) and kitchen associates will check daily to ensure all food has opened dates. Executive Director (ED) will check weekly to ensure all dates are on the open food. D. Dining Service Director (DSD) and kitchen associates will check daily to ensure there is no food past the manufacturer date. Executive Director (ED) will check weekly to ensure there is no food is past the manufacturer date. E.Executive Director or designee will go over the proper effective hair restraints. F. All staff will be educated by ED/DSD or designee on food delivery practices to prevent contamination. 4. White metal rack in reach-in freezer, metal rack in dry storage and black utility carts will be replaced. 5. Kitchen staff will check all food in the refrigerator to ensure there is an open date and not past the manufacturer use by dates. Executive Director or designee will check all dates in the refrigerator 2x week for 1 month and then weekly. 6. Dining Service Director will ensure all clean dishes are not stored below cleaning chemicals. Activities Space 1. Executive Director or designee will audit the cleaning schedules. Life Enrichment director will do, a walk through the activities space at least 2x per week for 1month and then monthly 2x per month to maintain compliance. 2. Staff food items placed in a bin that states staff food in the refrigerator. 3. A reach in refrigerator thermometer order to be placed in activity refrigerator. 4. All recyclable cans and bottle removed. L. Submitted a application for exception on not having the three compartment sinks.

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 12/17/25 from 11:45 am through 12:45 pm showed the following areas needed cleaning or repair: 1. Main kitchen and food storage area: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and/or grease was visible on or underneath the following: * Juice machine under by nozzles; * Industrial mixer safety “cage”; * Ceiling vent above prep table; * Reach-in cooler door seals; * Knobs for oven/griddle; * Exterior/knobs for industrial toaster; and * Interior of industrial toaster; b. The following areas were found in need of repair: * White metal racks in reach-in freezer with exposed rusted areas; and * Cabinet in dining area used to hold dish racks noted with multiple large areas of exposed porous wood. c. Multiple potentially hazardous food items were found stored in the refrigerator without dates opened or prepared. d. Potentially hazardous food items were found past their manufacturer’s use-by dates or past seven days from preparation date. Deli-style ham with an open date of 12/5 was observed in stand-up reach-in on the main line. e. Kitchen staff were observed to prepare foods or handle clean equipment without effective hair restraints. f. Kitchen staff were observed to handle food items with gloved hands, then continually touch a sanitation towel sitting on the reach-in station cutting board, and returned to preparing/handling food while wearing the same gloves, potentially contaminating the food items. g. Multiple kitchen towels were observed stored in various locations; i.e., kitchen counter, dining room cabinet, cutting board, and not in sanitation solution. The towels were not returned to the sanitation bucket. h. Warm to the touch “ham” wrapped in foil was observed stored in a reach in cooler. A package of deli turkey was stored on top of the ham in foil and was also warm to the touch. The ham was left over from lunch service and was placed directly into cooler after cooked and not allowed to cool properly. Staff 2 (Director of Dining Services) was not able to effectively demonstrate knowledge of appropriate cooling practices to ensure left over foods were cooled appropriately. He stated there were four hours to allow foods to cool to “room temperature” degrees instead of two hours. Staff 2 indicated he had not had the opportunity to review cooling process with staff. Surveyor observed incorrect cooling practice on survey. i. Facility did not have a three compartment sink as required. 2. Activities space: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and/or grease was visible on or underneath the following: * Interior of drawers and cabinets storing food/snack items and/or clean equipment At approximately 12:30 pm, surveyors reviewed findings with Staff 1 (Executive Director) and Staff 2, and items still out of compliance were acknowledged.

1. Main kitchen and food storage area: A. Daily, weekly and monthly cleaning schedules have been updated and implemented. Executive Director or designee will audit the cleaning schedules 3 times weekly x1 month, weekly x1month x 3 months, then monthly thereafter to maintain compliance. Dining consultant will audit quarterly. B. Metal racks in reach in freezer and dry storage area have been replaced. Wood cabinet in dining area has been removed. C. Dining Service Director (DSD) and kitchen associates will check daily to ensure all food has opened dates. Executive Director (ED) will audit once weekly x 1 month, once monthly x 3 months and consultant to audit quarterly to ensure all dates are on the open food. D. Dining Service Director (DSD) and kitchen associates will check daily to ensure there is no food past the manufacturer date. Executive Director (ED) will audit once weekly x 1 month, once monthly x 3 months and consultant to audit quarterly to ensure there is no food is past the manufacturer date. E. Hair restraints are now provided and available for all staff F. All staff will be educated by Executive Director/DSD on food delivery practices to prevent contamination. G. All staff will be educated on proper sanitation practices and Executive Director or designee will audit this practice once weekly x 1 month, once monthly x 3 months and consultant to audit quarterly to ensure compliance. H. All staff will be educated on proper cooling practices and DSD or designee will audit this process once weekly x 3 months. 2. Activities Space This space has been thoroughly cleaned and organized and Life Engagement Director will audit weekly x 1 month and once monthly thereafter to ensure cleaniness compliance.

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 to C240

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: