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: 1. Observation of the facility main kitchen occurred on 10/21/2025 from 10:15 am through 3:25 pm and the following was found: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on, in or underneath the following: • Inside lower cabinets under sink and beverage dispensing machines in the soup and beverage station; • Nozzle housing of juice dispensers; • Ceiling vents in beverage/soup station; dish room; and vegetable prep/baking area; • Ceiling fan in dishroom; • Ceiling and walls near shake machine; • Ice cream freezer; • Microwave; • Reach-in refrigerators found in beverage/soup station and service line area including undercounter refrigerator drawers; • Black utility carts; • Robotic delivery cart shelving; • Range; • Grill; • Fryer; • Reach-freezer next to fryer; • Food warmers in cook/fry line; • Hot plate warmer; • Hood fire extinguisher or gas lines above range; • Alto-Sham; • Blast chiller; • Rational combi-steamer; • Kettle skillet; • Sheet pan racks • Plexi-glass in vegetable/baking prep area; • Plastic lids on lower shelf in vegetable/baking prep area; • Tray underneath cutting boards in vegetable/baking prep area; • Wooden box attached to wall in vegetable/baking prep area; • Drawers in vegetable/baking prep area; • Insta-Pot; • Vita-Mix; • Immersion blender; • Slicer; • Weigh scale; • Walls and grout around sink in dishroom; • Sink disposer and power box in dishroom; • Utility sink grout and mop bucket; • Tops of cans and food storage bins in dry storage; • Ice machine inside storage bin; • Ice scoop holder; • Floors in dishroom under scrap sink; dishwasher; and three sink unit; • Floor in freezer; • Floor drains in dishroom; in front of ice machine; and • Garbage cans throughout the kitchen. b. The following areas have been identified for needed repairs or replacement: • Rusty rack in refrigerator located in beverage/soup station; • Door seals on refrigerator number five in service line; • Door gasket on Rational combi-steamer; • White cutting boards on all food prep tables in main kitchen; • Oven mitts and hot pads; c. Handwashing sink next to small food prep table near range needs splashguard to avoid potential contamination of food and food contact surfaces. d. Food contact surfaces of countertop mixers observed not covered or stored inverted to prevent potential contamination. e. Multiple food items were found in kitchen cold and dry food storages open and exposed to potential contamination. f. Kitchen staff observed to handle ready to eat items with potentially contaminated gloves used for other tasks. g. Kitchen staff observed preparing food with excessive and dangling jewelry causing a potential for cross contamination. 2. Observation of the Memory Care kitchenette occurred on 10/21/2025 from 11:15 am through 12:15 pm and the following was found: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on, in or underneath the following: • Hot food holding cabinet; • Drawers; • Grout behind sink; • Two household refrigerator/freezers; • Juice dispenser nozzle housing and drip tray; b. The following areas have been identified for needed repairs or replacement: • Leak underneath juice dispenser; • White cutting board on food-prep table; c. Open and unopened wine bottles used for service to residents were observed stored on the floor in supply cabinet. Room was used to store resident personal and incontinence supplies and was not a food storage space. d. Thermometer was not found inside hot food holding cabinet to ensure food was being hot held at required/appropriate temperatures. Staff 1 (Food and Beverage Director) verified there should be a thermometer located in or on the box to ensure appropriate temperatures were maintained. Food was observed held in the box for greater than 40 minutes until served to residents. Staff 1 toured areas with surveyors and acknowledged areas needing correction. At approximately 2:40 pm, surveyors reviewed above areas with, Staff 2 (Memory Care Administrator), and Staff 4(Executive Director) who acknowledged the identified areas.

1. At daily premeal meetings, the Food and Beverage director will review the plan of correction and discuss systems in place to ensure safety and compliance. She will review kitchen daily with a thorough inspection weekly, reviewed with Executive Chef 2. Kitchen has a detailed cleaning list (daily, weekly, monthly) schedule on clip board, clearly posted targeting each area of the kitchen. These include, but not limited to, fridges, shelves, stock room, walls, floors, drains and all appliances. All checklists have been reviewed and updated to ensure compliance with the recent kitchen survey. Checklists will be reviewed by Executive Chef for completion, to ensure all cleanliness standards are being met and maintained an a daily basis. Sous chefs will be responsible for signing off on checklist per shift per day. 3. All items on this plan will be monitored by Food and Beverage Director (daily, weekly, monthly) and signed off. 4. Kitchen cleanliness will be assessed with walk-through with Executive Chef, Executive Director, Maintance Director and Food and Beverage Director, reviewed weekly. C0240 has been addressed in the following way: food spills cleaned and sanitized; added to the per shift daily cleaning duties to be intialed by employee once complete. Sous chefs will be held responsible for checking out employees at the end of each shift. The executive chef will over see the checklist and hold staff accountable for cleanliness. a. The accumulation of debris -lower cabinets under sink and beverage dispensing machines in soup and beverage stations have been emptied, cleaned -nozzle house of juice dispensers have been removed and cleaned, a mainatance request has been made for the juice machines via Florida's Natural -ceiling vents in beverage stations, dish room and vegetable prep stations have been removed and cleaned, have been added to a rotating schedule with maintance crew -ceiling fan in dish room has been removed -ceiling and walls near ice cream freezer have been scrubbed has been added to nightly checklist -microwave and surrounding area has been cleaned and sanitized with staff training on 'clean as you go' -reach in fridges in beverage stations have been emptied and cleaned before reorganization, added to weekly checklist -black utility carts have been scrubbed and pressure washed to remove access debris, added to shift checklists -robotic delivery cart shelving has been removed, cleaned and reinstalled, added to nightly checklist -the range, grill, and fryer have been cleaned inside and out; staff has had training on which chemicals to use to ensure cleanliness, closers will be responsible for night cleaning -reache freezer next to fryer has been emptied, details and restocked, training on cleaning checklist has occured -food warmers in cook/fry line and hot plate warmer have been emptied and deep cleaned, added to nightly checklist -hood filters above range have been cleaned with a rotating schedule 4 times a year by Oregon Hood Cleaning. All accessible areas in hood will be cleaned daily and/or weekly, as needed. -alto sham has been cleaned, inside and out, staff training on how to wash nightly has been enforced -blast chiller has been wiped inside and out, added to checklist -rational combi oven has been cleaned with staff training on how to properly clean on a daily basis -kettle skillet has been deep cleaned, added to night shift checklist -sheet pan racks have been emptied and scrubbed, added to dishwasher checklist -plexi glass in vegetable prep station has been scrubbed, a replacement is being sought -plastic lids on lower shelf in vegetable prep area have been removed, all items cleaned and replaced, added to daily checklist -tray underneath cutting boards have been replaced, added to daily/weekly checklist, as needed -wooden box attached to wall has been removed -drawers in prep area have been emptied, detailed and restocked, added to the weekly checklist -the insta-pot, vita-mix, immersion blender, sliceer, weigh scale have been scrubbed and stored properly, staff training has occurred regarding proper storage -walls and grout around sink in dish room have been scrubbed, sanitized, training on proper cleaning protocol has occurred -utility sink grout has been scrubbed, mop buckets have been deep cleaned and added to weekly checklist. Tiles and grout are actively being replaced by Integrity Tile company -tops of cans and food storage bins have been removed, staff advised of keeping items sealed at all times when storing; personnel assigned to put away products is responsible for cleanliness of storage area -ice macine has been emptied, cleaned and refilled with "how to clean ice machine" instructions posted -ice scoop holder has been removed, cleaned and reattached and add to the "how to clean ice machine" instructions -floors in dish room have been scrubbed, staff training has occurred and added to nightly checklist -floor in freezer has been swept, mopped and scrubbed, added to checklist -floor drains in dish room and front of ice machine have been cleaned, staff training has occurred and items added to nightly checklist -garbage cans have been emptied, scrubbed, added to daily duties b. -rusty rack in refrigerators have been requested to Home Office for replacement -door seals on fridge #5; doors will be adjusted to prevent gasket getting bunched up in corners -door gasket on Rational has recently was replaced in October and will be adjusted for easier clean -white cutting boards on food prep tables will be either sanded and scrubberd of any stains or replaced by 12/01/25 -oven mits and hot pads have been replaced, executive chef to inspect daily, per job description c. installation of splashguard of handwashing sink next to food prep table has been ordered and will be installed by 12/1/25 d. food contact surfaces of mixers have been covered and bowls inverted with staff training on proper storage e. full inspection of food items in kitchen cold and dry food storages have been addressed, either thrown away or repackaged as needed; staff member responsible for putting away deliveries is tasked to clean food containers and check dates. f. kitchen staff has had training on glove usage and RTE foods 11/30/25 g. staff wearing excessive, dangling jewelry has been addressed, uniform policies enforced Additionally, Executive Chef will be held responsible for upkeep of equipment, cleanliness, safety issues and training in the kitchen per job responsibiliites as outline in job description and state mandates. Food and Beverage Director will conduct weekly inspections to assure quality, proper storage, cleaning, functioning equiment and trainings are upheld 2. Footsteps: -Food debris has been cleared, wiped and sanitized in the hot food holding cabinet and added to a daily checklist duty -drawers have been emptied, cleaned and reorganized, added to weekly checklist duties -grout behind sink has been srubbed and added to daily checklist duties -Two household refrigerator/freezers have been emptied, cleaned and restocked, added to weekly duties -Juice dispenser has been dismantled and cleaned, added to weekly duties b. Leak underneath juice machine has been repaired by Florida Natural Co -white cutting boards on food prep tables are scheduled to be sanded and scrubberd of any stains, or replaced if unable to refinish surfaces c. unopened wine was immediately removed from the floor of the non food storage space to a locked cabinet d. Thermometer to heat box was installed on 10/21/25 Footsteps Administrators will ensure cleaning and mainentance checklist will be completed daily. Furthermore, Executive Chef and Food & Beverage Director will walk through and inspect spaces on a weekly basis

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 411-057-0140(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 observation and interview, it was determined the facility failed to follow licensing rules for Resident care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240

see C 240

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: