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 ensure the kitchens were maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: 1. On 11/21/25 at 10:00 am, the facility main kitchen (which provided food to both the ALF and MCC) was observed to need cleaning in the following areas: a. Food spills, splatters, debris, dirt and black matter was observed on or underneath the following: * Sides of ovens and steamer; * Wall and pipes behind ovens; * Metal shelf beneath steamer; *Walls, pipes, garbage disposal and floor drain in dish machine area, * Wall next to fire extinguisher; * Floor drain near two-compartment sink; and * Flooring throughout, including perimeter, underneath appliances and shelving units, and in dry storage area. b. The following areas needed repair: * Caulking in the dish machine area was discolored; and * Dry storage room: scraped areas and rust stains on the door jamb, gouges on the door edges, and scrapes/gouges to the wall adjacent to the entrance. c. Three dietary staff, with facial hair, did not have it restrained. The areas in the main kitchen which required cleaning and repair were observed and discussed with Staff 1 (ED) and Staff 2 (Culinary Services Director) on 11/21/25 at 11:00 am. Additionally, the need to ensure dietary staff had facial hair restrained was discussed. The findings were acknowledged. 2. On 11/21/25 at 11:15 am, the MCC kitchen was observed to need cleaning in the following areas: a. Food spills, splatters, debris, dirt and/or black matter was observed on or underneath the following: * Drains of both sinks; * Microwave interior; * Wall vent; and * Cabinet underneath sink. The areas which required cleaning were observed and discussed with Staff 1 and Staff 2 on 11/21/25 at 11:25 am. The findings were acknowledged.

1. In service training with all dining staff to educate on facial hair coverings, cleaning procedures and best practices for using cleaning logs. This training will be conducted by the Culinary Director on Dec. 4th, 2025. Additional in service trainings will be conducted an a weekly and as needed basis until all deficencies are corrected and systems for maintaining compliance are learned by all dining staff. Thorough deep cleaning of all floors, walls, cooking equipment, metal shelves, pipes, floor drains, sinks and especially concentrating on the perimeter as noted on the report. This cleaning will be done by kitchen staff, maintenance staff and will be overseen by the culinary director. Weekly and daily projects will begin immediately and the kitchen will be ready for reinspection by January 15th, 2026 Repairs of walls, paint, rusted hinges and caulking in dishroom will be done by the maintenance director starting on Dec 8th, 2025, with projects scheduled to be complete and in compliance by Jan 15th, 2026. A proper cover for the stand mixer will be ordered and implemented immediately. The stand mixer will be covered when not in use. Compliance will be complete on or before Jan. 15th, 2026 Compass Rose kitchenette is scheduled for deep cleaning, including drawers, cabinets, under sink and microwave on Dec. 15, 2025 2. Cleaning logs will be updated to reflect current equipment and highlighting the perimeter cleaning needs to be addressed on daily and weekly schedules. These logs will be filled out by all dining staff on every shift starting immediately and compliance will be reached on or before Jan. 15th, 2026 Cleaning tasks will be assigned to positions and shifts rather than left for a volunteer basis to ensure accountability. Audits of cleaning logs will be done daily by the culinary director. Weekly TELS audits will be completed by the Culinary Director and submitted to the Regional Culinary Director and the Senior Executive Director. TELS is an online tool that uses photos and typed comments to show compliance in areas of cleaning, menu creation, use of logs/auditing etc. Corrective action including education, verbal and written counseling, suspension and termination will be used to hold dining services staff accountable to using these systems and maintaining compliance. The Culinary Director and Senior Executive Director will work as a team to correct dining staff that struggle to maintain best practices and compliance standards. 3. The main kitchen and Memory Care kitchenette will be evaluated or audited weekly by the Culinary Director using paper logs and the TELS audit tool. The main kitchen and Memory Care kitchen will be evaluated monthly by the Senior Executive Director and the Program Director to ensure accountability of the Culinary Director. 4. All corrections and completion deadlines will be monitored by the Culinary Director with support by the Maintenance Director, the Program Director and the Senior Executive Director All compliance corrections will be completed on or before January 15th, 2026.

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 Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240.

1. In service training with all dining staff to educate on facial hair coverings, cleaning procedures and best practices for using cleaning logs. This training will be conducted by the Culinary Director on Dec. 4th, 2025. Additional in service trainings will be conducted an a weekly and as needed basis until all deficencies are corrected and systems for maintaining compliance are learned by all dining staff. Thorough deep cleaning of all floors, walls, cooking equipment, metal shelves, pipes, floor drains, sinks and especially concentrating on the perimeter as noted on the report. This cleaning will be done by kitchen staff, maintenance staff and will be overseen by the culinary director. Weekly and daily projects will begin immediately and the kitchen will be ready for reinspection by January 15th, 2026 Repairs of walls, paint, rusted hinges and caulking in dishroom will be done by the maintenance director starting on Dec 8th, 2025, with projects scheduled to be complete and in compliance by Jan 15th, 2026. A proper cover for the stand mixer will be ordered and implemented immediately. The stand mixer will be covered when not in use. Compliance will be complete on or before Jan. 15th, 2026 Compass Rose kitchenette is scheduled for deep cleanin, including drawers, cabinets, under sink and microwave on Dec. 15, 2025 2. Cleaning logs will be updated to reflect current equipment and highlighting the perimeter cleaning needs to be addressed on daily and weekly schedules. These logs will be filled out by all dining staff on every shift starting immediately and compliance will be reached on or before Jan. 15th, 2026 Cleaning tasks will be assigned to positions and shifts rather than left for a volunteer basis to ensure accountability. Audits of cleaning logs will be done daily by the culinary director. Weekly TELS audits will be completed by the Culinary Director and submitted to the Regional Culinary Director and the Senior Executive Director. TELS is an online tool that uses photos and typed comments to show compliance in areas of cleaning, menu creation, use of logs/auditing etc. Corrective action including education, verbal and written counseling, suspension and termination will be used to hold dining services staff accountable to using these systems and maintaining compliance. The Culinary Director and Senior Executive Director will work as a team to correct dining staff that struggle to maintain best practices and compliance standards. 3. The main kitchen and Memory Care kitchenette will be evaluated or audited weekly by the Culinary Director using paper logs and the TELS audit tool. The main kitchen and Memory Care kitchen will be evaluated monthly by the Senior Executive Director and the Program Director to ensure accountability of the Culinary Director. 4. All corrections and completion deadlines will be monitored by the Culinary Director with support by the Maintenance Director, the Program Director and the Senior Executive Director All compliance corrections will be completed on or before January 15th, 2026.

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: