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 kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 11/19/25 at 10:30 am, the facility kitchen was observed to need cleaning in the following areas: * Ice maker – interior with black matter, exterior vent dusty; * Ceiling vents and tiles above service line – dust accumulation; * Walk in refrigerator fans – dust accumulation; * Wall behind spray hose sink and wall behind dishwashing machine in dishwashing area – significant build up of black matter; * Wall below and next to handwashing sink in dishwashing area – brown matter build up; and * Interior of microwave next to juice machine – splatters/spills. Other areas of concern included: * Colored and white cutting board – heavily scored and/or stained; * Three garbage cans in food service areas not covered when not being actively used; * Missing ceiling tile in dishwashing area; and * Lack of facial hair restraints. The areas of concern were discussed with Staff 1 (Kitchen Manager), Staff 2 (VP of Health & Wellness) and Staff 3 (Director of Nursing Services) on 11/19/25. The findings were acknowledged.

Ice maker: 1. Cleaned ice maker on 12/9/2025. 2. Added task of cleaning ice maker interior and exterior, inclduing vent thoroughly to the closing task list. (Completed on 12/10/2025). 3. Daily walkthroughs for all items on closing task list will be conducted to ensure tasks are completed. Ice maker to be deep cleaned at a minimum monthly and as needed following daily inspections. 4. Director of Dining Services will be responsible for ensuring lists are properly followed. Ceiling vents and tiles above service line: 1. Scheduled cleaning of ceiling vents and tiles above service line with Envrionmental Services Department - work order submitted. (Completed on 12/7/25). 2. Working with Envrionmental Services Department to implement cleaning of vents and surrounding areas on a monthly cleaning schedule. 3. Monthly inspections of ceiling vents and tiles above service line will be conducted to ensure they are free of dust accumulation. 4. Director of Dining Services and Director of Envrionmental Services to ensure that cleaning schedule is followed and maintained. Walk-in Refridgerator: 1. Cleaned walk-in refridgerator fans. (Completed on 12/8/25). 2. Added cleaning of walk-in fans to back of house weekly cleaning list to ensure dust does not accumulate. (Cleaning list updated 12/10/2025). 3. Weekly audits to be conducted to ensure cleanliness. 4. Director of Dining Services responsible for implementing cleaning list and completing weekly audits. Dishwashing Area: 1. Cleaned wall behind spray hose sink and wall behind dishwashing machine in dishwashing area and wall below and next to handwashing sink in dishwashing area. (Completed 12/8/25.) 2. Worked with Dining Services to implement cleaning of walls in dishwashing area. Added checking of walls and areas behind spray hose and dishwashing area to weekly cleaning schedule for dishwashing staff. Walls, ceiling and flooring scheduled for replacement in 2026. 3. Area needing correction to be inspected monthly. 4. Director of Dining Services to ensure cleaning schedules are maintained. Microwave: 1. Cleaned microwave interior and surrounding areas. (Completed on 11/19/25). 2. Added task of cleaning microwave and surrounding area thouroughly to the closing task checklist. (Completed on 12/8/2025). 3. Daily walkthroughs for all items on the closing task list will be conducted to ensure tasks are completed. 4. Director of Dining Services will be responsible for ensuring lists are properly followed. Colored and white cutting boards: 1. New cutting boards were ordered. (Ordered on 12/3/2025). Heavily scored and stained cutting boards were disposed of. (Delivery date TBD). 2. Added task of inspecting kitchen cutting boards on a monthly basis to check for integrity and replace as needed. 3. Bi-weekly inspection to be conducted to ensure cutting boards meet Food Sanitation Rule OARs 333-150-0000 4. Director of Dining Services responsible for completing monthly audit to ensure cutting boards are in approved condtition. Garbage Cans: 1. Garbage can lids placed on garbage cans upon inspection. 2. Added required covering of garbage cans when not in use to on-going/daily and end of day task list (Completed on 11/26/2025). 3. Daily walkthroughs for all items on task lists will be conducted during meal prep times, eg., before lunch/dinner service to ensure garbage can lids are in place when not in use. 4. Director of Dining Services will be responsible for ensuring all trash cans have lids in place consistently when not actively in use. Missing ceiling tile: 1. Replace ceiling tile in dishwashing area - Work order submitted; completed on 12/3/2025. 2. Working with Facilities Department to implement inspection of ceiling tiles in dishwashing area and surrounding areas on a weekly basis. 3 Weekly inspections of ceiling areas and tiles in dishwashing area will be conducted to ensure there are no missing tiles. 4. Director of Dining Services and Director of Facilities to ensure that inspection schedule is followed and maintained. Lack of facial hair restraints: 1. Use of beard netpolicy implemented 12/8/2025. 2. Inspect and reinforce policy for use. 3. Daily. 4. Director of Dining Services will be responsible for ensuring 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: