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 facility’s two food preparation kitchen areas, 4 meal service areas and two dry food storage areas occurred on 11/19/25 at 10:20 am through 3:15 pm and revealed the following areas: 1. Charles Reeds Plaza kitchen (Floor 4) 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: * Hot pads/mitts; * Interior of ovens; * Exterior of Turbo Chef Oven; * Industrial can opener and housing; and * Interior of plastic bin storing cooking utensils. b. The following areas were found in need of repair: * Multiple cutting boards heavily scored and stained; * Sauté pans scored/scraped with non-stick coating damaged; and * Multiple hot pads/mitts, torn or with holes. c. Multiple potentially hazardous food items were found stored in the refrigerator without dates opened or prepared. Multiple food items found not covered/protected from potential contamination while stored. d. Multiple dishwashing racks were observed stored on the floor. e. Multiple kitchen staff were observed to prepare foods or handle clean equipment without effective hair restraints. f. Containers of bulk dry food items observed with scoops stored inside the bins with the handles touching the food products potentially contaminating the food products. 2. Charles Reeds Plaza Kitchenette/food service (Floor 2) 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: * Black matt in front of dish machine; * Area under the black matt by dish machine; and * Knife holder and knives. b. The following areas were found in need of repair: * Walls behind dish machine with water damage. c. Plastic hose from dish machine observed stuck into floor sink drain touching the bottom of the drain. No air gap was identified to prevent potential back flow. Plastic piping touching bottom of drain that was not clean. Staff 2 (Dining Services Director) acknowledged the plastic pipe should not be resting in the bottom of the drain. d. Multiple dishwashing racks were observed stored on the floor. e. Multiple small plastic service bowls were observed with worn glaze, heavily scored and pitted needing replacement. 3. Garden view memory care kitchen 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: * Floors and walls under dish machine area; * Caulking behind hand wash sink at entry; * Interior of drawers holding utensils; * Interior of floor drain under sink in service area; and * Industrial can opener and housing. Staff 3 (Chef) toured areas with surveyors and acknowledged the above items needing addressed. 4. RCC main kitchen and dining 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: * Kitchen entry threshold corners/edges; * Flooring and wall under/around dishwasher; * Hot pads/mitts; * Interior of regular and convection ovens; * Floors under ovens; * Walls behind oven and grill; * Interior of hot food transport boxes; * Interior of drawers; * Sides of fryer, stove, oven; * Metal racks storing clean dishes; * Industrial can openers and housings; * Industrial slicer; * Walls and floors behind/under steam jacket kettle and tilt skillet; * Floor drains throughout kitchen; * Walk in cooler flooring in corners/edges under racks; * Walk in cooler stationary racks; * Movable baker/speed racks in walk in cooler; * Sprinkler head and ceiling in walk in cooler; and * Interior of ice machine. b. The following areas were found in need of repair: * Multiple cutting boards heavily scored and/or stained; * Sauté pans scored/scraped with non-stick coating damaged; * Oven mitts damaged/worn/holes; * Large gap in ceiling tile where electrical conduit enters/exits kitchen; * Cracked/missing cove base tile threshold entry way to kitchen; * Missing caulking/seal in freezer holding ice cream. Same freezer with large amount of frost/ice build up. c. Hot temperature dish machine was not registering proper sanitizing temperatures. Multiple cycles were run without rinse temperature reaching above 160 degrees. Staff 4 (Sous Chef) was interviewed and stated that he belived the temperature should be 160 degrees. Proper sanitizing temperatures for hot temp machines should reach 180 degrees. Records were reviewed and multiple entries were observed under 180 degrees. Staff 2 was interviewed and confirmed the temperature of the dish machine should be reaching 180 degrees for effective sanitizing. Facility was not sure how long the dish machine was not effectively sanitizing dishes. Facility ensured the dishes would be sanitized using three compartment chemical sanitizing until the dish machine could be fixed. d. Multiple dishwashing racks were observed stored on the floor. e. Multiple kitchen staff were observed to prepare foods or handle clean equipment without effective hair restraints. f. Multiple ice cream bars and/or sandwiches were found stored in a freezer that were soft and not frozen. Staff 2 stated no items should have been stored in that freezer as it was not freezing properly. Staff 2 indicated those items would be discarded. g. Slicer was noted to be stored uncovered and exposed to potential contamination. h. Multiple oven racks observed stored on the floor next to the convection ovens. i. Multiple green metal racks noted with yellow tape along the edges. The tape was worn, pealed, and frayed in multiple areas. Multiple areas leaving a sticky residue behind. This yielded a non-smooth surface. j. Salad bar area was observed during lunch service. A staff member was observed to replenish salad area and was handling Ready to Eat lettuce/spinach bare hands. That staff member had longer painted nails. Staff 2 acknowledged the staff member should have been waring gloves and directed the staff member to wear gloves. 4. RCC main dry 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: * Floors in the corners/edges and under metal racks; * Metal cart; and * Metal food storage racks. b. The following areas were found in need of repair: * Light switch and electrical outlet with missing or damaged outlet cover. c. Multiple metal racks observed with yellow tape. Tape was worn, ripped, frayed in areas yielding a non-smooth surface. Where tape had pulled away or worn left a sticky residue. 4. RCC floor kitchenette 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: * Floors under tables in the dining room; and * Chairs in the dining area dirty and/or stained. b. The following areas were found in need of repair: * Large hole found by piping of dish washer; * Multiple cabinets observed with porous wood exposed where protective coating had worn or pealed; and * Large section of countertop by stove area was found with porous wood exposed. c. Bulk coffee bin observed with scoop stored in bin with handle touching the food product potentially contaminating food. Staff 2 toured all kitchen areas with surveyors and acknowledged findings. Staff 3 toured areas 1, 2, and 3 with surveyors and acknowledged areas. Staff 4 toured RCC areas with surveyors and acknowledged findings. At approximately 3:00 pm, surveyor reviewed all findings with Staff 1 (Administrator) who acknowledged areas needing correction.

Corrective Action Taken for All Residents Affected AREAS AND EQUIPMENT CLEANING AND SANITATION All identified areas with food spills, debris, grease, dust, and black matter have been cleaned and sanitized as follows: 1. Charles Reeds Plaza – Kitchen (Floor 4) Accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease as identified in the statement of deficiencies has been cleaned and sanitized, including: • Hot pads/mitts • Interior of ovens • Exterior of Turbo Chef Oven • Industrial can opener and housing • Interior of plastic bin storing cooking utensils cleaned and utensils being stored out of bin. 2. Charles Beals (Reeds) Plaza – Kitchenette/Food Service (Floor 2): Accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease has been cleaned and sanitized, including: • Black mat in front of dish machine • Area under the black mat by dish machine • Knife holder and knives (knife holders were replaced) 3. Garden View Memory Care – Kitchen: Accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease has been cleaned and sanitized, including: • Floors and walls under dish machine area • Caulking behind hand wash sink at entry • Interior of drawers holding utensils • Interior of floor drain under sink in service area • Industrial can opener and housing 4. RCC Main Kitchen and Dining Area: Accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease has been cleaned and sanitized, including: • Kitchen entry threshold corners/edges • Flooring and wall under/around dishwasher • Hot pads/mitts • Interior of regular and convection ovens • Floors under ovens • Walls behind oven and grill • Interior of hot food transport boxes • Interior of drawers • Sides of fryer, stove, oven • Metal racks storing clean dishes • Industrial can openers and housings • Industrial slicer • Walls and floors behind/under steam jacket kettle and tilt skillet • Floor drains throughout kitchen • Walk-in cooler flooring in corners/edges under racks • Walk-in cooler stationary racks • Movable baker/speed racks in walk-in cooler • Sprinkler head and ceiling in walk-in cooler • Interior of ice machine 5. RCC Main Dry Storage Area: Accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease has been cleaned and sanitized, including: • Floors in corners/edges and under metal racks • Metal cart • Metal food storage racks RCC floor kitchenette: accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and/or grease on or underneath the following areas has been cleaned and sanitized: * Floors under tables in the dining room; and * Chairs in the dining area AREAS AND EQUIPMENT REPAIRS AND REPLACEMENT All areas identified in the statement of deficiencies have been repaired, replaced, or discarded as follows: 1. Charles Beals (Reeds) Plaza – Kitchen (Floor 4) • Cutting boards heavily scored and stained • Sauté pans scored/scraped with non-stick coating damaged • Multiple hot pads/mitts torn or with holes 2. Charles Beals (Reeds) Plaza – Kitchenette/Food Service (Floor 2) • Walls behind dish machine with water damage • Plastic hose from dish machine stuck into floor sink drain touching the bottom of the drain with no air gap (corrected) • Plastic piping touching bottom of drain (corrected) • Multiple small plastic service bowls with worn glaze, heavily scored and pitted (discarded and replaced) 3. RCC Main Kitchen and Dining Area • Multiple cutting boards heavily scored and/or stained • Sauté pans scored/scraped with non-stick coating damaged • Oven mitts damaged/worn/holes • Large gap in ceiling tile where electrical conduit enters/exits kitchen • Cracked/missing cove base tile at kitchen entry threshold • Missing caulking/seal in freezer holding ice cream with frost/ice buildup • Dish machine serviced to ensure sanitizing temperatures =180°F; test strips purchased 4. RCC Main Dry Storage Area • Light switch and electrical outlet with missing or damaged outlet cover • Metal racks with worn, peeled, and frayed tape replaced or cleaned to maintain smooth surfaces. 5. RCC floor kitchenette * Large hole found by piping of dish washer has been repaired; * Multiple cabinets observed with porous wood exposed where protective coating had worn or pealed; and * Large section of countertop by stove area was found with porous wood exposed will be repaired by 1/15/2025 or Kitchennette will be closed until repairs occur without interruption of services to residents. Audit and Additional Actions (1/07/2026) • All undated, uncovered, and improperly stored food items and equipment discarded; staff retrained on proper dating, labeling, and covering food and slicer when not in use • Dishwashing racks relocated to approved shelving • Oven racks relocated from floor to proper storage • Damaged equipment replaced or discarded • Water-damaged walls repaired and sealed • Freezer defrosted, sanitized, and serviced • Dish machine serviced to ensure sanitizing temperatures =180°F; test strips purchased • Improper food handling corrected; gloves enforced; hair restraints implemented (beard nets) • Electrical outlet and switch covers repaired SYSTEMIC CORRECTION TO SUPPORT SUSTAINED COMPLIANCE: • Kitchen Sanitation & Food Safety Policy revised with daily checklists and weekly deep-clean protocols • No Bare-Hand Contact policy retrained and enforced • Facial hair restraint policy reissued • Daily Sanitation Checklist implemented; Weekly Deep-Clean Protocol added • Monthly QA audits and quarterly environmental inspections scheduled • Repair & Replacement Log created for equipment and utensils • Staff retraining on Food Sanitation Rules and hygiene requirements • New employee orientation materials updated to include strengthened sanitation procedures EVALUATION FREQUENCY AND RESPONSIBILITY: Daily: • Sanitation checklist completed by staff; dish machine logs reviewed by kitchen supervisor or designee Weekly: • Executive Chef and Administrator (or Assistant Administrator) conduct walkthroughs and deep-clean verification Monthly: • Dining Services Director performs QA audits; Maintenance inspects plumbing and walls • Administrator reviews audit results with Executive Chef or designee Quarterly: • Preventive maintenance for structural integrity • QA Committee reviews findings monthly; retraining triggered by non-compliance RESPONSIBLE STAFF • Dining Services Director: Oversees QA audits and compliance • Executive Chef: Conducts daily and weekly sanitation checks • Maintenance Team: Handles monthly inspections and repairs • All Dietary Staff: Complete daily checklists and follow updated protocols • Administrator or designee: Reviews weekly and monthly audit results at QAPI meetings until sustained compliance is achieved Full compliance expected by January 18, 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: