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 a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen, food storage areas, lunch preparation and meal service was completed on 12/03/25 between 11:00 am and 2:50 pm, and the following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, and/or black matter was visible on or underneath the following: * All cupboards and shelves; * All interiors and exteriors of drawers; * Flooring; * Drain and walls under ware washer; * Top of ware washer; * Blinders near steam table; * Stove; * Oven; * Vents; * Industrial can opener; * Ceiling, especially near steam line and food service area; * Reach-in fridges and freezers in kitchen and dry storage area, exterior and interior; * Reach-in fridge in dining room, interior; * Food delivery cars, plastic and metal; * Juice machine; * Light switches; * Underneath metal racks in dry storage area; * Food storage bins; and * Windowsill near steam line. b. The following areas were in need of repair: * Approximately 12-inch square near the vent hood which appeared to have burnt foam and tin foil loosely hanging; * The ice maker present in the dining room had significant build-up and appeared to be leaking, with the floor water-damaged around it and a five-gallon bucket partially filled with filmy brown water present underneath the ice machine; * The steam line had standing water pooled underneath, and multiple wet towels and a piece of wet wood underneath; * Shelves and drawers throughout the kitchen and dry storage areas had peeling surfaces and exposed wood, resulting in non-cleanable surfaces; * Stand mixer; and * Holes in the ceiling which had been patched with tape, which was peeling. c. Scoops and spoons were observed in food containers in the kitchen and dry goods storage area with handles touching food surfaces. d. Multiple food items were observed stored in kitchen cabinets, the dry storage area and/or freezers that were not closed or covered and were exposed to potential contamination. e. Multiple cutting boards were found heavily scored or stained and in need of replacement. Multiple oven/hot mitts were found damaged with holes and rips. Multiple pots and pans were found to be peeling, or surfaces were heavily scored. f. Staff items including purses and dead flowers were stored on the kitchen counter. g. Multiple trash cans were observed in the kitchen without a lid when not in use. h. Expired juice and/or dented cans were observed in the kitchen. i. . Multiple items in the reach-in fridge were expired or stored past seven days, including peach and pineapple chunks, “meat sauce,” and buttermilk. j. A large plastic container with substance containing tuna, prepared by the facility, was in the reach in fridge and was dated 11/24/25, greater than 7 days prior. A ticket came across the kitchen for a tuna sandwich. At approximately 12:30 pm a staff member used the tuna to make a sandwich and placed it on the line to be served. The surveyor intervened and took the sandwich to Staff 2 (Dietary Manager) and reviewed that the sandwich could not be served as the tuna was past serving date. k. A mop and mop bucket full of brown water were present next to the counter where food was being prepared. l. During an interview, Staff 2 stated that multiple residents requested and were served eggs over-easy for breakfast. She stated that she believed all eggs ordered were pasteurized. Upon observation, the eggs in the fridge were not pasteurized, and therefore should not have been used for food items which were not thoroughly cooked to prevent potential contamination. m. Multiple staff were observed to contaminate gloves by touching items including meal tickets and microwave handle, and then touching ready-to-eat food items and prepared food items. A staff member was observed scooping butter out of a large plastic container, using her potentially contaminated gloved finger to push the butter off the spoon onto a ready-to-eat item, and then reaching back into the butter again with the spoon which had been touched. n. Multiple flies were observed in the kitchen. o. A staff member was observed using a thermometer without ensuring it was clean prior to and after inserting it into food items. There was no protective covering over the probe, and the probe was in a container with multiple other items which could cause potential contamination. p. Staff did not check the temperature multiple food items, including instant mashed potatoes and hamburger, prior to serving. q. Staff 2 was interviewed regarding how often sanitizer buckets were changed and indicated they were changed at 6:00 am, 10:00 am, 2:00 pm and 5:00 pm, not every two hours or as needed per rule. r. Dinner place settings including utensils and cups were set at approximately 2:30 pm. Dinner meal service was scheduled between 4:30 pm and 5:00 pm. Utensils were observed uncovered and open to potential contamination. The need to ensure the kitchen was maintained and food stored and served in accordance with the Food Sanitation Rules was reviewed with Staff 1 (ED), Staff 2, Staff 3 (Regional Maintenance Director) and Staff 5 (Regional Vice President) on 12/03/25 at 2:50 pm. They acknowledged the findings.

1) A. After initial survey 12/3/25 we deep cleaned the following items : All cupboards, Flooring, Drains and walls under ware washer, Stove, Oven, Vents, industrial can opener; Ceiling, especially near steam line and food service area; Reach-in fridge in the diningroom, interior; Food delivery cars, plastic and metal; Juice machine, Light switches; underneath metal racks in dry storage area; Food storage bins; and windowsills near steam line. B.12-inch square near vent hood with "burnt foam" and tin foil hanging was repaired and covered on the evening of 12/3/25. Ice maker was immediately removed from service on 12/3/25. It has been thoroughly cleaned and leak has been repaired--bucket removed and is now functional. Flooring area under ice maker will be replaced and water damage repaired. Water under steam table was addressed on 12/3/25, towels and wet wood was removed. Steamer covers(Blinders) have been replaced with alternative covers to minimize water drips under table. Shelving and drawers were all cleaned and resurfaced with contact paper to ensure it is a cleanable surface. Stand mixer has been removed. Holes in ceiling have been patched and repainted. C: all scoops in food containers inside kitchen and dry storage were removed on 12/4/25 and staff educated to ensure no scoops/spoons are kept inside them. D: Staff have been educated regarding food safety and storage—all food items will have proper coverings and lids. E: All cutting boards were replaced on 12/3/25. Oven mitts will be replaced. New pots and pans have been ordered and will replace existing, damaged items. F: Staff have been educated that storing personal items and non-food items will not be stored on kitchen counters or other food prep/storage areas. G: trash cans were replaced with cans that have lids on 12/3/25 H: all expired juice and dented cans were removed on 12/3/25. I: All expired items or items stored past 7 days were removed from kitchen reach-in fridges on 12/3/25. J: Tuna dated 11/24/25 was removed from reach-in fridge at time of survey(12/3/25). K: Staff have been educated to ensure no cleaning products including mop/mop water will be stored or left near food prep areas. L: Staff have been educated on pasteurized vs. non-pasteurized eggs usage/rules—non-pasteurized eggs will only be used for thoroughly cooked items. M: staff have been re-trained regarding proper glove use and safe food handling procedures. N: In order to mitigate flies entering kitchen to the highest extent possible, staff will only leave exterior door open for shortest possible time. O and P: Staff have been re-trained on thermometer use and policy regarding cleaning, use and storage as well as ensuring food is properly temped prior to serving. Q: Staff have been re-trained regarding proper sanitizer use—will be changed every 2 hours or as needed. R: Utensils for dining settings will be rolled and set on tables to ensure not open to contamination. 2) Re-training staff 12/11/25, continued education. Weekly audits and cleaning schedule. Twice monthly walk through with ED and Dietary Manager. Repair book for all repair needs. Maintenance director will check days worked for repair needs. 3)Kitchen staff will follow the daily cleaning schedule. Dietary Manager will take 1 day a week as a office day to assist with deep cleaning and audit. Dietary Manager and ED will do twice a month rounds togather to look for areas of improvement. Maintance log will be check regularly for any repair needs. 4) Dietary Manager will monitor the kitchen for cleanliness and put in any work orders needed for repairs. Dietary manager and ED will do twice monthly rounds to ensure kitchen is clean and free of any needed repairs. Dietary Manager will also do a weekly kitchen audit tool and correct any issues noted.

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: