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 a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the kitchen on 12/11/25 showed the following areas needed cleaning or repair: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, white billowy matter, and/or black matter was visible on or underneath the following: * Food debris, dried spills/liquids observed on dining room chairs before and after cleaning of area between meal periods: * Hood vents above range; * Bottom of cabinets on prep island; * Baseboard at bottom of center prep island; * Windowsill of window in kitchen next to back door; * Bottom of freezer in dry storage area; * Reach-in refrigerator in dry storage area; * Threshold of back door into kitchen; * Underside of Kitchen Aid mixer head; * Toaster; and * Floor drain under prep island. b. Items in need of maintenance or repair: * Multiple cutting boards observed with scoring and or embedded black debris; * Black gasket/seal on lower door of stand-up reach-in freezer; * Ice build-up on lower shelf of freezer in dry storage; * Enamel/caulking on floor drain under prep island; * Reach-in refrigerator in dry storage area not holding proper temperature, and * Exhaust hood removable vents dented and not fitting properly. c. Multiple open containers found beyond manufacturer’s use-by date. Staff 2 (Cook/Person-in-Charge) acknowledged the items were outdated and should have been discarded. Multiple items found in cold storage without legible open and/or prepared dates. d. Staff 3 (Cook) was observed to have a towel attached to their person instead of being stored in the sanitation bucket. The towel was observed to be touched multiple times with gloved hands, potentially contaminating them. The towel was not observed being returned to the sanitation bucket after use. e. Staff 3 was observed to drop a paring knife used for food prep on the floor and return the knife to the work station without washing/rinsing/sanitizing it first. f. Staff 3 was observed to use their thermometer, and then sanitize the thermometer in quaternary ammonia based solution but did not rinse it afterwards. Staff 3 then was observed to use that thermometer, potentially contaminating food with sanitizing solution. g. Staff 2 was unable to adequately describe the two-stage cooling method for hot foods. h. The reach-in refrigerator in the dry storage area did not contain a thermometer. A large metal container of soup for residents was observed being stored in the refrigerator. Staff 2 was asked to temp the resident food and the food was found to be at 50 degrees Fahrenheit, which is an unsafe temperature. The surveyor’s thermometer was used to check the temperature of the refrigerator, and it was found at 47 degrees Fahrenheit, six degrees higher than the required temperature. i. Staff 2 and Staff 3 were not able to state which sanitizing method (heat or chemical) was being used for the ware washing machine final cycle. Staff 2 was not able to state the appropriate sanitizing heat temperature. The facility did not have a system to effectively monitor the sanitizing agent of their ware washing machine. j. Test strips for the ware washing machine had been dropped in liquid and were no longer functional. The facility was using a different chemical for surface sanitizing buckets, and they did not have test strips for that chemical. The facility did not have a system for ensuring that surface sanitizing solution was at appropriate concentration levels for effective sanitation. k. Multiple dented/damaged food products were observed in the dry storage area, stored with ready-to-use products. l. Staff 3 was observed to wash dishes without a protective barrier over their clothing. Staff 3, after washing dirty dishes, continued with food preparation and service. This practice caused a potential for contamination. m. All care staff were observed to handle/deliver food to residents without wearing aprons/protective barriers over their clothing to minimize the potential for cross contamination. n. Multiple dishwashing racks were observed to be stored on the floor. o. Surveyors observed food that had not been properly cooled and instructed Staff 2 to discard the food product. Staff 3 was not able to demonstrate knowledge of proper cook-to and reheat temperatures. p. The facility staff identified as the Person-in-Charge was not able to effectively demonstrate adequate knowledge of multiple food code principles. The facility did not demonstrate effective systems to ensure safe food service operations during the survey. Upon entrance to the facility for the kitchen inspection, Staff 1 (Executive Director) was interviewed and indicated there was not a “Kitchen Manager” or designated person for oversight of the kitchen and food operations. Staff 1 stated that the facility was “too small” to have a position like that. Staff 2 indicated they did have a designated “person in charge,” which was the cook on duty for each day/shift when food was prepared and served. During the kitchen survey, the staff that were designated “person in charge,” Staff 2 and Staff 3, lacked sufficient knowledge to ensure safe and sanitary practices were upheld and enforced. There was no clear kitchen/foodservice leadership and/or oversight. Both Staff 1 and Staff 2 were full time cooks working 4 days per week cooking/preparing food for residents. Both Staff 1 and Staff 2 were unable to demonstrate the necessary knowledge, practices, or oversight to ensure safe food operations. At approximately 12:45 pm, the surveyors reviewed the need to ensure the kitchen was kept clean and in good repair with Staff 1 (Administrator) and Staff 4 (Facility Owner). The staff acknowledged the findings.

C0240: OAR 411-054-0030 (1)(a) a. A cleaning checklist and training will be completed with the community care staff to ensure dining room chairs and areas between meal periods are thoroughly cleaned, and free of food debris and dried spills/liquids. Care staff will document completion of these tasks on a paper checklist during their shifts and management will review for task completion. A weekly cleaning checklist has been implemented and shared with the kitchen staff to ensure routine cleaning of all kitchen areas is completed. This cleaning checklist includes hood vents above range, bottom of cabinets on prep island, baseboard at bottom of center prep island, windowsill of window in kitchen next to back door, bottom of freezer in dry storage area (now located in activity room), threshold of back door in kitchen, underside of KitchenAid mixer head, toaster, and floor drain under prep island. Reach-in refrigerator in dry storage area has been removed. The kitchen staff member on duty during scheduled cleaning task is responsible for its completion in that respective week. The community administrator will ensure that the cleaning checklists are implemented and adhered to, and will verify with staff each month that tasks are being performed, in addition to daily and weekly visual reviews of the kitchen and dining areas. b. Items in need of maintenance or repair have been addressed and will be monitored by the kitchen staff, who will report any future maintenance or repair needs to the administrator immediately. The cutting boards with observed scoring and/or embedded black debris have been removed and replaced with new. The black gasket/seal on lower door of stand-up reach-in freezer has been repaired. Ice build up on the lower shelf of the freezer in dry storage (now the activity room) has been removed and cleaned. Enamel/caulking on floor drain under prep island has been cleaned and re-caulked. Reach-in refrigerator in dry storage has been removed from the facility as it was observed to not hold proper temp at time of survey. Exhaust hood removable vents will be repaired/secured. c. Open and undated items found in cold storage were removed at time of survey. Kitchen staff will check for open or undated items daily during their scheduled shifts to ensure these items are removed and discarded. d. Kitchen staff observed to have a towel attached to her person at time of survey was immediately educated/reminded of the potential for contamination and now ensures the towel is returned to the sanitation bucket after use. e. Kitchen staff have been educated/reminded of the potential for contamination when dropping items/tools on the floor and will ensure items are either disposed of or washed/rinsed/sanitized as appropriate. f. Kitchen staff have been educated/reminded of the necessity to rinse items after sanitizing with the quaternary ammonia-based solution to avoid potentially contaminating food with sanitizing solution. g. Kitchen staff have been re-educated on the two-stage cooling method for hot foods and CBC educational resources have been provided as a resource to reference. h. The reach-in refrigerator in the dry storage area has been removed from the facility as it did not hold proper temp. The food found in this refrigerator at the time of the survey was discarded immediately after determining it was at an unsafe temp. i. The kitchen staff have been educated/reminded of the chemical sanitizing method used for the ware washing machine. The machine’s chemical log has been updated to track the daily testing of the sanitizer levels and monitoring the sanitizing agent’s effectiveness. Sanitizer test strips were immediately delivered by Rose’s to implement this monitoring system. j. Test strips for the ware washing machine were found to be no longer functional and Rose’s delivered new ones immediately. Extra test strips were ordered and available to ensure daily monitoring can be completed. Test strips for the surface sanitizing chemical were ordered and are used each time surface sanitizer solution is prepared in the bucket to ensure appropriate concentration levels for effective sanitation. k. Kitchen staff have been educated/reminded to check and refuse any dented/damaged food products at time of delivery. Any food products found to have become dented/damaged while in the facility will be discarded. l. Two rubber aprons were immediately ordered and are used by staff when washing dishes to ensure there is a protective barrier over their clothes. m. Additional cloth aprons were ordered and care staff were educated/reminded of the requirement to wear aprons/protective barriers over their clothing when handling.delivering food to minimize potential for cross contamination. n. Kitchen staff have been educated/reminded to store dishwashing racks on proper holder, not on the floor. o. Kitchen staff have been educated/reminded of proper cook-to and reheat temps, in addition to food cooling process. Additional CBC resources have been provided for kitchen staff to reference. p. The facility Person-in-Charge was identified and has been provided with additional education and training to ensure they are able to effectively demonstrate adequate knowledge of food code principles. All kitchen staff will be provided with additional training and education to ensure they have sufficient knowledge for safe and sanitary practices. The Person-in-Charge will continue to monitor the other kitchen staff to identify additional training/education needed, as any kitchen staff member on duty should have the ability to demonstrate the same knowledge of kitchen practices to ensure safe food operations as the Person-in-Charge.

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(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. This Rule is not met as evidenced by: Based on observation and interview, it was determined the licensee failed to ensure adequate administrative oversight of facility operations regarding kitchen sanitation practices, which posed a risk to the safety of residents. Findings include, but are not limited to: During the annual kitchen inspection, conducted 12/11/25, administrative oversight to ensure adequate food sanitation practices in the facility kitchen was found to be ineffective based on multiple systems and practices which did not meet the Oregon Food Sanitation Rules and which put residents at risk, Refer to C240.

See C 240

OAR 411-057-0140(1) Administration Responsibilities (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, and comfort. This includes the supervision, training, and overall conduct of the staff. 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 observations and interviews, 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 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: