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 Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen areas and memory care kitchenettes were reviewed on 01/06/26 from 10:15 am through 1:15 pm and the following was identified: 1. Main Kitchen area a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Reach in coolers/freezers; * Exterior of ovens, stove and fryer: * Stove top spiders; * Drip pans under stove top; * Interior and exterior of steamer; * Flooring under and between major equipment; * Flooring under steam table/service line; * Open stainless steal shelving throughout kitchen; * Bottom shelves of work tables and spaces; * Metal movable shelving/carts; * Black utility carts; * Stainless steel wall adjacent to and behind stove, fryer and grill top; * Interior and exterior of microwave oven; * Stainless steel shelf on top of service line; * Knobs, handles of appliances and equipment; * Matts on floor by service line; * Commercial toaster; * Area under and around toaster; * Flooring in walk in cooler; * Movable metal speed rack in walk in cooler; * Metal stationary racks in walk in cooler; * Floor drain in beverage area off of main dining room; * Floor drains in kitchen; * Hand held digital thermometers; * Metal pans holding utensils and service items on service line; * Interior of both deli reach in refrigerators. Both lower cabinet area and upper service areas; * Walls and flooring by dish machine; * Floor drain under dish machine; * Main flooring in dry storage; * Flooring under racks in dry storage; * Large metal can rack in dry storage; * Vent above back door to kitchen; * Area outside storing grease disposal can; and * Walls behind trash cans in kitchen and directly outside of kitchen areas. b. The following items were noted to be in need of repair; * Sections of caulking surrounding the dish machine areas and three compartment sink area with black debris and/or missing sections of caulking and in need of removal/replacement. c. Multiple potentially hazardous food items were found without open or prepared dates in reach in coolers and walk-in cooler. d. Multiple food items found stored open to potential contamination in reach in and walk in coolers. Upon entry to facility a tray of plated fruit cups were found in the dining room uncovered. e. Dry bulk food items were observed with scoops stored in the bins placing the food items at risk of contamination from the scoops. 2. Memory Care Kitchenette Aspen a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Flooring in kitchenette; * Drawers holding utensils; and * Cabinets storing clean dishes; b. Items found stored in reach in refrigerator without open dates. c. Food item found in reach in refrigerator dated 12/15/25 well past the seven days when it should have been discarded. d. Staff observed to handle lip contact surfaces (rims) of glasses with potentially contaminated gloves when serving residents beverages for lunch. e. Staff observed to touch residents, chairs, surfaces of tables, handles of wheelchairs and not change gloves when contaminated. f. Staff were observed to transport resident lunches to resident rooms with the plates not covered/protected from potential contamination during transport. 3. Memory Care Kitchenette Maple a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Flooring in kitchenette; * Drawers holding utensils; * Cabinets storing clean dishes; and * Digital thermometer. b. Staff were asked about sanitizing process for digital thermometer and there was no current process identified to sanitize the thermometer before/between or after use. Staff discussed cleaning with soap and water but did not know the need to sanitize. At 12:30 pm, the surveyor reviewed areas with Staff 2 (Dining Services Director) who acknowledged the needed cleaning and staff practices that were needing addressed. At 12:45 pm the surveyor discussed the findings with Staff 1 (Executive Director) and Staff 3 (Memory Care Administrator) who acknowledged the areas.

1. a. A thorough audit was completed on the following areas and all food spill, splatters, loose food and trash debris, dirt, dust, and/or black matter visible or underneath the following items have been scheduled to be professionally cleaned by "Spear Pro" 1/29/26 and 2/2/26 Areas found to have rule violation: Main Kitchen AL building * Reach-in coolers/freezers; * Exterior of ovens, stove and fryer: * Stove top spiders; * Drip pans under stove top; * Interior and exterior of steamer; * Flooring under and between major equipment; * Flooring under steam table/service line; * Open stainless steel shelving throughout kitchen; * Bottom shelves of work tables and spaces; * Metal movable shelving/carts; * Black utility carts; * Stainless steel wall adjacent to and behind stove, fryer and grill top; * Interior and exterior of microwave oven; * Stainless steel shelf on top of service line; * Knobs, handles of appliances and equipment; * Mats on floor by service line; * Commercial toaster; * Area under and around toaster; Flooring in walk-in cooler; * Movable metal speed rack in walk in cooler; * Metal stationary racks in walk in cooler; * Floor drain in beverage area off of main dining room; * Floor drains in kitchen; * Handheld digital thermometers; * Metal pans holding utensils and service items on service line; * Interior of both deli reach-in refrigerators; * Both lower cabinet area and upper service areas; * Walls and flooring by dish machine; * Floor drain under dish machine; * Main flooring in dry storage; * Flooring under racks in dry storage; * Large metal can rack in dry storage; * Vent above back door to kitchen; * Area outside storing grease disposal can; and * Walls behind trash cans in kitchen and directly outside of kitchen areas. Area found to have the rule violation: Memory Care Kithenette Aspen * Flooring in kitchenette * Drawers holding utensiles * Cabinets storing clean dishes Area found to have rule violation: Main Kitchen AL building 1. b. The sections of caulking surrounding the dish machine area and three compartment sink area with black debris and/or missing sections of caulking will be removed and re-caulked after the kitchen is professionally cleaned. 1. c. The noted potentially hazardous food items found without open/prepared dates in reach-in cooler and walk-in were removed and discarded. A audit was was completed to ensure all items have open/prepare dates in both reach-in cooler and walk-in. 1. d. The noted food items found stored open to potential contamination in reach-in and walk-in coolers were removed and discarded. The tray of plated fruit cups found in the dining room uncovered were removed and discarded. An audit was completed to ensure no other food items were stored open. 1. e. The noted dry bulk food item that were observed with scoops stored in the bins, placing the food in items at risk of contamination from the scoops were discarded. An audit was completed on all dry food bins to ensure scoops were not stored in the bins. Area found to have rule violations: Memory Care Kitchenette Aspen b. A thourough audit was done and all items found stored in reach-in refrigerator wihout open dates were removed and discarded. c. A thorough audit was done and all Items found stored in reach-in refrigerator without open dates were removed and discarded. d. All staff were immidiately advised not to handle lip contact surfaces (rims) of glasses with potentially contaminated golves when seving residents beverages. e. All staff were immediately advised not to touch residents, chairs, surfaces or tables and handles of wheelchairs unless they first change their gloves. f. All staff were immediately advised to cover resident meals to protect them from potential contamination while transporting meals to rooms. Area found to have rule violations: Memory Care Kitchenette Maple: * Flooring in kitchenette * Drawers holding utensiles *Cabinets storing clean dishes * Digital thermometer b. Staff were immediately advised of the sanitizing process for digital thermometer before, between or after use. 2. All Staff will be trained on: 2. a. Cleaning all areas of kitchen, 2. b. Checking for cleanliness of caulking being free of dirt, debris, and missing sections, 2.b. The sanitizing process for digital thermometers before, between or after use. 2. c. Food has open prepared dates on them, 2. d. How to handle glasses without touching lip contact surfaces (rims) of glasses with potentially contaminated goes when serving residents. 2. d. Food is stored covered or sealed while in and outside coolers to ensure there is no potential for contamination. 2. e. Scoops are not left in bulk food bins. 2. e. Not to touch residents, chairs, surfaces or tables and handles of wheelchairs unless they first change thier gloves. 2. a, b, c, d, e. A daily shift check list was created for each shift to ensure the items listed in training above are addressed before they leave their shift. 2. f. To cover resident meals to protect t hem from potential contamination while transprting meals to rooms. 3. The areas needing correction will be evaluated on a daily basis by staff completing the check list addressing each area. The checklists focusing on the areas needing correction will be reviewed weekly by the Dining Services Director during their weekly walk through using the same checklist. The weekly walk throughs and daily checklists will be reviewed monthly by the Administrator and Dining Service Director at their monthly meeting. 4. The Administrator and DSD will be responsible to see that the corrections are completed/monitored.

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 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: