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: Observation of the facility cottage kitchens and facility food storage and distribution areas on 01/08/26 from 10:35 am through 1:15 pm revealed the following deficiencies: 1. Main food storage/distribution area: a. Multiple items noted in main walk-in cooler that did not have open or prepared dates. Containers of tomato sauce had an open date of 12/07/25, past the seven-day use-by period. Multiple containers of pesto with direction to use within 60 days did not have a pull date from the freezer or a specific use-by date, indicating when it was safe to use by. b. A box of takeout pizza was observed stored with resident food. Staff 3 (Food Distribution Director) confirmed it was staff food and was not aware of the potential cross contamination risk and that staff food should be stored separate from resident food. c. Clean dishes were observed stored/drying directly next to the handwashing sink without a splash guard to protect clean dishes from potential contamination. d. Staff 3 confirmed the facility was not monitoring the chemical concentration of the solution for use for the three-compartment sink method used to wash distribution dishes/equipment. e. Case of water bottles were observed stored on the floor of the walk-in cooler. f. A food and water dish for a facility pet cat was observed stored on the floor directly in front of a freezer and a large rack storing dry foods. 2. Cedar Cottage: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on, underneath or between the following: * Interior of reach-in refrigerator; * Interior of drawers; and * Interior of cabinets. b. Multiple food items were found without open or prepared dates on potentially hazardous foods. c. Raw meats were observed stored with ready-to-eat meats in a shared “defrosting” drawer, causing potential contamination from raw meats to ready to eat meats packaging. Staff 2 (Food Service Quality Assurance Director) was unaware raw meats could not be stored with ready to eat meats when defrosting. d. A scoop used for dispensing ice was observed stored touching and potentially contaminating ice, which is a food product. e. Multiple cooking pans were noted to be worn, scratched, and in need of replacement. Nonstick pans were found scratched and scored indicating the nonstick surface had a metal utensil used during cooking and the protective pan coating was scratched off during cooking, potentially contaminating the food product. f. Human head hair was observed in multiple areas where food and/or cooking utensils/equipment were stored indicating effective hair restraints were not consistently used as required and posed a potential contamination risk. 3. Diamond Peak Cottage: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on, underneath or between the following: *Interior of cabinets (under sink and corner). b. Multiple potentially hazardous foods were observed without open and/or use-by dates. Containers of cottage cheese were observed stored multiple days past the manufacturer’s use-by date of 01/04/26. c. Chemical dishwasher was in use for sanitizing dishes. Facility did not have chemical test strips to monitor the machine for effective sanitizing. Cottage staff and Staff 2 did not know the sanitizing agent used nor the effective parts per million (PPM) that was required to ensure dishes were effectively sanitized. d. A large spoon was observed stored in the bulk ice container with the handle touching the ice, potentially contaminating the food product. 4. Mount Hood Cottage: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on, underneath or between the following: * Interior of freezer outside storage area; * Floor of outside storage area in front of freezer; * Interior of cabinets and drawers; and * Interior of microwave. b. Interior of corner (lazy Susan) cabinet had damaged and exposed porous wood surfaces needing repair. c. Rack for dishwasher observed stored on the floor. d. Raw meats were observed stored with ready-to-eat meats in a shared “defrosting” drawer, causing potential contamination from raw meats to ready-to-eat meats packaging. e. Chemical dishwasher was in use for sanitizing dishes. Facility did not have chemical test strips to monitor the machine for effective sanitizing. Cottage staff and Staff 2 did not know the sanitizing agent used nor the effective PPM that would be required to ensure dishes were effectively sanitized. f. Coffee station with coffee pot and condiments for coffee were stored directly beside the sink where handwashing and/or dishwashing occurred. There was no splash guard to prevent the food/beverage equipment and service area from potential contamination from these tasks. g. Two containers of cottage cheese were found stored in the reach-in refrigerator that were multiple days past the manufacturer’s use-by date of 01/04/26. h. Freezer in outside storage area noted leaking onto flooring. A large sheet of ice build-up was found in the interior. The bottom face of the refrigerator was noted with rust build-up. Staff indicated the door was not closing/latching properly and they had attached fasteners to “help” keep it closed. Staff 2 acknowledged the freezer was in need of replacement. 5. Mount Vernon Cottage: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on, underneath or between the following: * Ground next to composting container with large build-up of dropped food debris. b. Multiple potentially hazardous foods were observed without open and/or use-by dates. Containers of cottage cheese were observed stored multiple days past the manufacturer’s use-by date of 01/04/26. c. Sink observed full of dirty dishes directly next to storage of ready-to-eat (RTE) fruits and vegetables. There was no splash guard to prevent potential contamination of the RTE foods from the sink. d. Surfaces sanitizer bottle was tested and did not register any PPM (Parts-per-million) of sanitizer. A new container was created right from the dispenser in the laundry room, which also was not registering any PPM of sanitizer. Facility maintenance staff investigated and determined there was a faulty part. Staff 2 was not sure how long the dispenser was not dispensing correctly, and the facility had not been effectively sanitizing surfaces. Surveyor toured food storage area with Staff 2 and Staff 3, who acknowledged the areas in need of correction. Staff 2 toured all cottages with surveyor and acknowledged the findings above. At 12:45 pm, all identified areas were discussed with Staff 2 and Staff 1 (Executive Director), and they acknowledged the identified areas.

1. Main Food Storage/distribution area: a) Items in walk in cooler are dated with open, pulled or prepared/use by dates. This will be ensured by Food Service Director or designee at the beginning and end of each shift. b)Take out box of pizza was removed immediately, no staff food will be kept in food distribution area, staff will utilize the breakroom fridge at the watering hole. c)clean dishes will be dried/stored on stainless steel table away from hand washing sink, to avoid cross contamination. d)Chemical concentration log of the solution for use for the 3 compartment sink method used to wash dishes/equipment will be monitored daily by food service team, log is visible and will be kept with magnet on communication board. e)Water was removed, nothing to be stored directly on the floor. f)Pet food has been removed from food service area. 2. Cedar Coattage: a)Interior of refrigerator, Interior of cabinits and interiors of drawers deep cleaned. b)all open items were dated or removed. c)Ready to eat meat and raw meats have been seperated.Ready to eat meats will be stored in labeled drawer in refrigarator. Designated mini fridges have been purchased strictly for the defrosting of meats. Food Service will utilize containers to separate meats to begin defrosting period in main walk-in, all deforsting meats will be delivered to home, labeled and dated to be stored in meat fridge. d) Ice scoops removed and will not be stored in bin. e)pans noted to be worn or scratched were removed, all homes have been purchased new pot & pan sets. f)Kitchen check of cleanliness was completed, all foods labeled & dated, daily checks (completed during shift report) to ensure gloves, hairnets and sanitation regulations/ requirements are met, this has been added to the caregiver shift report, to be completed with each shift change report, any noted items not meeting policy will be brought into compliance in the moment. 3.Diamond Peak Cottage: a)interior of cabinets under the sink have been deep cleaned. b)all food has been labeled and dated appropiately, already expired items were disposed of. This is now on caregiver shift planner and will be checked during each change of shift report. c)chemical dishwasher in use without strips;The maintenance department has received training from Auto-Chlor to identify, troubleshoot and remedy possible scenarios where the sanitizer is not properly distributing to the machine for a wash cycle. Maintenance will carry out a daily task of draining, filling and testing for proper PPM of sanitizer in each machine, documentaion via checxklist in place. d)Large spoon removed from ice bin-also part of report checklist 4.Mt. Hood Cottage: a)outside stoarge area has been deep cleaned, freezer has been replaced with new unit, interior of cabinets, drawers and microwave were deep cleaned. b)lazy susan cainet with exposed wood has been fixed and painted. c)rack for dishwasher was removed from floor and will be stored in dishwasher when not in use. d)Ready to eat meats and raw meats have been sperated, ready to eat meats will be stored in labeled drawer of fridge and the defrosting meats will be in designated meat fridge located in food storage outside of home. e)Maintenance will carry out a daily task of draining, filling and testing for proper PPM of sanitizer in each machine, documentation via checklist in place. f)Coffee station moved away from sink to avoid potential contamination, in homes where that is not possible splash guard will be used. g)Expired cottage cheese disgarded. h)Outside freezer has been replaced with a new unit. 5.Mt. Vernon cottage: a)ground next to compost has been cleaned of all food debris. This too has been added to the check at shift change. Maintenance team to deep clean area once a week. b)Cottage cheese was disgarded, all foods labeled and dated appropiately, to be checked during shift report via shift planner. c)Fruit and vegetable platter has been removed from next to the sink and will be stored on opposite counter next to the stove/bar. d)Surface sanitizer bottle pour from dispenser not meeting PPM, this was found to be a faulty part and was fixed same day. Maintenance team will now do daily tests and staff will ensure during shift chage report that proper PPM has been met, testing with 2 staff members. Captured on shift planner. Food supply float/QA will perform scheduled and random checks weekly, monthly and quarterly to ensure all homes are in compliance, maintaining kitchen in good repair in a sanitary manner with the food and sanitation rules.

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.

Refer to plan of correction for C240

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: