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: 1. Observation of the facility kitchen on 01/23/26 at 9:45 am through 12:30 pm revealed the following deficiencies: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following: * Floors under dish machine; * Floors under and behind prep tables; * Floors behind and under major equipment; * Floors in walk-in cooler and freezer; * Drains under dish machine, under steam table, under ice machine; * Interior of ovens; * Exterior/side of grill; * Grill top/grease trap on side of grill; * Wall behind stove/grill; * Interior of toaster oven; * Table and area by condiment station in kitchen; * Exterior of white plastic bulk bins; * Ice scoop holder; * Wall behind ice machine; * Industrial can opener housing; * Industrial mixer; * Large horizontal vents in walkway; * Janitor closet wall, floors and floor sink; and * Fan cage in walk in freezer; b. The following was observed needing to be repaired. *Caulking floor sink in janitor closet missing and/or had black debris; * Multiple sections of flooring in kitchen where grout was worn down and heavy food/dirt debris in grout lines; * Large ice build-up in walk-in cooler; * Large sections of rust build-up on walls near floor in walk-in cooler; * Section of drain pipe under dish machine too long and pipe reaching inside of drain past floor plane causing potential back flow issue; * Cabinets under sink in beverage station in dining room with observed water damage; and *Caulking behind sink in beverage station in dining room was found damaged/stained/cracked and in need of repair. c. Multiple potentially hazardous food items were found opened and/or prepared without labels or dates as required. d. Multiple food items were found past seven days of preparation and/or past the posted manufacturer’s use by dates and should have been discarded. e. Multiple food items were observed stored in the walk-in cooler that were not securely covered/protected from potential contamination. f. A staff lunch bag was observed stored in the walk-in cooler on a shelf with resident food/beverages, creating a potential cross contamination hazard. g. A pan holding a package of a raw pork roast was observed stored on top of a container of prepared and cooled food product creating a potential for cross contamination. h. Containers holding single use utensils were noted on the room tray cart stored with food contact surfaces upward exposing them to potential contamination. i. Multiple packages and food storage containers in the walk-in cooler were observed wet with a large accumulation of condensation. A large amount of ice and rust build-up was observed in multiple areas of the cooler. Staff 2 (Dining Services Manager) and Staff 3 (Lead Cook) indicated the walk-in cooler was in need of repair, and that the facility was looking at bids for replacement vs repair. During a tour of kitchen areas, Staff 2 and 3 acknowledged areas in need of cleaning and repair. Staff 3 indicated it had been greater than 6 months since a deep clean was done and that it was “well past due.” Staff 3 indicated that the facility had been without a Dining Service Manager for multiple months. Staff 2 acknowledged the need for cleaning and oversight of dating/food storage. At approximately 12:30 pm surveyor reviewed above areas with Staff 1 (Executive Director) acknowledged the identified concerns.

1. Immediately following the kitchen surveyor's visit, the Dining Services Manager (DSM) completed corrective actions to address identified sanitation, maintenance, and food safety concerns. A comprehensive deep cleaning and sanitization of the kitchen, food storage, and support areas were completed. This included: floors under and behind equipment, dish machine areas, prep tables, major equipment, walk-in cooler and freezer surfaces, drains, vents, walls, condiment stations, equipment interiors and exteriors, utensil storage areas, tray carts, and janitor closet surfaces. Potentially hazardous food items that were improperly labeled, undated, expired, improperly covered, or stored in a manner that posed a risk of cross contamination were immediately removed and discarded. Food storage was corrected to ensure raw foods were stored below and separate from prepared foods. Food items were securely covered, and personal staff food items were removed from resident food storage areas. Maintenance-related concerns were identified and corrected or initiated through our work order process. The specific items included: cutting the dish machine drain piping, repair of damaged caulking, and addressing water-damaged cabinetry. 2. The ED and DSM will continue to work together to strengthen sanitation, food safety, and preventive maintenance systems. A detailed cleaning schedule has been implemented outlining responsibilities, including non-routine and harder to reach areas. Food safety procedures require opened or prepared foods to be labeled with open dates, discarded within required timeframes, securely covered, and stored to prevent cross contamination. Staff's personal food is prohbited from resident food storage areas and staff were directed to use the employee break room fridge for their personal food items. Ongoing inspections will include flooring, grout, walls, cabinetry, drains, and caulking. Preventive maintenance tracking will ensure timely correction of any identified deficiencies. The walk-in cooler is monitored for condensation and ice buildup, and is scheduled to be replaced and repaired on February 19th, 2026. Dietary staff have been re-educated on sanitation and food safety standards during a mandatory meeting that was held on January 31, 2026. 3. The Dietary Services Manager or designee will conduct monitoring of kitchen sanitation, food labeling, storage, utensil handling, and walk-in cooler conditions. 4. Regular documented audits will be completed and reviewed by the Executive Director or designee. Any identified concerns will be corrected immediately.__

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: