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, record review, and interview, it was determined the facility failed to maintain the kitchen and food service areas 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 main kitchen and memory care food storage and service areas on 02/04/26 from 10:15 am through 1:15 pm revealed the following: 1) Main Kitchen 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: * Interior of microwave; * Blender base; * Drain under prep sink; * Movable metal speed rack in walk-in cooler; and * Stationary metal racks in walk-in cooler: b. The following areas needed repair: * Reach-in beverage cooler not holding at 41 degrees F or below; * Microwave with multiple areas of rust on ceiling/corners; * Blender base with rust; and * Prep sink pipe without appropriate air gap with pipe observed sitting inside the drain causing potential back-flow contamination hazard. c. Multiple potential hazardous food items were observed opened or prepared without dates. Entire container of dished tartar sauce cups dated 1/29 were noted eight days past prepared dates and should have been discarded. A container of multiple bags of boiled eggs were dated 1/27, ten days past prepared date, and should have been discarded. d. Multiple dished containers of ice cream were observed stored in the reach-in freezer that were not covered/protected from potential contamination. A box of frozen hamburger patties was observed open to potential contamination. e. Multiple staff drinks were observed stored in the walk-in cooler next to resident food, posing potential cross contamination risk. f. Reach-in beverage cooler storing juices and milk was observed to be at 58 degrees F. The temperature of the milk was also found to be at 58.2 degrees F. Staff 2 (Culinary Services Director) acknowledged the cooler should be at 41 degrees F or below. Staff 2 did not know how long the cooler was not holding at appropriate temperatures. Staff 2 indicated they could not locate temperature logs for that cooler for the month of February. 2. Memory Care Food Storage and Service Area 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: * Interior of microwave; * Interior of oven; * Interior of magic bullet blender base; * Interior of cupboards and drawers; * Interior of reach-in refrigerator and freezer; and * Interior of ice machine. b. The following areas needed repair: * Reach-in refrigerator nearest dining room not holding at 41 degrees F or below; and * Interior of cupboard holding clean dishes with section of porous wood exposed. c. Multiple potentially hazardous food items were observed in both reach-in refrigerators that did not have a date opened. Multiple food items were found past seven days, including sliced cheese and lunch meat, and should have been discarded. d. Reach-in refrigerator nearest the dining room thermometer was observed at 50 degrees F. The temperature of some milk from that refrigerator was checked and found at 48.6 degrees F. Temperature monitoring logs for that fridge were reviewed and found with only three days recorded for January 2026 and zero days for February 2026. On 01/05/26 there was a reading of 50 degrees F recorded. Staff 2 was interviewed and was unaware of any concerns with any refrigerators in the memory care unit having temperature issues. e. The dish machine in the memory care unit was a chemical sanitizing machine. Care staff were asked for test strips to test the chemical concentration of the machine. Staff did not know where any test strips were located. Staff indicated they did not test the machine, that the maintenance department tested it. Maintenance was contacted and the machine was tested and was not found to have any chemical sanitizing agent register after multiple cycles tested. Maintenance staff were asked how frequent the machines were tested and they indicated monthly. The machine had to be primed for an extended amount of time before any chemical sanitizer registered. Maintenance staff verified facility staff was not currently testing the dish machine. Staff 2 verified that kitchen staff were not testing the dish machines to ensure sanitation levels were met. Staff 2 verified that resident cups and glasses were washed in that machine after each meal. f. A trash can was observed in the memory care service area. The trash can had visible food and trash debris in the can. The trash can did not have a lid and was not in use. g. A large container of sugar was observed stored with the lid off exposing the contents to potential contamination. Staff 2 toured the main kitchen with surveyor and acknowledged the areas identified. At approximately 1:00 pm, the surveyor reviewed areas of concern for both the main kitchen and memory care areas with Staff 1 (Executive Director) and Staff 2. Both Staff 1 and Staff 2 acknowledged the above areas that needed to be cleaned and/or repaired and practices that needed to be addressed.

1 – Main Kitchen- All items mentioned have been replaced, repaired, fixed and clean. New microwave ordered- blender replaced – drain under prep sink- cleaned and repaired. Racks were cleaned – reach in beverage cooler serviced and repaired All food items with no open dates or out-of-date range were discarded . All food item not covered, ie ice cream, frozen hamburger patties were discarded Staff drinks were removed from residents’ food . Temp logs are now on all fridges with current to date recordings. A-Memory Care food storage and service area- All items listed have been Replaced, fixed, clean and repaired- microwave cleaned , oven cleaned, blender cleaned deep clean kitchen survey. Fridge cleaned B- Items have been repaired , fridge was replaced , cupboard was repaired C- no open dates on items were discarded , items past seven days were discarded , D- fridge was replaced, milk discarded. Temp logs are now current and up to date E- Dishwasher sanitation is now being tested with strips , to test chemicals . F- trash can now had a lid. G- Sugar is now stored in the container with lid on. 2. DSM educated staff on food safety protocol, open dates, temps, proper storage, items needing to be covered. Temp logs are on all fridges and current-to-date recordings. DSM will have on going Kirchen meetings to provide education, training and oversight on labeling, food storage, temps, general cleaning, and overall kitchen compliance as needed no less than 2 times a month Dishwasher sanitation is checked weekly and as needed. 3. DSM will ensure items are in compliance, daily, weekly and monthly. Temp logs are checked daily and will have follow up as needed. Fridge temps checked daily and will have follow up as needed. Dishwasher sanitation is checked weekly and as needed. Daly cleaning task list has been created , wipe down fridge, microwave, oven , cupboards , sweep, mop. New daily task sheet have been created to ensure compliance and check daily by DSM and or designee. ED will follow up once weekly to ensure kitchen compliance 4. DSM and MCD will ensure kitchen compliance ED will provide oversight.

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, record review, 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 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: