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 main kitchen and unit kitchenettes on 02/06/26, from 11:00 am through 1:30 pm, revealed the following: 1. Main Kitchen a. The following areas needed repair: * Sections of tile cove base under dish machine missing/damaged and in need of repair; * Area in the ceiling in dry storage room had visible prior water damage that had not been repaired, leaving bubbles and cracks in ceiling; * Metal racks in reach-in freezer with visible corrosion and/or rust build-up, yielding the racks a non-smooth and uncleanable surface; * Multiple sections of the dirty area of dish machine with missing caulking or gaps in caulking, allowing for moisture build-up/water damage to occur; and * Multiple sections of caulking in dish machine area with black debris build-up in and around caulking. 2. Unit Kitchenettes: a. Birchwood * Reach-in refrigerator was observed with thermometer that read 50 degrees F. Surveyor checked on the temperature multiple times throughout survey, and the thermometer continued to read 50 degrees F. Staff 2 (Dining Services Manager) adjusted the cooling dial; however, the thermometer continued to read 50 degrees F after 30 minutes. A container of applesauce stored next to the thermometer was checked using the surveyor’s digital thermometer, and the food product was found at 46 degrees F. Staff 2 acknowledged the refrigerator should be holding cold food at 41 degrees F or below. The temperature log for that refrigerator was reviewed and multiple missing temperatures were found. The last temperature recorded was 02/02/26. Staff 2 was not able to determine when the refrigerator was last at the correct temperature range of 41 degrees F or lower. The facility was not able to demonstrate adequate monitoring of cold food storage temperatures. * Residential style dish washer was observed in use. Care staff were not aware of a specific cycle to be used to ensure effective sanitation of resident dishes. Staff 2 was unaware of the cycle needed to effectively sanitize resident dishes. Staff 2 stated he did not have anything to do with the units to ensure effective sanitation. * Bowls and scoop plate were observed with pits and scratches, with heavy use damage and in need of replacement. b. Alderwood * Residential style dish washer was observed in use. Care staff were not aware of a specific cycle to be used to ensure effective sanitation of resident dishes. Staff 2 was unaware of the cycle needed to effectively sanitize resident dishes. Staff 2 stated he did not have anything to do with the units to ensure effective sanitation. c. Cedarwood * Residential style dish washer was observed in use. Care staff were not aware of a specific cycle to be used to ensure effective sanitation of resident dishes. Staff 2 was unaware of the cycle needed to effectively sanitize resident dishes. Staff 2 stated he did not have anything to do with the units to ensure effective sanitation. d. Dogwood * Residential style dish washer was observed in use. Care staff were not aware of a specific cycle to be used to ensure effective sanitation of resident dishes. Staff 2 was unaware of the cycle needed to effectively sanitize resident dishes. Staff 2 stated he did not have anything to do with the units to ensure effective sanitation. * A plate of food was observed transported to a resident room without being covered/protected from potential contamination. * A section of wood counter/cabinet by the coffee maker was observed with water damage and black debris and in need of repair. Staff 2 toured the kitchen and unit kitchenettes with surveyor and acknowledged the areas identified. At approximately 1:00 pm, the surveyor and Staff 1 (Executive Director) reviewed the areas of concern with kitchen and unit kitchenettes. Staff 1 acknowledged the above areas needing to be cleaned and/or repaired and practices that needed to be addressed.

1. What actions will be taken to correct the rule violation for each example/resident? Main Kitchen ? Replace cove base under dish machine ? Ceiling to be repaired/repainted ? Metal racks in the reach-in freezer will be refinished creating a smooth and cleanable surface. ? Remove all caulking build up. Repair and damage, place back splash to prevent further water damage Birchwood ? Refrigerator will be replaced ? Daily temperatures to be taken/logged by dietary staff. Monitored by dietary manager and executive director. ? Instructions for proper cycle use posted directly on residential style dish washer. Education posted in dietary binder with information regarding proper sanitation process to ensure effective sanitation of resident dishes. Monitored by ED and dietary manager monthly. ? Bowls and scoop plates replaced. Alderwood ? Instructions for proper cycle use posted directly on residential style dish washer. Education posted in dietary binder with information regarding proper sanitation process to ensure effective sanitation of resident dishes. Monitored by ED and dietary manager monthly. Cedarwood ? Instructions for proper cycle use posted directly on residential style dish washer. Education posted in dietary binder with information regarding proper sanitation process to ensure effective sanitation of resident dishes. Monitored by ED and dietary manager monthly. Dogwood ? Instructions for proper cycle use posted directly on residential style dish washer. Education posted in dietary binder with information regarding proper sanitation process to ensure effective sanitation of resident dishes. Monitored by ED and dietary manager monthly. ? Plate covers provided to Pod. Education on use of plate covers and the importance of covering food/beverage due to infection prevention at staff meeting 2/25/26. ? Section of wood repaired/replaced with cleanable surface.

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 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure staff maintained effective infection control practices to minimize the potential spread of infectious agents during meal service. This had the potential to affect all residents residing in the Dogwood neighborhood. Findings include but are not limited to: Lunch service was observed in the Dogwood neighborhood on 02/06/26, from 11:39 am to 12:45 pm. At approximately 12:15 pm a care staff member was observed to deliver an uncovered plate of food to a resident’s room just off the dining room. Approximately five to seven minutes after the plate of uncovered food was delivered to the resident’s room, a different staff member retrieved the uncovered plate of food and was observed to deliver it to a different resident seated at a dining room table. The uncovered plate of food had been mistakenly delivered to the resident room when it was intended for the resident seated at the table. The resident immediately started eating the potentially contaminated plate of food, before the surveyor could intervene. Other staff members observed this practice and did not prevent the potentially contaminated plate of food from being served to the resident in the dining room. At 1:00 pm, the surveyor reviewed this practice with Staff 1 (Executive Director) and Staff 2 (Dining Services Manager). Both acknowledged the plate of food delivered to the resident’s room should not have been delivered to the resident in the dining room. Both Staff 1 and Staff 2 acknowledged this was an infection control issue requiring immediate staff education.

? Training provided on proper meal services, infection control/prevention with meals service. Meal monitoring done daily for compliance by the management team.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991 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 and C295

1. What actions will be taken to correct the rule violation for each example/resident? See C240 and C295

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: