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, interview, and record review, it was determined the facility failed to serve palatable textured meals and maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observations of the eight cottage kitchen areas and the main food storage areas (Cooks food storage, freezer room, dry storage) were completed on 02/23/26 from 10:30 am through 2:00 pm and found the following: 1. Cooks Food Storage: a. Multiple potentially hazardous food items were found in the walk-in and were open, removed from original packaging and lacked a use-by date. b. A bag of recyclable pop cans and water bottles was observed stored hanging off a metal food storage rack, causing a potential cross contamination concern and potential attractant of pests. 2. Cottage 604: a. An open container of cottage cheese was found stored in the reach-in refrigerator without the date it was opened. b. The facility did not have chemical testing strips for the sanitation bucket. Surface sanitation solution was noted well over the max 200 parts per million (PPM). Staff were not aware of what chemical was being used for sanitation. c. A poster on the dishwasher was observed instructing staff to use the cycle “Normal-Heated Dry” to ensure dishes were effectively sanitized. The machine was observed in use during survey and was on the “Quick-Heated Dry” cycle and not the posted “Normal-Heated Dry” cycle as directed. 3. Cottage 608: a. The interior of the magic bullet blender base was found with a build-up of dried food debris. b. The can opener was found with rust build-up on mechanical parts and needed to be replaced. c. Multiple potentially hazardous foods were open without open dates. Two hard shell unpasteurized eggs were found in a bowl stored on top of the plastic container storing whole shell pasteurized eggs. There was no identifying information on the eggs indicating what they were for, or if they were cooked or raw. Staff in cottage were not able to clarify the intended use of the eggs. d. The cottage did not have test strips for verifying sanitizer level concentrations. e. Two visible overripe and rotting bananas were observed stored in the ready-to-eat bowl of fruit. The bananas were past acceptable ripeness. This was a non-cooking house and the bananas were not being saved for baking. 4. Cottage 610 (Food Preparation House): a. Multiple potentially hazardous foods were found open without open dates. b. The sanitizer bucket for surface sanitation that was made by caregiving staff was over the maximum of 200 PPM. c. A pureed texture meal item was observed. Cook had pureed the steak fingers with the green beans. The texture was too thin and product was observed running thru the tines of a fork. This was not the correct texture for pureed. Cook was not aware of any tests to ensure pureed items were at correct texture. Staff was also not aware they should not puree items together and verified that it was a practice they did commonly. Staff 1 (Administrator) and Staff 2 (Lead Cook/Person In Charge) were interviewed at approximately 1:45 pm. Both acknowledged that staff should not blend food items that did not normally go together for staff convenience. They acknowledged residents with altered textured diets should receive menu items separately the same as residents with regular texture diets. 5. Cottage 611 (Food Preparation house) a. The cabinet housing the cutting boards were noted to be worn with exposed porous wood yielding non-cleanable surfaces. This cabinet was also noted to be dirty with dust/dirt and food debris on the bottom where the clean cutting boards were stored. c. Multiple potentially hazardous foods were found open without open dates. Opened packages of sliced cheeses and deli meats did not contain use by dates and were past seven days. A container of apple sauce was dated 02/11/26 and should have been used or discarded by 02/17/26. A package of sliced ham for sandwiches had an open date of 02/10/26 and a use by date of 02/17/26 and should have been discarded. d. The bottom drawer had multiple items that did not have open dates. It was determined that this was a resident food storage area. Food items had resident name identifiers but no dates. Facility did not know resident food had to be dated. A package of visibly decaying cucumbers were found in this drawer and needed to be discarded. d. The cottage did not have test strips for verifying sanitizer level concentrations. Using surveyor test strips sanitizer bucket for sanitation was over the maximum of 200 PPM. Staff were not aware of what chemical was being used for sanitation. e. The window in front of the food preparation counter was observed open. The screen was noted to be very dusty and dirty creating a potential contamination concern. 6. Cottage 612 (Food preparation house) a. A container of salad dressing was found past the manufacturers’ use-by date of 02/21/26 and should have been discarded. A container of barbeque beans for a resident was found without an open date. The manufactures use by date was 02/21/26 and should have been discarded. b. Sanitizer bucket for sanitation was noted well over the max 200 parts per million (PPM). c. A cook was observed to mechanicalize the steak fingers and green beans together in the same container. Surveyor asked the staff why they were doing this and they stated it was “to save time so they don’t have to wash the bowl and blade between uses.” Staff verified this was a practice that was commonly used. d. The kitchen area was observed to contain dirty dishes in one side of the two-sided sink, and the other side was full of soapy water. Staff were observed to wash their hands multiple times over the dishes in the sink. There was not a dedicated sink available for hand washing. 7. Cottage 620: a. Staff food was observed stored with resident food in the reach in refrigerator, causing potential for cross contamination. c. Facility did not have test strips for surface sanitizer. Utilizing surveyor test strips, sanitizer bucket for sanitation was over the maximum of 200 PPM. 8. Cottage 622: a. There was no direction for staff on what cycle to use when washing dishes in the dishwasher. Staff 1 and 2 validated that all houses had different dishwashers and that different dishwashers needed to be on different cycles to ensure those met the sanitation guidelines. Staff 1 and 2 acknowledged the dishwashers should have had signs/directions on it. b. A can opener was found with the mechanical parts used for opening the can with rust and needing replaced. c. Sanitizer bucket for surface sanitation was over the maximum of 200 PPM. 9. Cottage 630: a. The reach-in refrigerator did not have a thermometer to monitor cold food storage temperatures to ensure they were stored at safe temperatures. b. Staff food was observed stored with resident food, causing potential cross contamination. c. Multiple potentially hazardous foods were observed open without open dates. d. The cottage did not have test strips for verifying sanitizer level concentrations. Using surveyor test strips sanitizer bucket for sanitation was over the maximum 200 PPM. At approximately 1:45 pm surveyor reviewed the above items with Staff 1 and Staff 2, who acknowledged the areas.

All corrective actions identified in this Plan of Correction were completed or initiated prior to the facility alleging compliance. The facility conducted a comprehensive inspection of all cottage kitchens and food storage areas following the survey. Immediate corrective actions were taken, staff education was reinforced, and enhanced Quality Assurance (QA) monitoring procedures were implemented to ensure ongoing compliance with food safety and sanitation standards. 1. Cook Storage Area 1. A full inspection of the cook storage area was immediately conducted. All unlabeled food items were discarded and replaced with properly labeled items that include food identification, date opened, and 'use by' date. The bag of recycled cans observed in the area was removed to eliminate potential contamination. 2. Food labeling procedures have been reinforced for all staff responsible for food storage. During the March 11th all-staff meeting, staff received additional education on proper labeling and storage practices. Pre-printed food labeling supplies have been distributed to each cottage kitchen to support compliance. 3. Quality Assurance (QA) inspections will include routine review of the cook storage area to verify proper labeling, storage practices, and sanitation standards. 4. The Dietary Director will monitor food storage practices. The Administrator or designee will provide oversight through ongoing QA inspections. 2. Cottage 604 1. A full inspection of Cottage 604 was conducted. All unlabeled food items were removed and replaced with properly labeled products. Chemical sanitizer test strips were immediately supplied and the dishwasher was reset to the correct sanitation cycle. 2. Staff received additional education regarding food labeling, sanitizer monitoring, and proper dishwasher operation. Sanitization procedures were reviewed with the Maintenance Director and alternative Sanitabs that can be divided more easily are being evaluated. Pill cutters have been supplied as an interim solution to ensure proper sanitizer preparation. 3. QA inspections will verify proper dishwasher cycles, sanitizer test strip availability, and food labeling compliance. 4. The Dietary Director will monitor kitchen sanitation practices. The Administrator or designee will verify compliance through QA inspections. 3. Cottage 608 1. The Magic Bullet blender was immediately cleaned and the rusted can opener was removed. All unlabeled foods were discarded and replaced with properly labeled items. Sanitizer test strips were supplied and overripe fruit was removed. 2. Staff received reminders regarding cleaning expectations for small appliances, food labeling requirements, and sanitizer testing procedures. New can openers have been purchased for each cottage. 3. QA inspections will include review of appliance cleanliness, labeling practices, and sanitizer testing supplies. 4. The Dietary Director will monitor sanitation practices. The Administrator or designee will oversee compliance through QA inspections. 4. Cottage 610 1. A full kitchen inspection was conducted and all unlabeled foods were replaced with properly labeled items. The sanitizer bucket concentration was corrected to the appropriate PPM level. The previously served meal with incorrect texture could not be corrected after service. 2. Staff were retrained regarding meal texture requirements and the importance of avoiding mixing food textures. Labeling procedures and sanitation expectations were reinforced during the March 11th staff meeting. 3. QA inspections will verify labeling compliance, sanitizer PPM levels, and proper meal texture preparation during meal service. 4. The Dietary Director will oversee meal service practices and sanitation compliance. The Administrator or designee will review QA inspections. 5. Cottage 611 1. The cabinet storing cutting boards was repaired. All unlabeled foods were discarded and replaced with properly labeled items. Expired or unlabeled resident food was removed. Chemical test strips were supplied and the damaged window screen was replaced. 2. Staff were reminded to report damaged equipment or maintenance concerns promptly. Food labeling expectations were reinforced and pre-printed labels were distributed. Residents received written communication explaining that expired or visibly spoiled food must be discarded in accordance with food safety guidelines. 3. QA inspections will include review of cabinet condition, labeling compliance, sanitizer test strips, and window screen integrity. 4. The Dietary Director and Maintenance Department will monitor kitchen equipment and sanitation conditions. The Administrator will oversee QA inspections. 6. Cottage 612 1. A full kitchen inspection was completed. Unlabeled foods were discarded and replaced with properly labeled items. The sanitizer bucket concentration was corrected and dishes were relocated to the correct side of the two-compartment sink. 2. Staff received retraining regarding proper meal texture preparation and kitchen sanitation practices. Staff also received education on the appropriate use of handwashing and dishwashing sinks. 3. QA inspections will verify labeling compliance, sanitation practices, and sink usage procedures. 4. The Dietary Director will monitor kitchen operations. The Administrator or designee will verify compliance through QA inspections. 7. Cottage 620 1. All staff food items were immediately removed from the resident refrigerator. Chemical sanitizer test strips were supplied. 2. Administration is working with Maintenance and the COO to provide a dedicated refrigerator for staff food storage. Staff were reminded that resident refrigerators may not be used for staff food. 3. QA inspections will verify that staff food is not stored in resident refrigerators and that sanitizer buckets maintain appropriate PPM levels. 4. The Dietary Director will monitor kitchen practices. The Administrator or designee will review QA inspections. 8. Cottage 622 1. The dishwasher was immediately reset to the correct sanitation cycle. The sanitizer bucket concentration was corrected and new can openers were ordered for all cottages. 2. Maintenance installed signage identifying the correct dishwasher cycle. Staff received reminders regarding proper kitchen cleaning and sanitation procedures during the March 11th all-staff meeting. 3. QA inspections will verify correct dishwasher cycles, sanitizer bucket strength, and appliance cleanliness. 4. The Dietary Director will monitor sanitation practices. The Administrator or designee will review QA inspection results. 9. Cottage 630 1. The reach-in refrigerator thermometer was replaced and additional thermometers have been ordered. Staff food items were removed from the resident refrigerator. A full kitchen inspection was conducted and all unlabeled foods were replaced with properly labeled items. Chemical sanitizer test strips were supplied. 2. Thermometer checks have been added to the QA inspection checklist. Administration is evaluating the addition of a dedicated staff refrigerator. Labeling procedures were reinforced during the March 11th staff meeting. 3. QA inspections will verify kitchen cleanliness, food labeling compliance, thermometer availability, and sanitation supplies. 4. The Dietary Director will monitor kitchen operations and sanitation practices. The Administrator or designee will oversee QA inspections.

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 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: