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 facility main kitchen and memory care kitchenette occurred on 02/17/26, from 10:15 am through 1:15 pm found the following: 1) Main Kitchen Areas: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Top of juice machine; * Top of service line; * Behind oven/range/grill top; * Industrial can opener and housing; * Industrial mixer; * Cooling fan in front of reach-in cooler; * Cooling fan cages in walk-in cooler; * Metal racks in walk-in cooler; * Ceiling and piping/conduit in walk-in cooler; * Floors under racks in walk-in freezer; * Floor drains; * Interior and exterior of steamer; * Wall above hand wash sink near hood; * Removable hood vents; * Celling vent above back food prep area; * Interior of ice machine with black debris/other build up; * Interior of microwave; * Interior of blender base; * Drain under sink in dining room beverage area; and * Interior of drawers under coffee station in dining room. b. The following areas needed repair: * Rust and peeling paint on metal racks in reach-in coolers; * Black debris build-up on caulking behind dirty side of ware washer area; * Rust on metal shelving in reach-in cooler; * Steamer not operational; * Reach-in cooler not holding proper temperatures; * Multiple drainage hoses were observed stored deep inside floor drains, causing potential for back flow issues if drains backed up and flooded.; and * Cracked/chipped lid on trash can next to hand washing sink. c. Commercial mixer with food contact surface of bowl and paddle stored uncovered when not in use. d. Multiple cutting boards and cutting surfaces were found heavily stained and scored. e. Multiple opened food items stored greater than 24 hours observed without open or prepared dates. Multiple food items found past seven days from prepared dates and should have been discarded. f. Multiple food packages were found open in freezer, exposing food products to potential contamination and food quality issues. g. Large two-door reach-in cooler thermometer on the outside was noted at 60 degrees F. The inside thermometer was found at greater than 50 degrees F. Staff 2 (Dining Services Director) checked the temperature of a boiled egg, and it was found at 45 degrees F. The facility was not able to produce temperature logs for that unit to determine how long the unit was not holding proper temperatures. Staff 2 checked the temperature of food items and discarded all food out of acceptable temperatures and moved all other food to the walk-in cooler. Staff 2 was not aware of that unit having issues holding temperatures. 2) Memory Care Kitchenette a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Interior of reach-in refrigerator; and * Interior of microwave. b. The following areas needed repair: * Cracked/chipped trash can lid needed to be repaired or replaced; * Reach-in refrigerator was found at 50 degrees F and not holding proper cold food storage temperatures. c. Multiple opened food items stored greater than 24 hours were observed without open or prepared dates. Multiple food items found past manufacturer’s use-by dates and should have been discarded. d. A plastic zip bag of sliced cheese was found open, exposing the food product to potential contamination, with visible drying and quality concerns. A bag of sliced turkey breast for sandwiches was observed without at date, and the color was off. Surveyor opened the bag and a foul smell immediately arose from the bag, indicating the food product was spoiled and needed to be discarded. e. The interior thermometer of the reach-in refrigerator was found at 50 degrees F. A container of yogurt stored inside the refrigerator was tested and found at 47 degrees F. Care staff in the unit were interviewed and indicated they were not checking/monitoring temperatures of the refrigerators and believed maintenance was, but did not know the frequency. Staff were not checking/monitoring dates of food products. Staff 2 was informed and did not know who was to be monitoring the temperatures of the refrigerator in the kitchenette. She acknowledged that the temperature was too high and that they would review items in that refrigerator and discard food items. A maintenance staff member was interviewed and they indicated they do check on refrigerator temperatures, but only if care staff indicate there are concerns. The staff was unaware of any reported concerns with that refrigerator. Staff 1 (Executive Director), Staff 2, and Staff 3 (Memory Care Administrator) acknowledged a system for monitoring food storage temperatures and dates of food was needed. At approximately 1:00 pm, surveyor reviewed above areas with Staff 1, Staff 2, and Staff 3, who all acknowledged the identified areas.

Plan of Correction for C240: 1)Main Kitchen Areas: a)Upon notification the dining director, maintenance staff immediately conducted a deep Clean of the kitchen and food storage areas. The following areas were cleaned and sanitized -Juice maching _Top of the service line -Industrial mixer -behind oven/range/grill top -Cooling fan in the reach in -cooling fan cages in walk in -ceiling and conduit piping in walk in cooler B) New metal racks have been ordered and will be installed. floors under racks swept and cleaned. Floor drains cleared and free of any debris. Steamer has been removed as it has been non-operational. ceiling vent above food prep area. Ice machine was taken apart and professionally cleaned by 3rd party vendor on a yearly schedule. Kitchen staff to do monthly. Chiped garbage can replaced C: Mixer Cleaned and covered after each use D:Cutting boards have been replaced with new ones kithchen staff re-educated on proper storage and cleaning protocols. E: All food items found without open or preperation dates or exceeded allowable storage were discarded immediately to prevent recurrence, kitchen staff will label and date all open prepped food.Dining Service Director will monitor compliance through daily kitchen checks and review of storage areas. Which will be monitored by weekly inspections F: All packages food packages have been properly sealed, covered, or placed in appropriate food containers to protect the food. Dining service director will monitor freezer storage practices in her daily inspections. The Dinning Service Director will monitor compliance. G:All food found in the reach cooler that were above safe temp was immediately New thermometer for both inside and outside are in place to prevent recurrence the facility has implemented daily refrigeration monitoring logs for all units. Kitchen staff will check and document temps once per shift to ensure unit is maintaining safe food storage temp All logs will be reviewed by the Dining Services Director and she will have the binder in her office readily available 2)Memory Care Kitchenette: a. A deep clean of the refrigerator and microwave has been completed. Care staff will clean the microwave after each use, and the refrigerator will be cleaned by Noc shift staff. b. The trash can lid has been replaced with a new one. A new refrigerator has been ordered. C. Care staff have disposed of the food item without open or prepared dates and food items past the manufactured date. A cleaning list has been created for staff to complete on the Noc shift and Labels with open dates have been Order for staff to use before storing any food item. d. Care staff have disposed of the food item and any other item without an open label. A cleaning list has been created for staff to complete on Noc shift and labels with open dates have been ordered for the staff to Use before storing any food items in the fridge. e. The current refrigerator will be replaced with a new one with a new thermostat F. Refrigerator temperature log has been created and care staff are obtaining the temperature twice a day and recording it. Executive Director will audit temperature logs weekly

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.

Plan of correction for Z142 will be to same as 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: