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 ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen, food storage areas, food preparation, and food service on 02/24/26 from 10:50 am through 1:45 pm revealed the following; a) Accumulation of, splatters, spills, drips, dust, black matter, food and other debris noted on: * Interior of ice machine; * Industrial can opener and housing; * Removable hood vents; * Reach-in freezer exterior vent; * Stainless steel bottom shelf of back prep table storing clean dishes and cutting boards; * Oven mitts/hot pads; * Interior of small reach-in refrigerator in dining room; b) The following areas/items were found needing repair; * Seal of small-reach in refrigerator in dining room found with cracks/damage and needed repaired/replaced. c) Interior of ice machine found with excessive build-up of black and pink debris/organic matter on the interior of the machine. Staff 2 (Dining Service Director) did not know when the last time the machine had been cleaned/serviced. Staff 2 believed it was the maintenance personnel who was responsible for the cleaning/maintenance. Staff 2 acknowledged the build up was concerning and posed a potential contamination issue of the ice. Staff 2 indicated he would empty the ice and get it cleaned/maintenance as soon as possible. d. Surface sanitation buckets were noted at zero parts per million (PPM) of sanitizer. Staff 2 (Dining Services Director) indicated buckets were to be switched every two hours, and the cook on duty should make the bucket first thing when coming on shift. Cook on duty stated she did not make the bucket and did not know when the bucket was made stating “probably last night.” The bucket water was cold to the touch. Staff 2 made a fresh bucket which tested at the correct PPM. e. Multiple potentially hazardous food items were noted stored without open dates. Multiple items were found past seven days of opened/prepared or past the posted manufacturer’s use-by date. Staff 2 stated those items would be discarded. f. Multiple cutting boards were observed with deep scoring/damage and in need of repair or replacement. Multiple plate cover dome lids were observed melted/damaged yielding non cleanable surfaces and in need of replacement. g. Care staff were observed to enter the kitchen area multiple times, handled kitchen equipment and prepared drinks for meal service, and did not wash their hands. h. Care staff did not have facial hair effectively restrained when in kitchen area and was observed handling clean dishes and preparing drinks for meal service. This care staff also was not wearing his apron correctly so that the apron covered the torso area to create a clean barrier between care giving tasks and meal service activities posing a potential cross contamination issue. i. Non dietary staff were observed to enter and pass through kitchen utilizing it as a short cut, posing potential contamination concerns. Non-essential and unauthorized staff are prohibited from kitchen and meal service areas. j. Cook on duty was observed to potentially contaminate her gloves during meals service by handling meal tickets, marker, drawer handles, and other items, then proceeding to touch ready to eat food items (corn bread, cut up chicken). k. Trash can in kitchen did not have a lid for when not in use. Staff 2 verified there was no lid for that trash can. i. Staff were observed to pour drinks for room tray service and deliver to rooms without placing covers over the drinks, causing potential contamination issue during meal/beverage transport. At 1:15 pm, surveyor reviewed areas with Staff 2 who acknowledged findings. At 1:30 pm the areas in need of cleaning, repair and attention were reviewed with Staff 1 (Administrator). She acknowledged the findings.

A. The ice machine was cleaned and was added to the monthly cleaning schedule. The industrial can opener and housing were cleaned and were added to the daily cleaning schedule, and will be cleaned after every use. The removeable hood vents were cleaned and were added to the weekly cleaning schedule. The reach-in freezer, exterior vents were cleaned and were added to the monthly cleaning schedule. The stainless steel, bottom shelf of the back prep table was cleaned and was added to the daily cleaning schedule, and will be cleaned as needed. New oven mitts/hot pads were ordered. The interior of the small reach-in was cleaned and was added to the daily cleaning schedule, B. For the damaged seal on the small, reach-in fridge, replacement parts were ordered from the manufacturer and will be installed before 4/25/26. C. Ice machine was fulled drained, cleaned, and restocked with ice. D. The water & sanitizing solution in the sanitation buckets will be replaced every 2 hours and monitored on a log one time per shift. E. Appropriate labeling stickers were ordered and are being used to label all food with the date it was opened and a description of what it is. This will be monitored daily. F. New cutting boards ordered and old ones were thrown away. New plate covers were also ordered, G. Formal Hand Washing training was conducted with all staff members, and on-going training will be conducted as needed. H. Formal training was conducted about facial hair restraints and how to wear an apron properly is scheduled for 3/18/26 with all staff members, and on-going training will be conducted as needed. I. Formal training was conducted to explain that staff should enter the kitchen for dining related purposes, not as a pass through or walk through to get to another part of the community. A sign was posted on the entrance door of this area discouraged staff from using it as a pass through. J. Formal training was conducted with all dietary staff about proper use of gloves and handling of raw food without utensils. K. A trash can lid for kitchen trash can was purchased. L. Formal training was conducted about putting lids or coverings on all drinks delivered through room/tray service. 2. Trainings for staff was coducted to educate and reeducate all staff regarding these topics. Additionally, updated logs were put into place to monitor compliance with the regulations. 3. On-going training on these topics will be conducted quarterly and as needed. Logs will be reviewd weekly. 4. Dining Services Director and Executive Director.

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 ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the main facility kitchen, food storage areas, food preparation, and food service on 05/13/26, from 12:00 pm through 1:15 pm, revealed the following: a. Interior of ice machine was noted with accumulation of black, grey, and rust colored material on the interior sides. b. Handwash sink was observed without a splash guard. Splash debris was visible along the edges of the sink. The sink was directly next to food prep area and clean dishes. Active food prep was occurring within the splash radius of the sink, causing potential contamination. c. Staff was asked for test strips to check the sanitizer bucket concentration. The provided strips indicated zero parts per million (PPM) of sanitizer in the bucket. The cook was asked when the bucket was made, and she did not know. The cook stated it was there when she arrived at facility at 8:00 am that morning. The cook validated the buckets should be changed every two hours and/or when soiled. Staff were unaware that the strips provided to surveyor were not testing for the active chemical from their wall dispenser. The surveyor was able to validate the chemical coming from the wall dispenser was dispensing at correct sanitizing concentrations (PPM). The cook validated that the facility did not have a system to track sanitation concentrations to ensure sanitizer buckets were changed timely and were at the correct PPM. d. Multiple potentially hazardous food items were noted stored without open dates. Multiple items were found past seven days of being opened/prepared. e. Kitchen staff did not have facial hair effectively restrained when preparing sandwiches. f. Multiple dome lids to cover plated food were noted to be melted/damaged and no longer providing a smooth, cleanable surface. At 1:00 pm the areas in need of cleaning, repair, and attention were reviewed with Staff 1 (Administrator). She acknowledged the findings.

1A- The ice machine was cleaned and added to a calendar for bi weekly cleaning unless it is determined that it needs cleaned more often. 1B- New splash guard was ordered and adhered to the sink so that it stays in place. It will be replaced as needed. 1C- Correct test strips implemented 1D- Labels were ordered that include open date, expiration date, and the product. 1E- Enforced facial hair restraint. 1F- Discarded dome lids with melted/damaged tops and ordered new ones. 2A- The ice machine will be cleaned bi monthly, and will be monitored for additional cleaning needs. 2B- A new, more durable splash guard was adhered to the counter. It will be monitored for durability and effectiveness. 2C- Correct Sanitizer strips were ordered and are available for use. A log is in place to monitor consistency and compliance, and training was conducted at all staff meeting. 3D- Staff educated on proper way to fill out labels, to include date received, date opened, expiration date, and product name. Food keeper app was shared with kitchen director and other staff. OHA Food Sanitation Rules were printed and placed in binder, located in kitchen director's office for reference. 2E- Staff educated on facial hair restraints and the requirement to wear one if you have facial hair. 2F- New dome covers were ordered and staff educated to not stack plates under heat lamp, which caused bubbling and ultimately uncleanable surfaces. 3. A,B,C,D,E,F- will be monitored weekly and ongoing, frequency increased as needed. 4-Dining Service Director and Executive director will monitoring these items and are responsible for staff training.

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 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: C455: Based on interview, observation and review of records, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

Refer to C 240.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: