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 a sanitary manner in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the memory care kitchen area, as well as the food storage building, on 04/29/26 from 10:45 am through 2:00 pm revealed the following deficiencies: 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 reach-in freezer on the door seal; * Interior of multiple drawers storing food service equipment; * Black utility cart in main food storage area; and * Water and ice dispenser in the kitchenette reach-in refrigerator unit. b. Multiple potentially hazardous foods were observed stored in the reach-in refrigerator in the main kitchen without open dates. c. Multiple food items were found in the reach-in refrigerator that were past the manufacturer’s use-by date and should have been discarded. d. Multiple packages/containers of raw meat/protein foods were observed together and were not separated during storage, creating a potential for cross contamination of the packages. This practice was observed in the main kitchen reach-in refrigerator and freezer, along with the reach-in refrigerator and freezer in the back-up food storage space in the administrative building across the parking lot. e. A large pot of soup was found stored in the reach-in cooler. The lid contained a large amount of condensation. Staff 2 (Administrator/Person in Charge) could not articulate the correct cooling process. f. All shelving in dry storage was made from untreated/sealed wood product, yielding entire shelving a non-smooth/non-cleanable surface. Multiple cabinets in the main kitchenette showed signs of wear, leaving exposed sections of porous wood. At 1:30 pm the areas above were reviewed with Staff 1 (Owner) and Staff 2, who acknowledged the areas.

1. A. The Interior door seal of the reach-in freezer has been ordered and will be replaced as soon as it arrives. The interior of the drawers have been cleaned thouroughly. The black utility cart in main food area has been deep cleaned and the water and ice dispenser in the kitchenette reach-in refriderator has been cleaned. The Black utility cart and water and ice dispenser has been added to the maintence supervisors logs and duties. B. All food items within the reach-in refridgerator were gone through and all items without an open date were disposed. C. All food items within the reach-in refridgerator were gone through and all items manufacture use-by dates were checked and all were disposed that were past the date. Staff has been retrained on proper labeling when pulling and opening food containers. D. All raw meat/protein in all refridgerators and freezers were gone through and separated to ensure there is no potential for cross contamination. Containers were bought that fit within drawers to ensure packages do not touch to prevent potential cross contamination. E. Pot of soup was disposed and not utilized. Cooling process signs were printed and posted on refriderator in main kitchenette. Staff were also trained on cooling process. F. Shelving unit in dry storage will be covered with cleanable vinyl and waterproof wood sealent to ensure surface is smooth and cleanable. Main Kitchenette cabinettes will be re-sealed and protected to ensure no sections of porous wood is exposed. 2. Finding A-F has been discussed and trained with all staff individually and will also be trained and discussed on monthly All staff meeting which is scheduled to be held on 5/15/2026. An Audit was created using the annual kitchen state survey form that will be completed twice monthly. The Audit includes the Food Storage and Food Preparation section of the survey form. 3. The above will be evaluated twice monthly and community walk throughs will be completed often. 4. The Administrator will be responsible to see that the corrections were completed and will continue to monitor utilizing audits and walkthroughs.

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.

Refer to C240 POC

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: