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 kitchenette was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-00. Findings include, but are not limited to: On 05/12/26 and 05/13/26, during a kitchenette and dining room tour, the following was observed to be in need of cleaning or repair: * The floor near the windows leading to the outside had large chips and uneven surface which were not smooth and cleanable; * Walls between the dining area and the activity supply storage, had spillage and brown matter; * The half wall between the dining area and the activity supply storage, the wooden handrails had chipped area and splintered surfaces; and * The windows throughout the kitchenette and dining room had white matter on them. On 05/13/26 at 11:00 am, a walk-through of the above areas was conducted with Staff 1 (ED) and Staff 2 (RN). Staff acknowledged the findings.

For the windows and the flooring, the windows are being cleaned weekly, the whole wall, window and flooring is being replaced. We are currently getting bids for this project. I will need to ask for an extension to secure the funding for this project. The walls between the dining area and the activity supply storage, has been cleaned, sanded and painted. To ensure that it remains a clean surface. Administrator and maintance director will monitor this on the monthly walk throughs to ensure that the surfaces stay clean and in good repair.

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 411-054-0030 (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 dining room was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-00. Findings include, but are not limited to: * The floor near the windows leading to the outside had large chips and uneven surface which were not smooth and cleanable. On 08/07/26 at 1:40 pm Staff 1 acknowledged the finding and the required extension.

To get back into complience, we are replacing the window section with a new wall with windows, we are replacing the flooring in the entire dining room to ensure that it is a smooth cleanable surface. I am currently getting bids. I will have to secure funding through my boards of directors. To stay in complience, the administrator and the maintance director will do monthly walk throughts of the facility to ensure that all surfaces remain smooth cleanable surfaces. The administrator and the maintance director will be responsible for ensuring this stays in complience. I will be seeking an extension for this to ensure I have funding to complete the project. Funding has been approved.

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: Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to: C240

Monthly walking rounds with the administrator and the maintance director walking the inside and out of the building making sure that the facility stays in compliance. Utilizing the TELS network that we have for the staff to report anything that needs repaired in a timely fashion. The administrator and the maintance director will be responsible for ensuring that the facility stays in compliance.