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 prepare puree diets at appropriate textures 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: Observation of the four cottage kitchen areas, two cooking kitchens and food storage (cooks shack) were reviewed on 04/29/25 from 10:430 am through 1:15 pm and found the following: 1) House 2625 a. Multiple items were found stored in the reach in refrigerator that were past seven days from open and/or prepared and should have been discarded. b. Both sinks in the kitchenette were observed with dishes and other items located inside the sinks with no dedicated sink for hand washing. c. A dish drying rack was observed directly next to the sink without a splash guard to protect clean dishes from potential splash contamination. Staff indicated that clean and sanitized dishes were stored there to finish drying after coming from the dishwasher. d. Care staff were observed without aprons on during meal service causing a potential cross-contamination issue from previous care giving tasks. 2. House 2623 a. Both sinks in kitchenette were observed full without a dedicated sink for hand washing. One sink was full of dishwashing water, the other sink was full of pans that were used for baking. b. A dish drying rack was observed directly next to the sink without a splash guard to protect clean dishes from potential splash contamination. Staff indicated that clean and sanitized dishes were stored there to finish drying after coming from the dishwasher. 3. House 2619 a. Meal items for puree diet textures were observed very watery with chunks of unprocessed food items. There was no smooth uniform consistency as needed for appropriate texture. Staff 3 (Cook/caregiver) was asked what consistency he was looking for and he was not able to state appropriate mechanicalized puree texture. Survey explained the food needed further processing prior to being served and explained the texture needed. Staff 2 (Cook/Person In Charge) was touring the area with surveyor and acknowledged the items were not at the appropriate consistency. Surveyor ensured the puree items were at the correct texture prior to serving to the resident requiring puree. b. The cook was observed to contaminate his gloves touching multiple items and then touch/handle ready to eat foods when cutting up the items prior to service. 4. Cook Shack a. Large accumulation of empty cardboard boxes and emptied large food cans were observed on a cart in the dry storage area. Staff 2 confirmed that was for recycling. Staff 2 was informed that those items once opened and food removed can no longer be stored in food storage area as it is an attractant for potential pests. b. A dish drying rack was observed directly next to the dedicated hand-washing sink without a splash guard to protect clean dishes from potential splash contamination. Clean and sanitized dishes were observed drying in the rack. c. Multiple items were observed in the walk-in cooler past seven days from opening/preparing or their identified use by dates. Staff 2, toured areas with surveyor and acknowledged the above. At approximately 1:00 pm, Staff 1 (Chief Operating Officer) was informed of the areas in need of correction and staff acknowledged areas.

1.* House 2625 & Cook Shack Expired Items: All food items found past 7 days from opening or preparation, or past their identified use-by dates in the House 2625 reach-in refrigerator and the Cook Shack walk-in cooler, were immediately discarded. * House 2625 & 2623 Kitchenette Sinks: All dishes, pots, and pans were immediately cleared from the kitchenette sinks in both houses to restore unimpeded access to a designated handwashing area. * Splash Guards (House 2625, 2623, and Cook Shack): Commercial-grade, non-porous splash guards will be ordered and permanently installed between the sinks and adjacent dish drying racks to prevent water splash contamination. * Staff Aprons (House 2625): Care staff were instructed to immediately put on clean aprons prior to resuming meal service, and a dedicated station for clean service aprons has been set up in the cottage kitchen. * Puree Diet Texture (House 2619): At the time of the survey, the watery meal items containing chunks were immediately pulled and further processed to a smooth, uniform, mechanically altered puree consistency. The surveyor verified the correct texture before it was served to the resident. * Glove Contamination (House 2619): The cook was immediately instructed to discard the contaminated gloves, thoroughly wash hands with soap and water for 20 seconds, and apply a fresh pair of gloves before handling any ready-to-eat foods. * Cook Shack Waste/Recycling Control: All accumulated empty cardboard boxes and large food cans were immediately removed from the dry storage cart and transferred to the facility's exterior recycling receptacles. 2. * Enhanced FIFO & Date-Marking System: A strict First-In, First-Out (FIFO) protocol has been reinforced. Large, highly visible "Date Opened" and "Discard Date" tracking labels are now mandatory for all prepared or opened foods across all cottages and the Cook Shack. * Dedicated Handwashing Sink Maintenance: Staff will be strictly prohibited from stacking dishes, pans, or food prep materials inside sinks designated for hand hygiene. Visual "Hand Washing Only" signage has been posted above the designated sinks. * Pureed Texture Standard Operating Procedure (SOP): The facility has adopted a standardized visual guide for mechanically altered and pureed diet textures. All dietary and care staff will be retrained on using thickeners or additional blending cycles to achieve an absolute smooth, uniform consistency free of chunks. * Glove Use & Food Service Hygiene SOP: Staff have been retrained on proper food handler protocols, specifically highlighting that gloves must be changed immediately after touching surfaces, clothing, or non-food items, and always before handling ready-to-eat foods. Clean aprons are now a mandatory uniform requirement for anyone participating in active meal service. * Pest Control & Storage Sanitation SOP: The Cook Shack dry storage area layout has been revised to eliminate staging clutter. A strict "no-retention" policy for empty recycling items has been implemented; all boxes must be broken down and taken outside immediately after a product is opened. 3. * Daily Facility Audits: The Lead Cook or designated staff will visually inspect all five cottage kitchen areas, the two main cooking kitchens, and the Cook Shack dry/cold storage once daily at the end every lunch service. This check ensures sinks are clear, dates are accurate, aprons are worn, and recycling is removed before the dinner service. * Bi-Weekly Texture & Hygiene Competencies: The Lead Cook will perform unannounced direct observations of meal preparation and pureed diet assembly at least twice per month to verify correct food consistencies and proper glove/hygiene compliance. * Weekly Supervisory Quality Checks: The Lead Cook will conduct comprehensive weekly kitchen audits of all refrigeration units to confirm zero expired items and verify that splash guards remain structurally sound and effective. * Monthly Administration Audits: The Executive Director or Assistant Administrator will complete a monthly food service quality assurance audit, reviewing shift logs, physical kitchen conditions, and staff compliance records. 4. Who will be responsible to see that the corrections are completed/monitored? * The Lead Cook (Staff 2) holds primary responsibility for the direct execution, training, daily monitoring, and tracking of the corrected dietary systems. * The Administrator and/or designee maintains ultimate administrative oversight to ensure that all corrective interventions are fully executed, ongoing audits are completed, and the facility maintains continuous compliance with OAR 411-054-0030.

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: