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 maintained a dishwasher and sanitation system to meet OAR 333-150-0000 Food Sanitation Rules. Findings include but are not limited to: On 05/28/26 between 11:00 am and 02:00 pm, the kitchen was observed, and the following was identified: The Bachelor/Main and Washington Kitchens had commercial dishwashers, and Broken Top and Sisters Kitchens had residential type dishwashers. Staff 1 (Culinary Director) reported that the temperature and/or chemical requirements could not be met, and the manual three sink process was used in all buildings. At approximately 1:30 pm, the surveyor observed kitchen staff using the residential type dishwasher in the Sister’s Kitchen without a system for monitoring temperatures and/or chemicals. Staff 1 stopped the dishwasher, initiated and demonstrated the correct manual three-sink dishwashing process. Staff 1 educated staff and planned to use the three-sink manual dishwashing process in all kitchens until repairs and/or equipment replacements were made. The areas of concern were observed and/or discussed with Staff 1 (Culinary Director), Staff 2 (Executive Director) and Staff 3 (Assistant Administrator) at approximately 02:00 pm on 05/28/26. Staff acknowledged the findings.

1. Effective immediately, all tableware and cookware will be washed and sanitized operated in accordance with Oregon Food Sanitation Rules and Regulations applicable to Residential Care Facilities, including OAR 4-501.112 (Mechanical Warewashing Equipment, Hot Water Sanitization) and OAR 4-204.113 (Warewashing Machines, Data Plate Operating Specifications), as well as the manufacturer's operating specifications identified on the equipment data plates. Approved sanitization methods will be utilized to ensure proper cleaning and sanitization of all dishes and cookware. 2.During equipment repairs or replacement, staff will use the approved three-sink compartments doing manual dishwashing and sanitizing process. 3.Kitchen staff have been educated on the proper policy and procedures for cleaning and sanitizesing of tablewares. The Culinary Director and Facility Administrator or designee will provide routine oversight and monitoring of each meal for two weeks and than randomly each week for two months to ensure continued compliance in washing of tablewares. 4. The Culinary Director and Facility Administrator are jointly responsible for ensuring full compliance with the regulations and the continued implementation of this plan. 5. Completion Date: July 27, 2026

OAR 411-054-0200 (7)(e) Kitchen and Food Storage (e) KITCHEN AND FOOD STORAGE. Kitchen facilities and equipment in residential care facilities with a capacity of 16 or fewer may be of residential type except as required by the building codes. Residential care facilities licensed for a capacity of more than 16, must comply with OAR 333-150-0000 (Food Sanitation Rules). The following are required: (A) Dry storage space, not subject to freezing, for a minimum one-week supply of staple foods. (B) Refrigeration and freezer space at proper temperature to store a minimum two days' supply of perishable foods. (C) Storage for all dishware, utensils, and cooking utensils used by residents must meet OAR 333-150-0000 (Food Sanitation Rules). (D) In facilities licensed to serve 16 or fewer residents, a dishwasher must be provided (may be residential type) with a minimum final rinse temperature of 140 degrees Fahrenheit (160 degrees recommended), unless a chemical disinfectant is used in lieu of the otherwise required water temperature. In facilities of 17 or more capacity, a commercial dishwasher is required meeting OAR 333-150-0000 (Food Sanitation Rules). (E) In residential care facilities with a capacity of 16 or fewer, a two compartment sink or separate food preparation sink and hand wash lavatory must be provided. In residential care facilities with 17 or more capacity, a triple pot wash sink (unless all pots are sanitized in the dishwasher), a food prep sink, and separate hand wash lavatory must be provided. (F) Food preparation and serving areas must have smooth and cleanable counters. (G) Stove and oven equipment for cooking and baking needs. (H) Storage in the food preparation area for garbage must be enclosed and separate from food storage. (I) Storage for a mop and other cleaning tools and supplies used for dietary areas must be separate from those used in toilet rooms, resident rooms, and other support areas. In residential care facilities with a capacity of 17 or more, a separate janitor closet or alcove must be provided with a floor or service sink and storage for cleaning tools and supplies. (J) Storage must be available for cookbooks, diet planning information, and records. (K) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the kitchen maintained a commercial dishwasher to meet OAR 333-150-0000 Food Sanitation Rules. Findings include, but are not limited to: On 05/28/26 between 11:00 am and 02:00 pm, the kitchen was observed, and the following was identified: The Bachelor/Main and Washington Kitchens had commercial dishwashers, and Broken Top and Sisters Kitchens had residential type dishwashers. Staff 1 (Culinary Director) reported that the temperature and/or chemical requirements could not be met, and the manual three sink process was used in all buildings. At approximately 1:30 pm, the surveyor observed kitchen staff using the residential type dishwasher in the Sisters Kitchen without a system for monitoring temperatures and/or chemicals. Staff 1 stopped the dishwasher, initiated and demonstrated the correct manual three-sink dishwashing process. Staff 1 educated staff and planned to use the three-sink manual dishwashing process in all kitchens until repairs and/or equipment replacements were made. The areas of concern were observed and/or discussed with Staff 1 (Culinary Director), Staff 2 (Executive Director) and Staff 3 (Assistant Administrator) at approximately 02:00 pm on 05/28/26. Staff acknowledged the findings.