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, record review, and interview, it was determined the facility failed to ensure meals were served at palatable temperatures and correct textures and that the dedicated person in charge had appropriate knowledge according to OAR 333-150-000. Findings include, but are not limited to: Observation of the facility kitchen on 06/08/26, from 10:45 am through 12:45 pm, found the following: a. Staff 2 (Cook/Person in Charge) was interviewed to validate adequate knowledge and was not able to correctly discuss proper cooling processes and temperatures, correct reheating temperatures, and proper surface sanitation concentration levels for sanitizing. b. Facility did not have chlorine test strips for validating effective sanitation concentrations for their surface sanitizing solution buckets. c. Facility had multiple residents with modified texture diet orders, which included minced and moist, soft and bite size, bite size, and mechanical soft. Staff 2 was cutting food items into bite size pieces for all these diet texture types. Staff 2 (dedicated PIC) was not aware of the correct textures and particle sizes for the different diets, and food would have been served to the residents with the wrong texture from what was ordered without surveyor intervention. The facility had not properly trained Staff 2 on how to prepare food for modified texture diet orders. Surveyor interviewed Staff 1 at 12:30 pm, and he indicated that the textures were related to chewing issues/concerns and not swallowing issues, and the resident on minced and moist would be moving back to a regular diet as his chewing issues had resolved. Staff 1 acknowledged the need for further education for cooks to ensure future residents on altered texture diets would be served correctly. e. Staff 2 started plating lunch at approximately 12:00 pm. Staff was putting one item at a time on all plates. The hot food items were sitting on the stove without heating elements and were uncovered during the process. Plated food was sitting on the countertop without covers, allowing items to cool while waiting to be served. The first plate was served at 12:25 pm. Surveyor asked the staff to check the temperature of the hot food items of the unserved plates remaining on the counter, and they were as follows: Hot dog 95 degrees F, macaroni and cheese 108 degrees F. Food must be held and served at 135 degrees or hotter. Food served to residents at this meal was not at a hot/palatable temperature. At approximately 12:30 pm, surveyor reviewed above areas with Staff 1 (Administrator), who acknowledged the identified areas of concern.

Citation C0240-a: Person in Charge Lacks Knowledge 1. Action Taken to Correct the Violation: All kitchen staff will complete food safety training that includes the specific elements: proper cooling processes, correct reheating temperatures, and proper surface sanitation concentration levels. 2. System Correction to Prevent Recurrence: All kitchen staff will complete initial food safety training 3. Evaluation Schedule: An evaluation will be done after training to ensure staff has retained knowledge 4. Responsible Staff Position: Administrator will ensure training completion Citation C0240-b: Missing Chlorine Test Strips 1. Action Taken to Correct the Violation: Chlorine test strips were ordered on 06/11/26 and will be delivered by 06/12/26. The facility will begin daily sanitizing solution concentration testing and documentation immediately upon receipt. 2. System Correction to Prevent Recurrence: Chlorine test strips added to standard kitchen inventory with minimum par level 3. Evaluation Schedule: Monthly kitchen checks to make sure chlorine strips are in inventory 4. Responsible Staff Position: Administrator will ensure test strips are available Citation C0240-c: Inadequate Modified Texture Diet Training 1. Action Taken to Correct the Violation: The resident referenced in this citation has been re-evaluated by their PCP. The dietary order was updated on 06/10/26 to regular diet, soft and bite-sized, with thin liquids. All kitchen staff will receive formal training on modified texture meals. 2. System Correction to Prevent Recurrence: Kitchen staff will be trained on modified textures 3. Evaluation Schedule: Daily checks of modified texture meals for two weeks (logged by Administrator) after kitchen staff has received training in order to ensure the training has stuck with them 4. Responsible Staff Position: Administrator will monitor training compliance Citation C0240-d: Food Temperature and Holding Issues 1. Action Taken to Correct the Violation: The facility has corrected the meal service process. Previously, all plates were prepared at once, causing earlier plates to cool while waiting for remaining plates to be completed. The corrected process is: • Plates are now served to residents immediately after being plated • Hot food items remain on the stove with heating elements on until ready to plate Staff 2 has been retrained on this corrected process as of 06/09/26. 2. System Correction to Prevent Recurrence: • Written meal service procedures developed requiring immediate service after plating 3. Evaluation Schedule: Administrator will observe at least two meal services per week for 30 days 4. Responsible Staff Position: Administrator will monitor meal service process and temperature compliance

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: Z 142: 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 C 240.

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: