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 was in good repair, and food was prepared and served in accordance with OAR 333-150-0000 Food Sanitation Rules. Findings include, but are not limited to: On 06/18/26 from 10:15 am to 1:10 pm the facility’s kitchen was toured, and infection control practices were observed during the lunch meal service. The following deficiencies were observed: * A white upright reach in freezer had a discolored and rusty bottom freezer wall and had pieces of the freezer wall broken off which exposed the insulation, rendering the surface uncleanable. * Staff 3 (Resident Care Manager) lacked knowledge of cooling methods and reported staff were not using the ice wands or other approved methods for proper cooling; * The handwashing sink lacked a splashguard to protect the food prep counter and the left side of the two-compartment sink (where food prep was observed); * Staff 3 was observed washing dirty dishes in the left side of the two- compartment sink. When she was finished, she began to rinse fresh strawberries, blackberries and raspberries in the same sink without properly cleaning and sanitizing the sink. * While Staff 3 was washing the berries, Staff 4 (Universal Worker) went to the right side of the two-compartment sink and began washing two large cutting boards with a cellulose sponge, tap water and dish soap which lacked chemical sanitizer. Staff 4 proceeded to lean the cutting boards against a window air conditioning unit air vent. * Staff 4 was observed removing clean dishes from the dishwasher, stacking wet cups and food trays and placing them in the cabinet without allowing them to be completely dry. * The tap water temperature was observed to measure 140 degrees F, and the dishwasher water temperature was observed to measure 131 degrees F, which was below the required 171 degrees F without a chemical sanitizer being used. * Staff 4 failed to have her hair effectively restrained throughout the survey. During an interview on 06/18/26 at 11:23 am, Staff 4 (Maintenance) acknowledged the facility was not using the proper surface sanitizer, didn’t have test strips for the surface sanitizer, and was not using a chemical sanitizer in the dishwasher. Staff 4 further reported that the facility did not have any policies or procedures that ensured the use of a three-compartment sink or other method that ensured sanitation was maintained for handwashed equipment. The need to ensure the kitchen was kept in good repair and food was prepared in accordance with food sanitation rules was discussed with Staff 1 (Administrator) on 06/18/26 at 1:10 pm. She acknowledged the findings.

1. Freezer in disrepair. Corrective Action: The damaged upright freezer has been replaced. Prevention: An equiptment inspection checklist has been implemented to our daily kitchen task list. Any equiptment showing wear, rust, or uncleanable surfaces will be removed from service or reapaired immedietly. Monitoring: The administrator or designee will complete and document monthly equiptment inspections, and findings will be reveiwed during monthly safety committee. Responsible Party: Administrator and Maintenance. 2. Improper cooling Methods Corrective Action: Staff were retrained on proper cooling methods on 06/23/2026, including use of ice wands, shallow pans, and rapid cooling procedure. Ice wands were cleaned, labeled, and placed in accessible storage. Prevention: A laminated "cooling Procedures Quick Guide" is now posted in theh kitchen. Cooling logs were implemented for all foods being cooled and stored. Monitoring: The Resident Care Manager will audit cooling logs 3 times a week for 30 days then monthly therafter. Responsible Party: Resident Care Manager 3. Missing Splash guard at handwashing sink. Corrective Action: A stainless steal splash guard was ordered on 06/23/2026 and installed on 07/01/2026. Prevention: Kitchen Layout will be reviewed annually to ensure complaince with food-sanitation seperation requirements. Monitoring: Administrator will verify splash guard integrity during monthly kitchen walk-throuhgs. Responsible Party: Administrator and Maintenance 4. Cross Contamination at Two-Compartment sink Corrective action: Staff were immedietly stopped and retrained on proper sink use, including required steps to sanitize the sinks before food prep is initiated. Prevention: A sign was posted above the sink to remind staff to empty the sink and sanitize the sink before preperation takes place. Monitoring: Daily visual checks will be completed by Universal Workers, also weekly by the Resident Care Manager. Responisble Party: Resident Care Manager 5.Improper Washing of cutting boards Corrective Action: Kitchen dishes that were too big to fit in the dishwasher were immedietly discarded. Staff were retrained on proper sanitizing procedures and on prohibited drying locations. Prevention: No dishes will be handwashed. Sanitizer spray and test strips are now requires at all food prep stations. A sanitizing log was implemented in the kitchen. Monitoring: Sanitizer concentration will be tested twice daily or when the sanitizing solution ins changed and documented. RCM eill review sanitizing log daily for the first 30 days and weekly therafter. Responisble Party: Universal Worker & Resident Care Manager 6. Improper Dishwashing Practices Corrective Action: Staff were retrained on air drying requirements. Wet stacking was discontinued immedietly. Dishwashing pods with proper sanitizing components were immediately implemented per surveyor advice. Prevention: Staff will continue to use the dishwashing pods to ensure proper sanitation of dishes in the dishwasher. Monitoring: Administrator will ensure dishwasher pods are stocked and in use at all times. Responisble Party: Administrator 7. Staff hair not properly restrained Corrective Action: All Kitchen staff were re-educated on hair-restraint policy and hair net use. Prevention: Hair nets are stored in a labled drawer in the kitchen enterance. Monitoring: Daily visual checks by management. Responsible Party; Administrator & Resident Care Manager. 8. Lack of Proper Surface Sanitizer & No test strips Corrective Action: Approved Bleach sanitizer and test strips were purchased on 06/23/2026. Staff were trained on proper mexing, testing, and documentation. Prevention: Sanitizer Spray now required in the kitchen. Test strips are stored in a labeled drawer. Monitoring: Sanitizing concentration will be checked twice daily or when changed and documented. Responsible Party: Universal Workers 9. No policy for three compartment sink Corrective Action: A formal policy was not developed due to the disontinuation of all handwashing based sanitation. The facility has transitioned fully to mechanical dishwasher using approved sanitizing dishwasher pods. Prevention: Handwashing of dishes will not be permitted under any cirumstances. Staff have been instruced on the updated procedure and the elimination of manual dishwashing practices. Monitoring: The administrator will obeserve staff during routine kitchen operations to ensure compliance with mechanical dishwashing process. Responsible Party: Administrator 10. Kitchen Not maintained in good repair Corrective Action: All Deficiencies identified during the survey were corrected as outlined above. The administraor acknowledged the findings and implemented a full ktichen sanitation overhail. Prevention: A kitchen sanitation program was implemented including monthly equiptment inspections, Daily sanitizer logs, Food cooling log. Monitoring: Administrator will conduct monthly kitchen audits and review logs during these audits. Responsible Party: Administrator.

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: