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 kitchen practices and protocols were in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 07/07/26, between 9:00 am and 10:45 am, the following was noted: 1. Sanitation/Cleaning: a. Main Kitchen: *Mixer/oven handles had food debris; *Dish machine did not reach required temperature for washing, had a defective rinse gauge, and lacked a system for monitoring sanitation; *Ice machine had black matter inside; and *Alcohol wipes were not available to sanitize thermometers. b. Maple Cottage Kitchenette and Dining: *Leftovers were undated/unlabeled and/or not stored in a refrigerator or freezer; *Handwashing sink was not clearly designated; and *Non-food contact surfaces were not being sanitized correctly, and the facility lacked a system for monitoring sanitation. c. Pines Cottage Kitchenette and Dining: *Leftovers were undated/unlabeled; *Sponge was being used for dish washing; *Handwashing sink was not clearly designated; and *Non-food contact surfaces were not being sanitized correctly, and the facility lacked a system for monitoring sanitation. d. Oak Cottage Kitchenette and Dining: *Handwashing sink was not clearly designated; *Sponge was being used for dish washing; and *Non-food contact surfaces were not being sanitized correctly, and the facility lacked a system for monitoring sanitation. At approximately 10:00 am, the surveyor observed the wash temperature on the dish machine was 110 degrees F, below the required temperature of 150 degrees F and the rinse gauge was not working. Staff 1 (Dietary Supervisor) acknowledged this and reported that a repair was planned and continued to use the machine. Staff 2 (Administrator) confirmed a pending repair quote from two months ago. Staff planned to use the three-sink for dish washing until repair could be completed. The areas of concern were discussed with Staff 1 and Staff 2 at approximately 10:45 pm on 07/07/26. Staff acknowledged the findings.

C240 1. Immediately following the survey exit interview, the facility corrected the identified deficiencies by removing the ice machine from service until it was thoroughly cleaned and sanitized, discarding all ice, and implementing a routine cleaning schedule with documented inspections and quarterly deep cleanings. The commercial dishwasher was removed from service until proper operating temperatures and gauge functionality are restored, and staff immediately began utilizing the approved three-compartment sink procedure. The commercial dishwasher is being fixed and addressed on Thursday 7.23.26. Kitchen staff cleaned all identified food residue from equipment and food-contact surfaces, including the mixer, oven handles, and kitchen counters. Unlabeled and undated food, household storage containers, and outdated leftovers were discarded from all cottage refrigerators. Sponges were removed from cottage kitchenettes and replaced with approved cleaning methods. Leftover food procedures, food labeling requirements, and standardized cleaning and sanitizing practices were implemented throughout the facility. 2. The facility has implemented a comprehensive food safety and sanitation program that includes revised policies and procedures for the main kitchen and all cottage kitchenettes. Standardized processes have been established for food storage, food labeling, leftover meal handling, sink designation, cleaning and sanitizing of food-contact surfaces, ice machine maintenance, dishwasher temperature monitoring, sanitizer concentration verification, and manual warewashing using the three-compartment sink. Staff have received education and competency validation on these revised procedures. New documentation logs have been implemented for ice machine inspections and cleaning, dishwasher temperature monitoring, three-compartment sink use, sanitizer concentration testing, and routine cleaning schedules. Standardized signage identifying handwashing and dishwashing sinks has been installed in each cottage kitchenette, and approved cleaning products and dispensing systems have been implemented to ensure proper preparation of cleaning and sanitizing solutions. (See attached documents) Facility purchased and provided sanitizing wipes for the food thermometers and placed them on Dietary Supervisor’s desk for all kitchen staff to use appropriately. 3.Compliance will be monitored through multiple levels of oversight: • Dietary staff will complete and document dishwasher temperature checks three times daily during meal service. • Sanitizer concentrations will be tested and documented each time a new sanitizing solution is prepared (every 4 hours). • Ice machine inspections will be documented weekly, with comprehensive cleaning and sanitizing completed every three months, or more frequently if indicated. • Kitchen cleaning schedules will be completed daily by dietary staff. • The Dietary Supervisor will complete weekly audits of the main kitchen and all cottage kitchenettes for eight (8) weeks following the survey and monthly thereafter as part of the facility's Quality Assurance program. • The Administrator will review audit findings, documentation logs, and corrective actions to ensure continued compliance. 4. Overall responsibility for implementation and ongoing compliance rests with the Administrator, Christina Bell, and the Dietary Supervisor, Chris Fincher.

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: Refer to C 240.

Z142 (see C240)

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: