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 maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main kitchen on 07/07/26, from 10:15 am through 1:30 pm, revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following: * Cabinets under steam table area; * Interior of cabinets storing clean dishes; * Ceiling vents above steam line; * Walk-in cooler fan cage; * Walk-in cooler ceiling; * Metal racks in walk-in cooler; * Interior of plastic storage bins/containers storing condiments; * Interior of plastic storage bins/containers storing clean utensils; * Flooring and walls behind/under dish machine; * Kitchen drains; * Dining room chairs; and * Dining room table bases. b. The following areas were in need of repair: * Multiple metal racks in the walk-in cooler rusted and no longer a smooth, cleanable surface; * Down spout of prep sink drain was observed reaching inside floor drain, causing potential back flow issue; and * Multiple dining room chair seats were heavily worn and in need of replacement. Seating surfaces were noted with permanent indentations from wear. c. Staff were observed handling dirty dishes or touching dirty areas of the dish machine and then touching clean dishes without washing their hands. d. Staff observed over-stacking dishes in dish washing racks so that dishes/utensils did not have unobstructed access to sanitizing agent. Staff observed loading dishwashing racks with dirty dishes on the clean side of the dish area, potentially contaminating the clean area of the dish washing space. e. Multiple staff were observed preparing or serving food or handling clean dishes/equipment without hair or facial hair effectively restrained. f. Facility did not have pasteurized shell eggs on hand. Facility served residents cooked-to-order eggs for breakfast that included soft and/or not fully cooked eggs. Staff 2 (Dietary Service Director) was interviewed at 12:45 pm and was unaware that the shell eggs in house were not pasteurized. g. Multiple bulk food items were observed with handles touching food products, causing potential contamination. On 07/07/26, at 1:30 pm, the surveyor reviewed areas needing attention/correction with Staff 1 (Executive Director), who acknowledged the findings.

1. There will be a complete audit of all areas of the kitchen for cleanliness and food sanitation items in the OARs. Regarding an (a) accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath specific areas in the kitchen; (b) the areas that need repair; (c) staff were observed handling dirty dishes or touching dirty areas of the dish machine and then touching clean dishes without washing their hands; (d) staff observed over-stacking dishes in the dish washing racks so that dishes/utensils did not have unobstructed access to sanitizing agent. Staff observed loading dirty dishes on the clean side of the dish area, potentially contaminating the clean area of the dish washing space; (e) multiple staff were observed preparing or serving food or handling clean dishes/equipment without hair or facial hair effectively restrained; (f) facility did not have pasteurized shell eggs on hand. Facility served residents cook to order eggs for breakfast that included soft and/or not fully cooked eggs; and (g) multiple bulk food items were observed with handles touching food products, causing potential contamination were addressed in the following manner: a. Cabinets under steam table area- all cabinets were cleaned and sanitized, Interior of cabinets storing clean dishes- all dishes were taken out of the cabinets and ran through the dishwasher; the interior of the cabinets was cleaned and sanitized, Ceiling vents above steam line- were dusted and cleaned of debris, Walk-in cooler fan cage and ceiling- were dusted and cleaned of debris and sanitized, Metal Racks in walk-in cooler- were cleaned and replacement racks were ordered, Interior of plastic storage bins/containers storing condiments and utensils- all containers were cleaned and ran through dishwasher, and all utensils were run through the dishwasher, Flooring and walls behind/under dish machine- the area under the dish machine was cleaned out and the area behind and under the dish machine were cleaned, Kitchen drains were cleaned of debris and grease, and Dining room chairs and tables were all cleaned and sanitized, and those chairs that had visible wear and tear on them were disposed of. b. Down spout of prep kitchen sink- was cut to make sure that the down spout is not reaching inside the floor drain, Dining room chairs were all cleaned and checked for heavy wear and tear; those that were visibly worn were thrown out, and replacements ordered, and Metal Racks in walk-in cooler- replacements were ordered. c. Kitchen Staff were educated on hand hygiene and the importance of hand hygiene taking place when switching from dirty dishes to clean dishes. d. Kitchen Staff were educated on clean verses dirty areas of this dish washing area and the importance of keeping these areas separate. Staff were also educated on the importance of not over stacking the dishing racks so that all dishes and utensils have unobstructed access to the sanitizing agent. e. Staff were educated on wearing hair and facial hair nets while preparing and serving food, touching clean dishes and equipment. f. The kitchen staff was educated on what pasteurized eggs are marked with, so that they can ensure that they are pasteurized before making cook to order eggs that are not fully cooked. Staff was then instructed that if eggs were not pasteurized then they must fully cook the eggs and we will not be able to serve cook to order eggs that are not fully cooked. g. Bulk food items that contained scoops were thrown out and replaced with new items. Scoops will no longer be left in bulk food item containers. 2. a. The cleaning task sheets were updated and added specific areas that were noted in this survey. b. Monthly tasks were added to the Maintenance team to check the wear and tear of dining room chairs for potential replacement and to check the metal racks in the kitchen for any rust. c-g. Kitchen and Care staff were educated on the importance of hand hygiene when switching from dirty to clean areas of the dish area, on clean verses dirty areas of this dish washing area and the importance of keeping these areas separate, on the importance of not over stacking the dishing racks so that all dishes and utensils have unobstructed access to the sanitizing agent, on wearing hair and facial hair nets while preparing and serving food, touching clean dishes and equipment. Kitchen Staff were educated on the importance of what pasteurized eggs are marked with and the importance of fully cooking eggs if they are not pasteurized, and the importance of completing cleaning tasks sheets during their shift to ensure the cleanliness of the kitchen and dining areas. 3. The Dietary Services Director (DSD) will audit the cleaning task sheets daily to ensure that cleaning tasks have been completed daily. The DSD will notify the Executive Director of any equipment or furniture that needs to be replaced. 4. The DSD and the Executive Director will be responsible to ensure the corrections are kept up to date and completed.

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: