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 areas, MCC servery, and unit kitchenettes on 07/07/26, from 10:15 am through 1:30 pm, revealed the following: 1. Main Kitchen 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 were rusted and no longer had 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. 2. MCC Servery a. Prep sink did not have a splash guard, and clean/sanitized dishes were observed stored next to the sink. During dishwashing cycle, spray from the drain of the sink was observed to splash up and onto the counter space where the clean dishes were staged. b. Facility did not have strips to test sanitation concentrations of dishwashing sanitizer to ensure proper sanitation was occurring. Surveyor used their strips and found that the dishwasher sanitizing cycle was not producing effective sanitizing levels. Multiple cycles were run and parts per million were 10 or less, not the 50 – 100 ppm required. 3. Sunset Unit a. Potentially hazardous food items were found in the reach-in refrigerator that were not labeled with the date opened or date prepared. b. Multiple plastic bowls were found with heavy scoring/pitting and did not have appropriate glaze to yield a smooth, cleanable surface. c. A container of bottles and cans for recycling was observed stored under the sink area without a lid, causing the potential of attracting pests/insects. d. Multiple drawers in kitchenette area were found dirty and in need of cleaning. 4. Silver Unit a. Potentially hazardous food items were found in the reach-in refrigerator that were not labeled with the date opened or date prepared. Items were found past seven days and needed to be discarded. b. Multiple plastic bowls were found with heavy scoring/pitting and did not have appropriate glaze to yield a smooth, cleanable surface. c. A container of bottles and cans for recycling was observed stored under the sink area without a lid, causing the potential of attracting pests/insects. A trash can with food debris was also observed without a lid. d. Multiple drawers in the kitchenette area were found dirty and in need of cleaning. 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. h. MCC Servery- A splash guard will be installed at the designated food preparation sink to prevent splash contamination during food preparation. The facility called ecolab to service machine and to bring test strips. Machines are in working order. i. Sunset Unit and Silver Unit Memory Care kitchens were audited for compliance with food sanitation requirements. All refrigerated food items were labeled and dated. Plastic bowls exhibiting scoring, cracking, or pitting were removed from service and replaced with food-safe containers. Bottle and can storage containers be removed from both kitchens. All drawers, cabinets, and food storage areas were thoroughly cleaned and sanitized. 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. Memory care- b. Staff were educated on maintaining proper food storage practices, including refrigerator labeling and dating requirements, maintaining clean food preparation surfaces, and ensuring food-contact equipment remains in sanitary condition, routine kitchen sanitation expectations, including proper cleaning of drawers, cabinets, food preparation areas, refrigerators, and food-contact surfaces to maintain compliance with Oregon Administrative Rules. c. Daily and weekly kitchen sanitation task sheets have been updated to include monitoring of sanitizer concentrations, refrigerator labeling and dating, food-contact equipment, drawers, cabinets, storage areas, and overall kitchen cleanliness and checking for wear and tear on bowls. 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. a. The LPN and Executive Director will audit the cleaning task sheets daily to ensure that cleaning tasks have been completed daily. The LPN will notify the Executive Director of any bowls that need 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:

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: 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.

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: