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 facility kitchen on 07/10/26 from 10:00 am through 1:00 pm revealed the following deficient practices. a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black and white matter and grease was visible on or underneath the following: * Under tables and chairs in dining room; * Handle of microwave oven; * Interior of ice machine: * Flooring under prep area/sink; * Interior of heated meal tray delivery cart; * Metal racks in walk in; * Walk in freezer floor; * Counter top mixer; * Area under griddle top above stove; * Interior of cabinets and drawers storing clean equipment; * Back of convection oven; * Foor and wall behind/under convection oven; and * Windowsill by air conditioning unit. b. The following areas needed repair: * Multiple cabinets and/or drawers were broken and/or missing pieces; * Multiple cabinets and/or drawers were heavily worn/scored/damaged and were no longer smooth/cleanable surfaces; and * Multiple metal racks in walk in cooler were heavily rusted. c. Multiple food items were not dated when opened and/or prepared. Multiple food items found passed seven days and did not have use by dates if able to go past seven days or were not discarded. d. Cook was observed to contaminate their gloves by touching the handle to the oven door multiple times during meal service. The cook was then observed to touch ready-to-eat food items with those contaminated gloves. e. Staff were observed to stack/overlap dishes in the dishwasher. Items must have an unobstructed spray for sanitizing agent to reach/cover all areas of the dish/utensil for effective sanitization. Staff 2 (Dining Service Director) toured the kitchen with the surveyor and acknowledged findings. Staff 2 acknowledged the damaged cabinets and drawers had been identified in the last survey and that the facility had planned on replacement but it had not happened yet. At approximately 1:00pm, the surveyor reviewed the identified areas with Staff 1 (Executive Director) and they acknowledged the areas needing correction.

C240-A 1. All areas identified during the survey were immediately cleaned and sanitized. This included the dining room floors, microwave handle, ice machine, prep area, heated meal cart, walk-in cooler and freezer, kitchen equipment, cabinets, convection oven, surrounding floors and walls, and windowsill. The kitchen was inspected to ensure it was clean and sanitary. 2. A cleaning schedule has been updated to include daily, weekly, and monthly cleaning tasks. Dietary staff have been re-educated on proper cleaning and sanitation procedures. Cleaning logs will be completed daily and reviewed to ensure all tasks are finished. 3. The kitchen will be checked daily by the Dietary Services Manager. The Executive Director will complete weekly audits for one month and then monthly to ensure continued compliance. 4. The Dietary Services Manager is responsible for completing and monitoring daily cleaning. The Executive Director is responsible for reviewing audits and ensuring the plan continues to be followed. C240-B 1. All damaged cabinets, drawers, and rusted metal racks were inspected. Any broken or unsafe items were removed from use. Repairs have been scheduled, and items that cannot be repaired will be replaced to ensure all surfaces are smooth, cleanable, and in good condition. 2. The community has implemented routine kitchen maintenance inspections to identify damaged equipment and surfaces before they become a concern. Repairs and replacements will be completed promptly, and maintenance requests will be submitted as soon as issues are identified. 3. The Dietary Services Manager will inspect the kitchen weekly for any damaged surfaces or equipment. The Executive Director will review findings monthly to ensure repairs are completed and maintained. 4.The Dietary Services Manager is responsible for identifying and reporting maintenance concerns. The Maintenance Director is responsible for completing repairs and replacements, and the Executive Director is responsible for monitoring compliance and ensuring corrections are completed. C240-C 1. All opened, prepared, and expired food items were immediately inspected. Any food that was undated, past the seven-day use period, or did not have a use-by date was discarded. All remaining food items were properly labeled and dated. 2. Dietary staff have been re-educated on proper food labeling, dating, and the seven-day discard policy. Daily checks of all refrigerated and stored food items will be completed to ensure all food is properly labeled, dated, and discarded when necessary. 3. The Dietary Services Manager will complete daily inspections of food storage areas. The Executive Director will conduct weekly audits for one month and then monthly thereafter. 4.The Dietary Services Manager is responsible for ensuring food items are properly labeled, dated, and discarded as needed. The Executive Director is responsible for monitoring compliance through routine audits. C240-D 1. The cook was immediately educated on proper glove use and hand hygiene. The contaminated gloves were removed and replaced, and any potentially contaminated ready-to-eat food was discarded. 2. All dietary staff have been re-educated on proper glove use, hand hygiene, and preventing cross-contamination during food preparation and meal service. Staff will be reminded to change gloves anytime they become contaminated or after touching non-food contact surfaces. 3.The Dietary Services Manager will observe food preparation and meal service daily to ensure proper glove use and infection control practices are being followed. The Executive Director will complete weekly observations for one month and then monthly thereafter. 4. The Dietary Services Manager is responsible for monitoring dietary staff during food preparation and providing ongoing education as needed. The Executive Director is responsible for reviewing observations and ensuring continued compliance. C240-E 1. Staff were immediately educated on the proper way to load the dishwasher. Dishes were reloaded correctly to allow proper water and sanitizer coverage, and all affected items were rewashed and sanitized. 2. All dietary staff have been re-educated on proper dishwasher loading techniques to ensure dishes and utensils are not stacked or overlapped. Staff will be expected to follow proper sanitization procedures during every dishwashing cycle. 3. The Dietary Services Manager will monitor dishwashing procedures daily. The Executive Director will complete weekly audits for one month and then monthly thereafter. 4. The Dietary Services Manager is responsible for ensuring proper dishwashing procedures are followed and providing additional training as needed. The Executive Director is responsible for monitoring compliance through routine audits.