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: Observation of the main kitchen on 07/22/26, from 12:00 pm through approximately 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: * Ceiling surfaces and ceiling vents; * Flooring and walls throughout the kitchen; * Inside reach in refrigerators and freezers; and * Flat top grill. b. The following areas were in need of repair: * Dish washing machine failed to reach the minimum temperature 120 degrees noted on the data plate. Machine was tested four times and failed to reach above 105 degrees; and * Large sections of the ceiling had been removed and were missing. Missing sections were noted with exposed insulation, wires, and plumbing pipes. On 07/22/26 at approximately 1:00pm, the areas in need of clean and repair were discussed with Staff 1 (Regional Vice President) and Staff 2 (Executive Chef). They acknowledged the findings.

1. Corrective action: The kitchen was placed on an immediate cleaning and repair plan. Ceiling surfaces and vents, floors, walls, reach-in refrigerators and freezers, and the flat-top grill will be deep cleaned and kept free of food debris, dirt, dust, black matter, and grease. The dishwashing machine will have a plumber will come and verify the temperature can reach a minimum of 120 degrees or he will fix the water coming into the dishwashing machine so the minimum temperature can be met. An approved alternative sanitizing method will be used until the machine is repaired. Missing ceiling sections will be repaired and sealed so insulation, wiring, and plumbing are no longer exposed. 2. System correction: A written daily and weekly cleaning schedule will assign each kitchen area to designated staff and require initials when completed. Dish-machine temperatures will be checked and documented before use.. The Chef will review cleaning and temperature logs daily. Dietary staff will receive in-service training on cleaning, sanitation, equipment temperatures, and reporting needed repairs. Deficiencies found during review will be corrected and documented. 3. Evaluation frequency: Weekly audits will be completed, and the results will be reviewed through QAPI weekly. Findings will be assigned for correction and tracked to completion. 4. Responsible persons: The Executive Director (ED) and Chef are responsible for completion, monitoring, documentation, and follow-up of this Plan of Correction.

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: