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 07/22/26, between 11:45 am and 02:00 pm, the following was noted: 1. Sanitation/Cleaning/Equipment: 1a. Main Kitchen: * Dish machine had non-working wash temperature gauge; * Test strips for monitoring chemical PH for sanitation were expired; * Frying pans had scored Teflon coating; * Alcohol wipes were not available to sanitize thermometers; * Walk-in cooler had extensive white matter throughout shelving/flooring; and * Walk-in freezer had hardened/torn gasket, bulging metal at doorway; preventing seal. At approximately 12:00 pm, the surveyor observed the gauge for the wash temperature on the dish machine was not working. Staff 1 (PIC/Cook) acknowledged this and reported that a repair was planned. Staff 3 (Executive Director) confirmed this. Surveyor tested the wash temperature at 120 degrees F, and staff continued to use the machine. 2a. Daisy Neighborhood: * Fridge had temperatures of 42-47 degrees F for ten days; * Handwashing sinks were not designated; and * Personal ice packs were found in the freezer. At approximately 1:00 pm, the surveyor found the temperature of the fridge in the Daisy neighborhood to be 43 degrees F. Through record review, the surveyor found the temperature to be 42-47 degrees F for the past ten days. Staff 1 and 3 reported that they were unaware. Unsafe foods were discarded until adjustments and/or repair could be made. 3a. Butterfly Neighborhood: * Fridge had temperatures 14-17 degrees F for four days; and * Handwashing sinks were not designated. At approximately 1:30 pm, the surveyor found the temperature of the fridge in the Butterfly neighborhood to be 17 degrees F. Through record review, the surveyor found the temperature to be 14-17 degrees F for the past four days. Staff 1 and 3 reported that they were unaware. Repair and/or adjustments were initiated. 4a. Cascade Neighborhood: * Personal ice packs were found in the freezer; * Refrigerator had undated mighty shakes; and * Handwashing sinks were not designated. 5a. Apple Neighborhood: * Handwashing sinks were not designated. The areas of concern were discussed with Staff 3 at approximately 2:00 pm on 07/22/26. Staff acknowledged the findings.

C240 1) A repair request work order was placed on 7/23/26 for dishwasher tempature gauge. A manual thermometer is being used to ensure proper temp has been reached prior to use. Dining Services Director instructed cooks and dishwasher on proper usage. Dishwasher temps are recorded 3 times daily and posted. Test strips for monitoring chemical PH were purchased on 7/22/26 and placed in kitchen to replace expired strips. Scored frying pans were discarded and replacements purchased. Alcohol wipes were placed in the kitchen immediately and kitchen staff was educated on storage location of alcohol wipes for replacement when needed. A repair request work order was placed on 7/23/26 for the broken freezer door gasket replacement parts have been ordered. Walk in shelving was removed and cleaned on 7/22/26 and 7/23/26. A deep cleaning of walk in was completed on 7/23/26. Handwash only signs were purchased and placed on neighborhood sinks on 7/24/26. Neighborhood refridgerators were serviced and are working properly. Staff was educated on placement of thermometers for accurate readings and on what to do if the temp is out of range. Temp logs with those instructions are placed in the neighborhoods for monitoring for compliance. Staff was instructed on dating and labeling any food item placed in refridgerators and were educated on not storing any non-food or personal items in neighborhood refridgerators. 2) Regular and weekly deep cleaning schedules are posted and in place. Dining Services Director (or designee) will monitor cleaning schedules daily to ensure completion. Dining Services Director and Executive Director will do daily walk throughs of kitchen to ensure cleanliness and to monitor for any repairs needed. Dining Services Director will monitor test strips quarterly to ensure non-expiration. Executive Director (or designee) will do daily walk throughs of the neighborhoods to ensure temp logs are being completed and temps are in range, as well as ensuring all items in refridgerator are labeled and dated. 3) Daily walk throughs of neighborhoods and kitchen, Quarterly checks on expiration date of sanitation test strips. 4) Dining Services Director, Executive Director.

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. This is a repeat finding. Findings include, but are not limited to: On 10/08/26, between 10:30 am and 11:30 pm, the following was noted: 1. Sanitation/Cleaning/Equipment: Main Kitchen: * Dish machine had non-working wash temperature gauge; * Test strips for monitoring chemical PH for sanitation were expired; * Walk-in cooler had extensive white matter throughout shelving/flooring; and * Walk-in freezer had hardened/torn gasket, bulging metal at doorway; preventing seal.

C240 1) Dishwasher temperature gauge was replaced on 10/12/26 and is in good working order. Dishwasher temps are being recorded 3x daily and posted. ED and Dining Services Director confirming accurate readings are being recorded. Kitchen staff was trained on how to utilize 3 sink sanitation in case of dishwasher temp not reaching required temperature. Test strips for monitoring chemical PH were purchased and delivered on 10/08/26 to replace recently purchased strips that were found to be expired. ED and Dining Services Director opened package prior to placing them in kitchen to confirm expiration date of 2028. Walk in shelving was removed and cleaned and a deep clean of walk in walls, floors, and ceilings was completed. Walk in shelving was placed on daily cleaning list and scheduled to be removed and pressure washed monthly. A repair request work order for the broken/torn freezer door gaskets was again placed with local vendor and replacement parts are being located for order. ED is following up daily with Plant Ops Director on progress with getting the parts and bid for work needed. ED has reached out to regional team for assistance in locating vendor who can repair gaskets or replace freezer door if parts cannot be located. Until repairs are completed, staff will monitor the affected units and take appropriate action to protect food safety, including transferring food to compliant refrigeration or freezer storage when necessary. Walk in and Freezer temperatures will be monitored and documented. 2) Regular, weekly, and monthly cleaning schedules are in place and posted. Dining Services Director, ED, or designee will monitor cleaning schedules daily to ensure completion. Dining Services Director, ED, or designee will monitor dishwasher temp logs daily and check against dishwasher temp readings to confirm accurate readings are recorded and in accordance with required temperatures. Dining Services Director and ED will do daily inspections of kitchen and walk in to ensure cleanliness and to monitor for any repairs needed. Dining Services Director will monitor test strips quarterly to ensure non-expiration. 3) Daily inspection of kitchen and walk in, daily check in with Plant Ops Director for updates on vendor and repair for freezer door gaskets, Quarterly checks on expiration date of sanitation test strips. 4) Dining Services Director, Executive Director

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval Temporary rule language in effect until 02/05/2027 (2) The facility must not interfere with a good faith disclosure of information by an employee, volunteer concerning abuse or other action affecting a resident’s safety or welfare, as described in OAR 411-054-0028(4). (3) The Department must visit and inspect every licensed facility to determine whether the facility is maintained and operated in accordance with these rules. (a) The Department must inspect every facility at a minimum: (A) No less than 90 days and no more than 120 days after an initial license is issued or after a change of ownership of a facility. (B) Upon receipt of a license renewal application fee. (C) For each year during which a facility does not have a full survey, the Department must conduct an in-person inspection of the kitchen and other areas where food is prepared for residents. (b) Inspections may be conducted at other times as determined by the Department. (c) Facilities not in compliance with these rules must submit a plan of correction that satisfied the Department, within 10 business days of receipt of the inspection report. (d) Facilities must correct deficiencies within timeframes outlined in the accepted plan of correction. (e) Failure to be in substantial compliance upon reinspection may result in regulatory action to compel compliance. (f) Achieving substantial compliance is ultimately the facility’s responsibility, whether or not a plan of correction was followed. (g) The Department may impose sanctions for failure to comply with these rules. (4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure the kitchen inspection survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240.

C0455 1) Facility acknowledges that the deficiencies identified in the accepted POC were not completed by the compliance deadline. The Executive Director will oversee completion of all outstanding corrective actions and will implement additional monitoring to ensure that corrections are completed and sustained. The dishwasher temperature guage has been repaired and is in good working order. ED will monitor temp logs daily M-F and dishwasher temp to ensure water temp in within required range and recorded accurately. ED had purchased replacement chemical test strips after first survey but did not confirm expiration date. Test strips were ordered and delivered on 10/08/26. ED opened and confirmed expiration date of 2028 prior to placing in kitchen. ED will confirm with Dining Services Director quarterly on current expiration status of test strips. ED worked with Dining Services Director to ensure that deep clean of walk in walls, floor, ceiling, and racks was completed and being maintained per the kitchen cleaning schedule. ED will do daily inspections to ensure that cleanliness is maintained. ED will be following up daily with Plant Ops Director and regional team on locating vendor who is able to repair and replace broken gaskets or replace the door if parts are not available until repair has been completed. 2) ED will audit kitchen daily, weekly, and monthly cleaning schedules to ensure kitchen is being properly maintained. ED will audit dishwasher temp logs and will check dishwasher temp readings daily M-F to ensure accurate readings are being recorded and temperature is within required range. ED will confirm with Dining Services Director quarterly on expiration date of chemical test strips. ED to follow up daily M-F with Plant Ops Director for updates on freezer door gasket repair, and will monitor affected units and walk in/freezer temperatures and will take appropriate action to ensure food safety when needed. 3)Daily inspection M-F of kitchen and walk in, daily check in with Plant Ops Director for updates on vendor and repair for freezer door gaskets, Quarterly checks on expiration date of sanitation test strips. 4) Executive Director

OAR 411-057-0140(1&6) Administration Responsibilities Temporary rule language in effect until 12/27/2026 (1) The licensee is responsible for the operation of the memory care community and the provision of person centered care that promotes each resident's dignity, independence, safety and comfort. This includes the supervision, training, and overall conduct of the staff. (6) The licensee must ensure that each administrator assigned responsibility for an endorsed memory care community: (a) Has completed and maintains compliance with the administrator qualification, licensure, and continuing education requirements applicable to the facility’s license type, including but not limited to: (A) OAR 411-054-0065 for assisted living facilities and residential care facilities; or (B) OAR chapter 853, division 30 for nursing facilities; and (b) Completes and documents Department-approved training specific to memory care operations, dementia-related risk factors, and the physical design, environment, and safety requirements of this division. (c) Nothing in this subsection alters, replaces or expands administrator licensure, authorization, or examination requirements established under other applicable statutes or administrative rules. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the Kitchen survey, conducted 10/08/26, administrative oversight to ensure adequate kitchen sanitation rendered in the facility was found to be ineffective based on the number of visits. Refer to deficiencies in the report.

Refer to C0455 POC.

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: Based on observation and interview, 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.

Z142 Please refer to C240 POC

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: Based on observation and interview, 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.

Refer to C240 and C0455.