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 OARs 333-150-0000. Findings include, but are not limited to: On 07/23/26 at 11:10 am, the facility kitchen was observed to need cleaning in the following areas: * Two door refrigerator near service line – bottom shelf with dried food spills; * Coffee counter and shelf below – dried coffee spills; * Commercial stand mixer – food debris/splatters; * Floor drain between ice maker and commercial mixer – brown matter build up; * Exterior and lid of bulk container holding brown sugar – dried food debris build up; * Small counter mixer – food splatters; * Lower and upper shelves throughout kitchen – spills/splatters/debris; * Interior of microwave – food splatters; * Hood vents above cooking equipment – dusty/greasy; * Operating fan in food prep area – dusty; * Behind steamer – build up of black matter; * Bulk bin lids – food debris build up (flour/granulated sugar/oats); * Dishwashing area – black matter build up on walls above back splash and caulking/dried debris on top of dishwasher; * Commercial can opener blade – build up of black matter; and * Flooring throughout the kitchen including under and behind equipment and counters – debris/dried stains/spills/food debris/black matter. Improper food storage included: * Scoop/cups stored in bulk food containers – dried cereal/pecans/brown sugar/flour; * Walk in refrigerator uncovered/undated food items - bean salad/two jello/tray of desserts/pitcher of tea; * Two door freezer – uncovered tray of desserts; and * Sack of onions on floor across from freezer units/open bag of powdered sugar on floor in dry storage. Other areas of concern included: * Garbage cans without lids when not in use. * Ceiling lights throughout the kitchen without covers. The areas of concern were observed by, discussed with and acknowledged by Staff 1 (Lead Cook) at 12:30 pm on 07/23/26. Findings were also discussed with Staff 2 (Lead Resident Care Coordinator and Staff 3 (Culinary Service Director from sister community) on 07/23/26. The findings were acknowledged by Staff 2 and 3 at 12:45 pm.

1. A deep clean of the kitchen to address all areas outlined in the SOD was completed on 8/5/2026 with oversight from Area Director of Culinary Services. Garbage lids were affixed to the garbage cans on _________ by the _____. Ceiling light covers were ordered on 8/5/2026 and expected deliver is 8/11/2026. Upon arrival, covers will be installed by the Maintenance Director. 2. ED or Designee will re-educate all culinary staff on daily, weekly and monthly cleaning schedules and will implement by 8/14/2026. ED or Designee will re-educate staff on proper food storage to include labeling food items, covering food items, and stoarge of scoops/cups used for dried bulk products by 8/14/20206. ED/Designee will educate all staff regarding garbage cans being covered by 8/14/2026. 3. Once training is complete, ED or Designee will audit cleanling logs and do spot checks on a daily basis for 2 weeks, then a weekly basis for 4 weeks, then a bi-monthly basis going forward. 4. ED/CSD/designee are responsible for attaining and maintaining compliance.

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 OARs 333-150-0000. This is a repeat citation. Findings include, but are not limited to: On 09/23/26 at 9:15 am, the facility kitchen was observed to need cleaning in the following areas: * Dish area at main entrance to kitchen: the trash can, rolling cart, walls, flooring and baseboards had an accumulation of food spills and splatters; * Two-door refrigerator near service line – bottom shelf had dried food spills; * Coffee counter and shelf below – dried coffee spills; * Floor drain between ice maker and commercial mixer – black matter build-up; * Lower and upper shelves throughout kitchen – spills/splatters/debris; * Interior ceiling of microwave – food splatters; * Black fan in food prep area – dusty; * Bulk bin exteriors – food debris (flour/granulated sugar/oats); * Dishwashing area – black matter build-up on wall above backsplash and caulking, black matter and food debris on wall underneath sink area; and * Tile flooring and grout throughout, including under and behind equipment and counters, walk in fridge, dry storage room, and dish machine area – debris/dried stains/spills/food debris/black matter. Other areas of concern: Staff 1 (Lead Chef) had facial hair that was not covered. The areas of concern were observed by, discussed with, and acknowledged by Staff 4 (Business Office Manager) at 10:00 am on 09/23/26.

A deep cleaning of the kitchen floor will be completed by 10/3/2026. The Executive Director (ED) or designee will provide re-education to all dietary staff by 10/10/2026 regarding the supplemental daily cleaning log created to address the items identified in the Statement of Deficiencies (SOD). The education will include expectations for completing and documenting all required cleaning tasks. The ED or designee will review the supplemental daily cleaning log daily for 14 days, weekly for 4 weeks thereafter, and then every other week on an ongoing basis to ensure compliance and completion of all assigned tasks. The ED or designee will also provide re-education to all dietary staff by 10/1/2026 on the proper use of hair restraints, including hair nets for both head hair and facial hair, to ensure compliance with food safety requirements.

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 correct deficiencies within the timeframes outlined in the accepted plan of correction. Findings include, but are not limited to: Refer to C240.

Refer to C240.