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: Observations of the main kitchen and MCC kitchenette were made on 07/29/26, between 10:45 am and 01:00 pm, and the following were noted: Sanitation and Equipment: *The molding on the wall near the floor beside dish machine was missing a section; *There were potatoes stored on the floor in the pantry; *There was a sponge used for washing dishes; *There was no designated handwashing sink; *Dishes had not been sanitized; *Refrigerator temperatures were below requirements and had not been monitored; *Dish machine temperatures had not been monitored; and *Chemical pH for non-food contact surfaces had not been monitored. At approximately 11:00 am, surveyor observed dishes air drying on the rack on the counter beside the handwashing sink which had dirty dishes in it. Staff confirmed that the dishes had been manually washed and not sanitized because the dishwasher was full and/or they were too large for the dishwasher and/or compartment sink. Staff acknowledged there was not a system in place to monitor and sanitize dishes and planned to implement one. At approximately 11:15 pm, surveyor observed refrigerator at 45 degrees F. A second thermometer was placed, and both thermometers were at 50 degrees F. The temperature log from 07/01/26 to 07/29/26 was reviewed and revealed no recordings. Food and beverages were discarded from the refrigerator, and staff were instructed not to use it until it was repaired. At approximately 12:00 pm, surveyor observed a cook touching a biscuit, a butter knife and the handle to open silverware drawer repeatedly wearing the same gloves. Surveyor provided education and requested the gloves be changed at the change of task. The areas of concern were discussed with Staff 1 (ED) and Staff 2 (Regional Operations Manager) at approximately 1:00 pm on 07/29/26. Staff acknowledged the findings.

1a) Purchased a sanitizing “bussing” bin to be able to provide the 3 sink process to sanitize oversized dishes and utensils. 1b) Purchased a new thermometer for each fridge. One fridge was replaced. All staff were trained on 7/30 on temping and what to do when it’s too high or too low. 1c) Molding near underneath the dishwasher has been replaced. 1d) Hard plastic bin was purchased to store potatoes in. 1e) All staff have been trained and instructed to use handwashing sink only for handwashing. 1f) Dishwasher temp strips were purchased and temp log put in place. 1g) Placed chemical testing logs for staff to complete upon refilling hard surface cleaning spray bottle. Chemical testing strips provided to staff with logs. 1h) All staff were trained on 7/30 on cross-contamination and proper use/disposal of gloves. Assigned all staff an Oregon Care Partners class on food safety. 2a) All staff are trained on the 3 sink process on how to use and will use for all oversized dishes and utensils. 2b) Thermometers will be checked by Executive Director weekly to ensure they are working properly. Executive Director/Assistant will spot check temp log to ensure staff are documenting consistently. 2c) Staff will notify maintenance immediately if any molding is missing. 2d) All potatoes will be stored in plastic bin. 2e) All Staff were trained on 7/30 and spot checks will be done daily. 2f) All staff have been trained on how to use dishwasher strips and how to document. 2g) All cleaning on non-food contact surfaces will be done daily using tested hard surface cleaning spray with chemical strips and a date placed for every refill of the bottle. Chemical testing log will be filled out by care staff. 2h) Food safety training quarterly with all staff. 3a) Executive Director/Assistant will spot check 3 times a week for one month and then once a month after. 3b) Weekly, 3 times a week. 3c) Maintenance will evaluate and replace molding as needed. 3d) Executive Director and Assistant will spot check weekly. 3e) Daily. 3f) Temp logs will be audited monthly. 3g) Spot checks 3 times a week. 3h) Weekly for one month then quarterly. 4a) Universal caregivers and Executive Director/Assistant 4b) Universal caregivers, Executive Director and Assistant. 4c) Universal caregivers and Maintenance. 4d) Executive Director/Assistant, Universal caregiver 4e) Executive Director/Assistant. 4f) Executive Director/Assistant 4g) Executive Director/Assistant 4h) Executive Director/Assistant, universal caregivers

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: 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.

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: