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 a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000 and failed to have effective systems in place to ensure staff were aware of residents’ food allergies to ensure appropriate food was served to residents. Findings include, but are not limited to: Observation of the facility kitchen on 08/10/26, from 10:30 am through 1:30 pm, revealed the following deficient practices: 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: * Metal shelving storing disposable single service cups/lids and other dishes/utensils/supplies; * Interior of ice machine lid; * Wall and piping behind ice machine; * Industrial mixer; * Grease trap; * Interior and exterior of steamer; and * Juice machine area by nozzles. b. Multiple food items were found stored in walk-in cooler and walk-in freezer uncovered and not protected from potential contamination. c. Multiple areas of caulking in the dish machine area found with black debris build-up and in need of repair/replacement. d. The facility did not have a system to effectively communicate the dietary needs of the residents to staff to ensure correct food items were served. At approximately 11:00 am, the surveyor interviewed the cook on duty, who denied any residents with allergies. The cook was not able to effectively demonstrate adequate knowledge of allergens as outlined in Oregon Food Sanitation Rules. The surveyor reviewed the diet book, which contained all the diets for the residents and included type of diet, textures, allergies, and likes/dislikes. There were four residents with a noted food allergy or multiple allergies and one with multiple intolerances. When reviewing the book with the cook on duty, she acknowledged there were multiple residents in the book who were no longer at the facility and the book was not up to date. The cook also acknowledged there were multiple residents that had allergies noted who were still at facility. At approximately 11:30 am, Staff 2 (Executive Chef) was interviewed and acknowledged the facility lacked a visual communication system for diet instructions. She also acknowledged the diet book was not updated. Staff 2 indicated she had been working on developing a system for better communication but had not implemented it yet. Staff 2 showed the surveyor a worksheet she had developed containing allergen/intolerance information, and she immediately posted the worksheet on the service line to ensure staff were able to accurately serve residents according to their needs. Staff 2 acknowledged that the cooks should know allergies and other diet information of the residents to ensure service of correct food items. At 1:00 pm, the surveyor reviewed the identified issues with Staff 1 (Executive director) and Staff 2, who acknowledged the areas of concern.

1. The actions that will be taken to correct the rule violation are: A. The Executive Chef will ensure all cited surfaces and equipment are cleaned and sanitized. A sanitation schedule will identify cleaning frequency. B. Uncovered food will be discarded if safety cannot be verified or placed in covered, labeled, and dated containers. C. Damaged or soiled caulking will be removed and replaced with cleanable, food-service-appropriate sealant. D. The allergy worksheet will be posted and remain available to dining staff. The Executive Chef, RCC, and nurse will reconcile the diet book and service-line list with current resident rosters and orders. The list will be updated after any admission, discharge, transfer, or dietary change. 2. The system will be corrected so the violation does not occur again by: a) The Executive Chef will revise the kitchen opening, closing, and weekly sanitation checklists to include the specific equipment, food-storage, and dish-area conditions cited in the survey. b) All dining staff will take the "food safety fundamentals" relias course to be educated on safe food storage. c) The Executive Chef and Maintenance Director will check weekly that the repaired surface is smooth, intact and cleanable. d) The Resident Care Coordinator or licensed nurse will notify the Executive Chef of every admission, discharge, transfer, and new or changed diet/allergy order on the same shift the change is received. The Executive Chef will update the controlled dining list before the next meal service. 3. The area needing correction will be evaluated by: a) The Executive Chef through a shift checklist daily, and the Executive Director will monitor weekly. Any area out of compliance will be addressed immediately. b) The Executive Chef will monitor repairs weekly through an audit checklist. c) The Executive Chef will monitor the diet/allergy system weekly and after every reported change. 4. The Administrator, Executive Chef and Maintenance Director will be responsible to see that the corrections are completed/monitored.

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: