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 good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observations of the facility kitchen and two unit kitchenettes were made on 08/18/26 from 10:55 am through 1:30 pm and found the following: 1. Main Kitchen a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, and/or black or white organic matter was visible on or underneath the following: * Top of dishwasher; * Walls and floors in dishwashing area; * Industrial floor/carpet fan stored in kitchen; * Walls behind ice machine; * Flooring under ice machine; * Kitchen drain under ice machine; * Metal shelving/racks storing clean dishes/supplies; * Industrial can opener and housing; * Industrial mixer; * Industrial slicer; * Toaster; * Wall beside steam table; * Interior of steam table wells; * Open stainless steel shelving/tables; * Stainless steel table legs; * Floor between steam line and cooking equipment grout lines; * Utility carts; * Interior of microwave; * Plastic trays on top of tray line storing misc items; * White plastic edging on top of tray line area; * Walk in cooler floors under racks; * Walk in cooler metal racks; * Walk in cooler fan cages; * Kitchen drains; * Interior of ovens; * Grill top, edges, sides and grease trap; * Wall behind ovens/grill; * Floor under and behind ovens/range/grill; * Ceiling vents/tiles; * Flooring under steam table; * Flooring in dry storage; and * Blue lids of bulk dry storage bins. b. The following areas were in need of repair: * Grout missing or low on section of tile between cooking equipment and steam line; * Walls in kitchen with scraped/scratched paint or wall damage; * Area in dry storage with gaps around pipes entering/exiting walls; and * Microwave with rusted areas. c. Ice machine drain with multiple hoses/tubes observed stored directly inside the drain. d. Utility cart noted to be damaged with multiple scoring marks or pealing plastic making the cart an unsmooth surface. Multiple scoop handles found damaged/peeling and in need of replacement. Multiple hot mitts found with holes and burn marks and in need of replacement. Multiple cutting boards were observed heavily scored or stained and in need of repair or replacement. e. Single use plates were found stored with food contact surfaces exposed to potential contamination. Mixing bowl and utensils and slicer were noted to be stored uncovered and not protected from contamination. f. Dish washing staff was observed handling clean dishes with a dirty shirt with wet splatter and food debris visible from his dish washing task. g. Staff washing dishes was observed to wash dirty dishes and contaminate his hands, then touch clean/sanitized dishes contaminating them from the dirty task. Surveyor interviewed the staff and he was unaware of the need to wash hands between washing dirty dishes and then handling clean items. h. Staff washing dishes did not use a facial hair restraint when handling clean and sanitized equipment. i. Multiple heavily dented cans were observed stored with regular undamaged stock in the dry storage area. Staff 2 (Cook/Person In Charge upon survey entrance) was interviewed and stated they were not aware that damaged cans could not be used or stored with ready to use products. Four large containers of salad dressing clearly labeled “Keep refrigerated” were observed stored unrefrigerated in dry storage area. Staff 2 was not aware those needed to be refrigerated when not open. These items were greater than 4 hours out of refrigeration and were discarded. Staff 3 (Food Service Designee), acknowledged the above items were not stored properly. j. Staff 2 was not able to effectively demonstrate adequate knowledge of effective cooling practices including the two-step method. She could not demonstrate the proper reheat temperature. k. Vegetable for lunch meal was observed to be cooked past doneness and was noted to be overly soft and of a mushy texture. The items were a squash mixture with asparagus. Individual vegetables were not visible as they were blending together due to loss of structural integrity. These vegetables were not palatable or prepared in a way to preserve their nutritional integrity. Staff 3 was shown the vegetables and agreed they were overcooked and likely not palatable. l. Multiple potentially hazardous food items were found in walk in cooler without open or prepared dates. Some items were found past seven days from preparation or past the printed use by dates. 2. Clair unit: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, and/or black or white organic matter was visible on or underneath the following: * Interior of reach in refrigerator; * Floors in kitchenette; * Floors under tables in dining room; and * Interior of drawers and cabinets in kitchenette. b. The following areas were in need of repair: * Cabinets storing clean dishes were heavily damaged and did not have a smooth/cleanable surface. * Walls in kitchenette with damaged/worn or scraped paint; and * Section of cove base/base boards missing in thresholds to dining area. c. Multiple potentially hazardous food items noted without open dates. d. Multiple food items were found past manufacturers’ use-by dates and in need of disposal. e. Large box of health shakes was observed without pull dates or expiration dates. Staff were unaware of dates the products needed to be used or discarded by. 3. Bridge unit: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, and/or black or white organic matter was visible on or underneath the following: * Interior of reach in refrigerator; * Floors in kitchenette; * Interior of microwave; and * Interior of drawers and cabinets in kitchenette. b. The following areas were in need of repair: * Cabinets storing clean dishes were heavily damaged and did not have a smooth/cleanable surface. * Walls in kitchenette with damaged/worn or scraped paint; and * Section of cove base/base boards missing in thresholds to dining area. c. Multiple potentially hazardous food items noted without open dates. d. Multiple food items were found past manufacturer’s use by dates and in need of disposal. e. Large container of health shakes was observed without pull dates or expiration dates. Staff were unaware of dates the products needed to be used or discarded by. At approximately 1:30 pm, surveyor reviewed above areas with staff 1 (Designated kitchen Person in Charge and Facility designee for kitchen survey) who acknowledged the identified areas.

Conducted in-service training with dining staff and care staff on 8/18/2026 in the following areas: -Handwashing/Use of gloves -Use of thermometers -Cooling/Chilling product -Use of hair restraints -Leftovers -Butler Kitchen/Main Kitchen labeling and dating completed including health shakes On 8/27/26 Proctored ServSafe Food Manager for Diana (Billing Office Coordinator/Executive Director) scored 95% Posted daily, weekly and monthly deep cleaning task sheets and the following were cleaned and scheduled to be cleaned after use and on a weekly basis: Cleaned Can opener, storage bins, wire racks in cooler, top of line and spice trays, grease traps under top and burners and mixer and toaster Cleaned flat-top grill and burners-scheduled daily. On 8/24/26 ordered new service cart, bowls, untensils, microwave, oven mits via Direct supply waiting on delivery Collaberated with building Maintenance Director Bret and leadership on getting quotes for floor deep clean and grout leveling, seal in dishroom, cabinets in bulter kitchens, air gap in storeroom, painting dining doors, walls, dining room walls, and bottom trim in dining rooms to be repaired. All work orders are submitted and elevated to critical. Conducted training on 8/24/26 with cooks on vegetable cooking times and textures. Removed kitchen floor fan and slicer on 8/28/26 Trained Cook in proper food storage and refusing unfit product on 8/26/26 Deep Cleaned dish area including floors on 8/27/26- scheduled daily Cleaned floor drains on 8/27/26- scheduled weekly Cooler fan scheduled to be cleaned on 9/1/26 and scheduled weekly *All cooks trained in proper food storage on 8/26/26 and will review during inservice on 9/16/26. The dry storage area was organized and labeled on 9/11/26 and a separate area was identified for storage of dented cans and signs posted. This will be audited weekly by DSC/ED. *All cooks have completed training in proper cooling practices and the reheating process through the ServeSafe course and are now certified. *All kitchen and care staff have been trained in the proper dating and labeling protocol. New labels have been acquired and signs posted as a reminder. The DSC/ED will audit twice weekly. The Dining Service Director and Executive Director are responsible to ensure corrections are completed and maintained.

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 observations and interviews, 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 plan of correction for 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: