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 the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main food prep kitchen, individual house kitchens and food storage areas on 09/03/26 at 10:15 am through 2:15 pm revealed the following: 1. Main Food Preparation kitchen (House 960) a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on/around or underneath the following: * Walls; * Kitchen drains; * Floors under/behind equipment; * Industrial can opener and housing; * Shelving in dry storage area; * Ceiling vent above food preparation areas; * Reach-in cooler; * Rack holding clean/sanitized dishes; * Windowsill; * Air conditioning unit; * Handwashing sink; * Spray nozzle and handle attached to handwashing/prep sink; * Kitchen floor; * Interior of ovens; * Stove top; * Drip pan under stove top; * Light fixtures; * Ceiling vent above dishwashing area; and * Interior of black insulated food transportation cart; b. The following was observed needing to be repaired: * Floor drain under handwashing/prep sink with visible signs of overflow; * Drain to prep sink downspout reaching inside of floor drain without proper air gap as required; * Door to outside with visible leaking gutter from blockage causing flooding into back door of kitchen; and * Wood around back door frame with visible rot/damage and in need of repair/replacement. Multiple kitchen staff stated that water from outside rain gutter floods into the kitchen when it rained causing the kitchen floor to flood. Kitchen staff stated this occurred frequently with heavy rain. Surveyor visualized evidence of full/clogged gutters outside the kitchen door along with visible damage to the door frame to the kitchen. c. Multiple items were found in reach-in cooler without open dates. Multiple items were found opened past seven days and needed to be discarded. A large container of shredded cheese was found open and not protected from potential contamination when stored. Two large baking pans of cooked breadsticks were found stored in dry storage area uncovered and not protected from contamination. d. Five packages of sliced deli sandwich meat was observed in a plastic container sitting on the counter top. Staff 2 (Cook/Dedicated Person In Charge) was interviewed and stated they were defrosting for the evening/dinner meal. Staff 2 stated those items were pulled and placed on the counter at 6:00 am. Staff 2 confirmed the items were not defrosted under cold running water. Staff were instructed to immediately return the food items to cold food storage. Five packets of frozen soup product and three packets of frozen imitation crab were observed sitting on a black utility cart outside of the kitchen for greater than an hour. Staff indicated they did not have adequate preparation sinks to quick thaw items under cold running water. e. Kitchen did not have a dedicated hand washing sink. Staff were using the sink under the window for both handwashing and food preparation. f. Staff drinks were found stored in reach-in refrigerator where resident food was stored. Staff drinks were not in approved containers, causing potential hand-to-lip contamination. g. Multiple pots, pans, and baking equipment were found blackened and with large amounts of baked on grease, food debris, and/or carbon deposits. Cutting boards were noted with heavy staining and deep scoring and in need of repair or replacement. Multiple dishwashing scratcher pads were noted heavily worn and in need of replacement. h. Staff personal items (coats, phone, drinks, etc) were observed stored next to spaces where cleaned/sanitized equipment was kept. A bottle of staff ibuprofen was observed stored on a shelf where there were spices and other cooking equipment located. i. Facility did not have chemical test strips to ensure dishes were effectively sanitized. Staff acknowledged they were not monitoring dishwashing sanitation. Staff did not correctly use three compartment sink method when sanitizing large equipment. They were not allowing items to soak in sanitizer for appropriate contact time to sanitize dishes. j. Multiple kitchen staff were not able to demonstrate effective knowledge of foods appropriate for residents with lactose intolerance. Staff prepared an alfredo sauce for residents with lactose intolerance. Surveyor reviewed the ingredients of the package that stated the product contained milk products. k. Upon entry no surface sanitizer bucket was located for staff to use to sanitize surfaces. A wet rag was observed lying on the counter top and staff was observed to wipe a thermometer probe with the rag on the counter top after checking the temperature of the chicken pasta sauce. 2. House 950 An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on/around or underneath the following: * Ceiling vents; * Industrial can opener and housing; * Industrial mixer; * Removable hood vents; * Ovens; and * Windowsill. 3. House 940 a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on/around or underneath the following: * Juice machine area by nozzles; * Grill top; * Grease trap; and * Stove top. b. Sink down spouts reaching inside of floor drain did not have the necessary air gap to prevent cross contamination. c. Multiple potentially hazardous food items were not dated when opened and/or prepared. Food items were past seven days or past manufacturer’s use by date and needed to be discarded. 4. House 920 a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on/around or underneath the following: * Free standing fan blades and cages; * Interior of reach-in refrigerator; * Plastic container storing silverware; * Walls; * Window and windowsill; * Floor drain under dishwasher; and * Juice machine by nozzles. b. Door to restroom in the kitchen area was open. Any restrooms located in food preparation/storage/service areas the door must be kept closed. c. Multiple potentially hazardous food items were not dated when opened and/or prepared. d. Food items in the reach-in refrigerator were not properly closed or covered to protect them from contamination when stored. e. Microwave oven was noted damaged, rusted and corroded on the interior top and in need of replacement. f. Window open without screen allowing entry of pests and insects. g. There were no test strips in the kitchen to monitor the dishwashing machine to ensure it was operating effectively. Staff acknowledged they were not monitoring the sanitation levels of the dish machine. h. Multiple drain down spouts or hoses were observed reaching in the floor drain below the floor surface not allowing for an effective air gap. i. Food items (salads, desert, beverages) were observed delivered to residents’ rooms uncovered and unprotected from contamination. 5. House 910 a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on/around or underneath the following: * Stainless steel sink; * Interior of reach-in refrigerator; and * Wall behind trash can; b. A trash can was observed full of trash with some food debris that did not have a lid as required. A container storing recyclable bottles/cans was also observed without a tight fitting lid. c. Potentially hazardous food items were found stored in the reach-in refrigerator without date open or date prepared. d. Plastic single use utensils were observed stored in a container without a lid allowing the food contact surfaces to be exposed to contamination. Visible food/dirt particles were observed inside the container. e. There was no dedicated hand washing sink. Kitchen staff did not wash hands or otherwise sanitize hands when entering the kitchen before starting to serve lunch. f. No surface sanitizer bucket or system to sanitize surfaces was identified. g. There were no test strips in the kitchen to monitor the dishwashing machine to ensure it was operating effectively. Staff acknowledged they were not monitoring the sanitation levels of the dish machine. 6. Food storage area in House 960 a. Food stored in reach-in freezer not stored in a manor to prevent contamination from frozen open raw meats and other food items. b. No thermometer was found in reach-in refrigerator storing dairy foods. At approximately 2:00 pm surveyor reviewed above areas with Staff 1 (ED) who acknowledged identified areas.

HOUSE 960 - MAIN FOOD PREPARATION KITCHEN 1(a): All identified surfaces, equipment and areas will be cleaned and added to cleaning schedules. Cleaning logs will be completed each shift and reviewed weekly by the Dietary Manager and/or Executive Director. 1(b): Identified drain/air-gap concerns will be repaired. The blocked gutter and damaged/rotted area around the back kitchen door will be repaired/replaced; contractor quotes are being obtained as needed. 1(c): Staff will be educated on proper dating, storage, covering and protection of food, including storage timeframes and use-by dates. 1(d): Staff will be educated on approved thawing methods. Food will not be thawed on counters or carts outside of temperature control. 1(e): Quotes are being obtained for installation of a dedicated handwashing sink. Staff will be educated on appropriate handwashing practices and use of designated sinks. 1(f): Staff beverages will be stored in designated areas and approved containers. 1(g): Pots, pans, baking equipment, cutting boards, scratch pads and other kitchen items that cannot be effectively cleaned/sanitized will be replaced and replaced again as necessary. 1(h): Staff personal items and medications will be stored outside food preparation, food storage and clean-equipment areas. 1(i): Chemical test strips have been purchased. Staff will be trained and competency checked on dish-machine sanitation, three-compartment sink procedures and required sanitizer contact time. 1(j): Staff will receive training and competency review regarding lactose intolerance and other resident-specific diets ordered/recommended by dietitians and PCPs. 1(k): Sanitizer buckets will be available and staff will be trained on proper use/storage of wiping cloths and sanitation of thermometer probes. HOUSE 950 2: Identified ceiling vents, can opener/housing, mixer, hood vents, ovens and windowsill will be cleaned and incorporated into cleaning schedules. Cleaning logs will be completed each shift and reviewed weekly. HOUSE 940 3(a): Identified juice machine/nozzles, grill top, grease trap and stove top will be cleaned and incorporated into cleaning schedules. 3(b): Sink downspouts will be corrected to maintain the required air gap. 3(c): Staff will be educated on proper dating, storage timeframes and manufacturer use-by dates. Management walkthroughs will monitor compliance. HOUSE 920 4(a): All identified surfaces/equipment will be cleaned and incorporated into cleaning schedules. 4(b): The restroom door in the kitchen area will be maintained closed; an automatic closer will be installed/used as needed to maintain compliance. 4(c): Staff will be educated on proper dating of potentially hazardous foods. 4(d): Staff will be educated to keep refrigerated foods properly closed/covered to prevent contamination. 4(e): The damaged/rusted microwave has been replaced. 4(f): Screening for the open window has been replaced/provided. 4(g): Chemical test strips have been purchased and staff will be trained and competency checked on monitoring dish-machine sanitation. 4(h): Drain downspouts/hoses will be corrected to maintain effective air gaps. 4(i): Staff will be educated to cover/protect food during delivery to resident rooms. HOUSE 910 5(a): Identified sink, refrigerator interior and wall surfaces will be cleaned and incorporated into cleaning schedules. 5(b): Trash and recycling containers will be replaced with containers having appropriate lids. 5(c): Staff will be educated on proper dating of potentially hazardous foods. 5(d): Single-use utensils will be stored in drawers or covered containers that protect food-contact surfaces. 5(e): Quotes are being obtained for installation of a dedicated handwashing sink. Staff will be educated and competency checked on hand hygiene before food service and when entering the kitchen as required. 5(f): Sanitizer buckets/systems will be available and staff will be educated and competency checked on proper surface sanitation. 5(g): Chemical test strips have been purchased and staff will be trained and competency checked on monitoring dish-machine sanitation. HOUSE 960 - FOOD STORAGE AREA 6(a): Staff will be trained and competency checked on storage of frozen and fresh foods to prevent cross-contamination. 6(b): Thermometers have been purchased and placed in refrigerators/freezers. Temperature logs will be completed each shift and monitored by the Dietary Manager and/or Executive Director. 2. To prevent recurrence, cleaning logs will be completed each shift; environmental/kitchen walkthroughs will be completed weekly; food-safety and sanitation practices will be monitored using the kitchen sanitation audit tool; and identified physical plant items will be tracked through completion. 3. Cleaning logs will be reviewed weekly. Environmental/kitchen sanitation audits will be completed weekly and identified corrective actions will be followed through to completion. 4. The Dietary Manager will be responsible for routine kitchen sanitation, staff education/competency and review of cleaning and temperature logs. The Executive Director will provide oversight and will monitor physical plant/maintenance corrections and unresolved deficiencies.

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.

Refer to above C0240