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 ALF kitchen on 09/17/26, from 10:50 am through 1:00 pm, revealed the following deficiencies: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and black and/or grey biological matter was visible on or underneath the following: * Range top; * Range top drip pans; * Industrial can opener; * Ceiling vent above the ice machine; * Flooring between work spaces and walls; * Interior of the ice machine; * Walk-in cooler pipes; * Walk-in cooler fans and cages; * Walk-in cooler metal racks; * Door edges and seal to walk-in cooler; and * Walk-in cooler floors under racks and along the edge of the floor where it met the wall. wall/floor edges; b. The following needed to be repaired: * Multiple metal racks in the walk-in cooler were rusty and the protective coating was peeling off, so the racks did not have a smooth and cleanable surface; * Multiple pipes and hoses from the dish machine were inside the floor drain, not allowing for adequate back flow prevention; * The seal to the ice machine was damaged; and * The seal on the door to the walk-in cooler was damaged. c. A cook was observed preparing and serving food without wearing a facial hair restraint. 2. Memory Care Kitchenette: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and black and/or grey biological matter was visible on or underneath the following: * Interior of the microwave; * Interior of the reach-in refrigerator; * Interior of the reach-in freezer; * Interior of drawers storing food or clean equipment; * Interior of cabinets storing food or clean equipment; * Interior of the dishwasher; * Interior and exterior of the insulated food cart; and * The grey utility cart. b. The following needed to be repaired: * The cabinet under the sink had water damage, creating exposed porous wood; * The industrial dishwasher was not operating correctly, yielding zero parts per million of sanitizing chemical; and * The reach in refrigerator was not holding at 41 degrees F or less. c. A care staff was observed plating food without a facial hair restraint. d. A staff member was checking temperatures of lunch food items and did not sanitize the thermometer probe before, between, or after checking items, potentially contaminating the food. e. The reach-in refrigerator was at 48 degrees Fahrenheit. The surveyor tested the temperature of the cream cheese container inside the refrigerator and it was also 48 degrees F. There was no documented evidence the facility had a system in place for monitoring cold food storage in the unit. Staff 2 acknowledged that she and that the kitchen staff were not monitoring the temperature of the refrigerator, and she did not know how long the food had been stored at inappropriate temperatures. e. The dishwasher chemical sanitation was checked, and it was not registering any parts per million of sanitizing solution. Unit staff were interviewed and indicated they were not monitoring the sanitation solution of the dishwasher. There were no test strips available in the unit to monitor the sanitation solution. Staff 2 acknowledged that kitchen staff were not monitoring the dishwasher in the unit and were unaware it was not sanitizing or that there were no test strips in the unit to monitor the sanitation solution. f. Staff were observed transporting multiple lunch dishes that were not covered to residents’ rooms. Staff were unaware of the need to protect food from contamination during transport to resident rooms. At approximately 12:30 pm on 09/17/26, the surveyor reviewed the above areas with Staff 2 (Dietary Services Manager), who acknowledged the findings. At 1:00 pm, the surveyor reviewed the identified areas with Staff 1 (Administrator), who acknowledged the findings.

Areas found to be out of compliance referenced in Section 1, subsections A, B, & C as well as Section 2, subsections A-F will be cleaned, corrected, repaired and replaced as applicable by 11/16/26. Dietary director and Memory Care director will use Quality Assurance Tools (Food Sanitation Audit, Monthly Quality Assurance Program Audit, and Cleaning Checklist) per Prestige policy to do monthly and weekly audits of Kitchen and Memory Care Kitchenette to ensure ongoing compliance with OAR's 333-150-0000 and 411 Div. 57. Executive Director will be responsible for continued compliance through weekly meetings with dietary and memory care directors, kitchen walkthroughs and quality assurance audits. Items referenced in section 1.a. in need of cleaning have been cleaned as of 10/5/26, with a deep clean of full kitchen and kitchenette scheduled for 10/25/26 and quarterly thereafter. Items referenced in section 1.b. are being addressed as follows: -New metal racks for walk in cooler were ordered on 10/5/26. Old racks will be removed and replaced with new upon their arrival. -Pipes ande hoses hanging in drain will be shortened in length to allow adequate back flow prevention by 11/1/26. -Equipment Vendor will be out to repair seal on ice machine and walkin cooler by 10/16/26. Item referenced in section 1.c is being addressed as follows: -Presence and availabilty of facial hair restraints has been verified by Dietary director and Executive Director. Staff received verbal coaching for the use of facial hair restraints on 9/18/26. Use of facial hair restraints will be reinforced with staff retraining at staff meeting on 10/19/26. Items referenced in Section 2.a. will be addressed as follows: -Cleaning list for memory care kitchenette has been revised to include all items referenced. -Dietary director and Memory Care director will receive training on utilizing the kitchen sanitation audit to ensure all areas of kitchenette meet required regulation. -Staff training scheduled for 10/19/26 to train on new cleaning checklist and expectations. Items referenced in Section 2.b will be addressed as follows: -Cabinet under sink will have surface refinished and liner placed to prevent further water damage and maintain a cleanable surface. -Dishwasher vendor will be coming to repair dishwasher on or before 11/1/26. In the interimof the memory care dishwasher being repaired, all dishes are being transported to the main kitchen for washing. -Upon repair of memory care dishwasher staff will be retrained on proper usage and testing. -Reach in refrigerator has been adjusted to proper temperature and temperature logs put in place to ensure ongoing monitoring of safe temperatures as of 9/18/26. Item referenced in section 2.c is being addressed as follows: -Presence and availability of facial hair restraints has been verified by Dietary Director and Executive Director. Staff received verbal coaching for the use of facial hair restraints on 9/18/26. Use of facial hair restraints will be reinforced with staff retraining at staff meeting on 10/19/26. Item referenced in Section 2.d. are being addressed as follows: -Staff training on proper use and sanitation of thermometers done on 9/18/26. This policy will also be reviewed with all staff at meeting on 10/19/26. Item referenced in Section 2.e have been addressed as follows: -Refrigerator temperature setting was adjusted on 9/17/26 and temperature log put into place with staff trained to check temperature and log daily to ensure safe temperatures. -Dietary Director and Memory Care director will audit this weekly to ensure continued compliance. Item references in Section 2.e has been addressed as follows: -Equipment Vendor will be coming to repair dishwasher on or before 11/1/26. Upon repair staff will be trained on procedure for testing machine for proper sanitization. Item references in section2.f has been addressed as follows: -Staff have received training on the need to cover any food leaving the dining area and dome lids have been provided for use as of 10/5/26. This procedure will be reviewed at staff meeting on 10/19/26.

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 C 240