Print Inspection: KIT001902

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, interview and record review, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair, kitchen staff did not follow hygienic practices, and proper food handling procedures were not followed in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 12/26/24 at 10:02 am the main kitchen, walk-in refrigerator and freezer were observed to need cleaning in the following areas: a. Kitchen area: * Pooling of a large amount of charred oil was observed on the floor on either side of the stove; * Pipes behind multiple appliances had grease, dirt, and debris on them; * Cooktop knobs and handles had sticky matter, built-up grease and dried food debris on them; * Interior walls of the ice-maker machine had unidentified yellow residue; * Cooktop and burners were covered with burnt-on grease and other residue; * Range hood filters were covered with grease; * Air return duct cover above the tray line was covered with dust; * Cooling racks had rust on them; * Waffle iron was covered with dirt and grease; and * Knobs, doors, and handles of various kitchen appliances were missing or covered with grease. b. Walk-in refrigerator and freezer: * Refrigerator and freezer cooling unit fans had a layer of dust and dirt. Ready-to-serve items stored under the cooling unit in the refrigerator were uncovered and open to direct dust and debris contamination from blowing fan; * Liquid discharge from box of defrosted meat products had leaked onto the refrigerator floor; and * Exterior surfaces and handles were covered with sticky residue. On 12/26/24 at 10:02 am, the main kitchen was observed to need the following repairs: * The molding around the door frame connecting the sous chef office and the main kitchen was missing and/or damaged, exposing underlying drywall and holes in the wall; * Holes in the ceiling up to approximately 6 inches surrounded the copper pipes from various appliances; * Displaced ceiling tile in dishwashing room in the far left corner exposing ventilation duct; * Drop ceiling tiles were cracked, missing, or out-of-place; and * Cabinets under serving station were missing doors. On 12/26/24 at 11:00 am, the following improper food handling practices were observed: * Multiple kitchen staff was observed using single-use gloves for multiple tasks, including food handling, cooking and operating appliances; * Industrial mixer was not covered when not in use as required; * Individual portions of food were plated on trays in the walk-in refrigerator and left uncovered; and * Multiple food items in the walk-in refrigerator and walk-in freezer were found not dated and only partially wrapped. Bulk food items were found not dated after opening. Kitchen staff was observed not following proper hygienic practices: * Kitchen staff were not wearing aprons when cooking and serving food; and * Three garbage cans in the kitchen were not covered with lids when not in use. Staff 5 (Cook), Staff 6 (Cook), and Staff 7 (Cook) did not have current food handler's permits. The findings were discussed with Staff 1 (Associate ED) and Staff 2 (Sous Chef) on 12/26/24. Both staff acknowledged the findings. c. On12/26/24 from 10:00 am to 10:10 am, an inspection of the kitchenette area in the memory care was conducted. The following observations were made: * A brown substance was present underneath the sink; * Five beverage jars in the refrigerator were uncovered and undated; * Premade thickened liquid beverages were open, but lacked labeling or dates; * The interior of the microwave in the second dining room was stained with a brown residue and the exterior surface was sticky to the touch; and * Cabinets and drawer surfaces were sticky to the touch and contained open salt and sugar containers in the drawers. In an interview on 12/26/24 at 11:24 am, Staff 4 (MT) stated “never made it clear” who was responsible for cleaning the refrigerator. The areas that required cleaning were observed and discussed with Staff 3 (Connections for Living Director) on 12/26/24 at 12:18 pm. The staff acknowledged the area needed cleaning. d. The MCC had 15 residents at the time of survey. There were 11 residents in the dining room for lunch on 12/26/24 and lunch service was observed from 11:47 am through 12:07 pm. During the observation, a caregiving staff provided 1-on-1 meal assistance to a resident. The caregiving staff was not wearing an apron or other type of barrier to prevent the potential cross contamination when providing meal assistance. Staff were observed setting tables with napkins and silverware, serving meals and beverages, and then clearing dirty dishes. During the process, staff touched residents, handled sandwiches on plates, and moved in and out of the dining room to retrieve juice and milk. Meals were served to residents without the staff changing their gloves or performing proper hand hygiene. The above observation was discussed with Staff 3 on 12/26/24 at12:23 pm. The staff acknowledged the findings.

Section a: Kitchen Area Q1. What Actions will be taken to correct the rule Violation? The team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Daily cleanings according to policy have been implemented. An after hours deep clean of the kitchen and appliances is scheduled for January 18th to ensure kitchen is in compliance. A Back of House All Staff meeting is scheduled for January 20th re-educate staff on compliance policies and procedures. Q2. How will the system be corrected so the violation will not happen again. The Food & Beverage Director is accountable to all Dining Dept. policies and procedures as well as Oregon Administrative Rules. As such, we have had turnover in the position and the new Director will ensure compliance utilizing all available resources. The team will receive ongoing and adequate support to ensure sustainable compliance. Director, Sous Chef, Lead Cooks will review prior day's logs and perform visual inspection to confirm compliance and take corrective action immediately if found to not be in compliance. a. All cleaning, temperature, and other relevant logs are confirmed to be in their accurate locations, accessible, and clear. b. Cleaning schedules and assignments have been posted for the kitchen and dining room areas. Each item needing to be cleaned and the frequency of cleaning are included on the cleaning schedule. c. Monthly In-service for Dining staff has been scheduled and attendance is mandatory. Q3. How often will the area needing correction will be evaluated? Daily through substantial compliance. Ongoing per policy for the areas/equipment being evaluated. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance January 31, 2025 Section b. Walk-in refrigerator and freezer: Q1. What Actions will be taken to correct the rule Violation? The team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Daily cleanings according to policy have been implemented. An after hours deep clean of the kitchen and appliances is scheduled for January 18th to ensure kitchen is in compliance. A Back of House All Staff meeting is scheduled for January 20th re-educate staff on compliance policies and procedures. Q2. How the system will be corrected so this violation will not happen again? A cleaning schedule has been placed for the kitchen. Each item needing to be cleaned and the frequency of cleaning has been included on the cleaning schedule. A training for all Back of the house kitchen team has been scheduled for January 20th to retrain and ensure all compliance information has been provided. Q 3. How often will the area needing correction will be evaluated? Daily through substantial compliance. Ongoing per policy for the areas/equipment being evaluated. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance January 31, 2025 Kitchen repairs: Q1. What Action will be taken to correct the rule Violation? Team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to guide the correction of the rule violations. The team has Utilized Direct Supplies TELS system to place maintenance requests to fix all Items listed on the Statement of Deficiencies. All deficiencies noted have been fixed. Q2. How the system will be corrected so this violation will not happen again? A kitchen physical inspection schedule has been established for the Environmental Services Team to evaluate for needed service ticket requests and repair completion. The Food & Beverage Director and Environmental Services Director will complete weekly walkthrough inspections. Q 3. How often will the area needing correction will be evaluated? Daily through substantial compliance. Ongoing per policy for the areas/equipment being evaluated. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? Food and beverage Director, Sous Chef, Dining room supervisor, and Environmental Services Director. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance January 31, 2025 Food handling practices: Q1. What Action will be taken to correct the rule Violation? The team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violations. I. Single use gloves: Retraining on MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL was held immediately followed up by visual inspection on all shifts daily. II. Industrial Mixer: All staff will follow the cleaning procedure in the DINING SERVICES POLICY & PROCEDURE MANUAL: CLEANING EQUIPMENT AND APPLIANCES. Mixer was cleaned and covered. III. Label and dating food items: Team will utilize MBK senior living Label ad dating procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Immediate retraining and visual inspection on all shifts daily. IV. Bulk Food items: Team will utilize MBK senior living Food Storing procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Immediate retraining and follow up daily. Q2. How the system will be corrected so this violation will not happen again? I. Immediate training and daily follow up to ensure all food is properly covered, wrapped and dated for all areas of the Kitchen. Collaboration between Food & Beverage Director, Sous Chef, Memory Care Director, and caregivers to ensure at least two people are accountable to policy and procedures for food handling. II. An all-staff training for all kitchen team members has been scheduled for January 18th to retrain and ensure all compliance information has been provided and will continue to be followed. Q 3. How often will the area needing correction will be evaluated? Daily through substantial compliance and ongoing as well. Q 4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? Food and beverage Director, Sous Chef, Dining room supervisor, Memory Care Director. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance January 31, 2025 Section c: Memory Care kitchenette Q1. What Action will be taken to correct the rule Violation? The team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Immediate in-service meetings with all shifts to re-educate staff. Immediate deep cleaning of kitchenette area and appliances. Q2. How the system will be corrected so this violation will not happen again? A cleaning schedule has been placed for the kitchen. Each item needing to be cleaned and the frequency of cleaning has been included on the cleaning schedule. A training for all Back of the house kitchen team has been scheduled for January 20th to retrain and ensure all compliance information has been provided. Q3. How often will the area needing correction will be evaluated? Daily through substantial compliance and ongoing per policy for the areas/equipment being evaluated. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? Memory Care Director, Food and Beverage Director, and Sous Chef. Executive Director, Associate Executive Director and Director of Resident Services to support when Memory Care Director and Food and Beverage department leadership is absent. Q5. Date facility alleges compliance January 31, 2025 Section d: Memory Care food handling and hygiene Q1. What Action will be taken to correct the rule Violation? The team will utilize MBK senior living Uniform procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violations. Immediate staff training to correct the rule violations. Audit of Food Handlers Cards III. Food handlers card received from all staff and copies in State mandated Food handlers Binder. Q2. How the system will be corrected so this violation will not happen again? An all-staff training for all kitchen team members has been scheduled for January 18th to retrain and ensure all compliance information has been provided and will continue to be followed. II. Garbage can lid inspections to be added to daily cleaning log. III. Separate compliance tracker created just for Food Handler’s Cards, and Food handlers’ binder updated and corrected. All staff have been audited for cards and any missing or outdated cards have been obtained/updated. I. Food and beverage Director, Sous Chef, Dining room supervisor or lead Chef on duty will review the previous day’s cleaning log to ensure all areas were acknowledged and completed. A visual inspection will follow. If not complete successfully, Food and Beverage Director will be notified to take follow up corrective action/Training. II. Associate Executive Director will complete weekly Audits of compliance tracker. Q3. How often will the area needing correction will be evaluated? Daily through substantial compliance and ongoing per policy. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Compliance tracking has been assigned to Associate Executive Director. Q5. Date facility alleges compliance January 31, 2025 Section c: Memory Care kitchenette Q1. What Action will be taken to correct the rule Violation? The team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Immediate in-service meetings with all shifts to re-educate staff. Immediate deep cleaning of kitchenette area and appliances. Q2. How the system will be corrected so this violation will not happen again? A cleaning schedule has been placed for the kitchen. Each item needing to be cleaned and the frequency of cleaning has been included on the cleaning schedule. A training for all Back of the house kitchen team has been scheduled for January 20th to retrain and ensure all compliance information has been provided. Q3. How often will the area needing correction will be evaluated? Daily through substantial compliance and ongoing per policy for the areas/equipment being evaluated. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? Memory Care Director, Food and Beverage Director, and Sous Chef. Executive Director, Associate Executive Director and Director of Resident Services to support when Memory Care Director and Food and Beverage department leadership is absent. Q5. Date facility alleges compliance January 31, 2025 Section d: Memory Care food handling and hygiene Q1. What Action will be taken to correct the rule Violation? The team will utilize MBK senior living Uniform procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violations. Immediate staff training to correct the rule violations. Audit of Food Handlers Cards III. Food handlers card received from all staff and copies in State mandated Food handlers Binder. Q2. How the system will be corrected so this violation will not happen again? An all-staff training for all kitchen team members has been scheduled for January 18th to retrain and ensure all compliance information has been provided and will continue to be followed. II. Garbage can lid inspections to be added to daily cleaning log. III. Separate compliance tracker created just for Food Handler’s Cards, and Food handlers’ binder updated and corrected. All staff have been audited for cards and any missing or outdated cards have been obtained/updated. I. Food and beverage Director, Sous Chef, Dining room supervisor or lead Chef on duty will review the previous day’s cleaning log to ensure all areas were acknowledged and completed. A visual inspection will follow. If not complete successfully, Food and Beverage Director will be notified to take follow up corrective action/Training. II. Associate Executive Director will complete weekly Audits of compliance tracker. Q3. How often will the area needing correction will be evaluated? Daily through substantial compliance and ongoing per policy. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Compliance tracking has been assigned to Associate Executive Director. Q5. Date facility alleges compliance January 31, 2025

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, interview and record review, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: On 03/06/25 at 10:30 am, the main kitchen located in the assisted living was observed to need cleaning and/or repair in the following areas: * Pooling oil was observed on the floor underneath and on either side of the stove and grill area; * Multiple ceiling vents and ceiling tiles had a buildup of dust and debris; * Cooling racks, serving racks and carts had buildup of dust and debris; * Walk-in freezer door seal was worn, causing the freezer door to not close properly, and the bottom of the door was rusted and deteriorating; * The molding around the door frame connecting the sous chef office and the main kitchen was damaged, rendering the surface uncleanable; * Holes in the ceiling up to approximately six inches around pipes above prep table; and * Multiple garbage cans in the kitchen were not covered with lids when not in use. During a tour of the main kitchen the above findings were discussed with Staff 2 (Sous Chef) and Staff 8 (Dietary Manager) on 03/06/25 at 11:40 am. The need to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules was discussed with Staff 1 (ED) and Staff 8 on 03/06/25 at 12:15 pm. They acknowledged the findings.

Section A Q1. What actions will be taken to correct the rule violation? The team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Daily cleanings according to policy have been implemented. An after hours deep clean and maintenance of the kitchen stove grease Trap is scheduled for March 20th to ensure the stoves grease trap is cleaned and working efficiently. A Back of House All Staff meeting was scheduled for March 23rd re-educate staff on compliance policies and procedures. Q2. How will the system be corrected so this violation will not happen again? The Food & Beverage Director is accountable to all Dining Dept. policies and procedures as well as Oregon Administrative Rules. The Director will ensure compliance utilizing all available resources. The team will receive ongoing and adequate support to ensure sustainable compliance. Director, Sous Chef, Lead Cooks will review prior day's logs and perform visual inspection to confirm compliance and take corrective action immediately if found to not comply. A. All cleaning, and other relevant logs are confirmed to be in their accurate locations, accessible, and clear. B. Cleaning schedules and assignments have been posted for all kitchen areas. C. Each item needing to be cleaned and the frequency of cleaning are included on the cleaning schedule. D. An In-service for all back of house staff has been scheduled and attendance is mandatory. Q3. How often will the area needing correction will be evaluated? Daily inspection thorough and substantial compliance. Ongoing per policy for the areas/equipment being evaluated. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A. Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance March 23rd, 2025 Section B Q1. What actions will be taken to correct the rule violation? A. Maintenance team cleaned ceiling tiles in Park Kitchen on March 10th. Monthly purchases of a box of ten tils to be purchased every month until all tils are replaced. All vents in Park Kitchen have been cleaned on March 10th. Q2. How will the system be corrected so this violation will not happen again? A. Reoccurring TELS work order has been set up for a monthly deep cleaning of vents and tiles to be completed by Maintenance team. Weekly vacuuming of vents and tiles to be completed by back of house kitchen team. B. All cleaning, and other relevant logs are confirmed to be in their accurate locations, accessible, and clear. C. Cleaning schedules and assignments have been posted for all kitchen areas. D. Each item needing to be cleaned and the frequency of cleaning are included on the cleaning schedule. Q3. How often will the area needing correction will be evaluated? A. Weekly inspections thorough and substantial compliance. Ongoing per policy for the areas/equipment being evaluated. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A. Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance March 23rd, 2025. Section C Q1. What actions will be taken to correct the rule violation? The team will utilize MBK senior living cleaning procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Daily cleanings according to policy have been implemented. An after hours deep clean and maintenance of the Cooling racks is scheduled for March 23rd to ensure racks are cleaned. A Back of House All Staff meeting was scheduled for March 23rd re-educate staff on compliance policies and procedures. Q2. How will the system be corrected so this violation will not happen again? The Food & Beverage Director is accountable to all Dining Dept. policies and procedures as well as Oregon Administrative Rules. The Director will ensure compliance utilizing all available resources. The team will receive ongoing and adequate support to ensure sustainable compliance. Director, Sous Chef, Lead Cooks will review prior day's logs and perform visual inspection to confirm compliance and take corrective action immediately if found to not comply. E. All cleaning, and other relevant logs are confirmed to be in their accurate locations, accessible, and clear. F. Cleaning schedules and assignments have been posted for all kitchen areas. G. Each item needing to be cleaned and the frequency of cleaning are included on the cleaning schedule. Q3. How often will the area needing correction will be evaluated? A. Weekly inspections will be conducted to ensure thorough and substantial compliance. Ongoing evaluations will follow policy guidelines. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A. Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance March 23rd, 2025. Section D Q1. What actions will be taken to correct the rule violation? Freezer maintenance company, TELS business services was called on March 16th, inspection date for company to inspect freezer door set for March 20th . Maintenance date to follow inspection process. Q2. How will the system be corrected so this violation will not happen again? A. The team will utilize MBK senior living GENERAL KITCHEN AND DINING ROOM SANITATION GUIDELINES: Freezer procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation and ensure proper maintenance of the freezer. Q3. How often will the area needing correction will be evaluated? A. Quarterly inspections will be conducted to ensure thorough and substantial compliance. Ongoing evaluations will follow policy guidelines. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A. Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance March 23rd, 2025 Section E Q1. What actions will be taken to correct the rule violation? A. Painting of the molding was completed on March 12th by community painter. Q2. How will the system be corrected so this violation will not happen again? A. Quarterly inspections will be conducted to ensure thorough and substantial compliance. Q3. How often will the area needing correction will be evaluated? A. Quarterly inspections will be conducted to ensure thorough and substantial compliance. Ongoing evaluations will follow policy guidelines. B. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A. Environmental Service Director. Executive Director, Associate Executive Director to support department when leadership is absent. Q5. Date facility alleges compliance March 12th, 2025 Section F Q1. What actions will be taken to correct the rule violation? A. Maintenance has filled the holes to ensure there are no gaps around hoses. Q2. How will the system be corrected so this violation will not happen again? A. Maintenance team is now aware of facility requirements regarding spacing of pipes running through ceiling openings. Q3. How often will the area needing correction will be evaluated? A. Quarterly inspections will be conducted to ensure thorough and substantial compliance. Ongoing evaluations will follow policy guidelines. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A. Environmental Service Director. Executive Director, Associate Executive Director to support department when leadership is absent. Q5. Date facility alleges compliance March 13th, 2025. Section G Q1. What actions will be taken to correct the rule violation? A. Garbage lids were purchased on DSSI 3/19/2025 Q2. How will the system be corrected so this violation will not happen again? A. An In-service for all back of house staff has been scheduled for March 23rd and attendance is mandatory. Education on state requirements for the placement of garbage lids. B. Disciplinary action for removal of garbage lids will be enforced. Q3. How often will the area needing correction will be evaluated? A. Daily inspection thorough and substantial compliance. Ongoing per policy for the areas/equipment being evaluated. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A. Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance March 19th, 2025.

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 411-054-0030 (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 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation, interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

Q1. What actions will be taken to correct the rule violation? The team will utilize MBK senior living procedure listed in DINING SERVICES POLICY & PROCEDURE MANUAL to correct the rule violation. Re-education, Training and corrective actions, according to policy have been implemented. A Back of House All Staff meeting is scheduled for March 23rd re-educate staff on compliance policies and procedures. Q2. How will the system be corrected so this violation will not happen again? The Food & Beverage Director is accountable to all Dining Dept. policies and procedures as well as Oregon Administrative Rules. The Director will ensure compliance utilizing all available resources. The team will receive ongoing and adequate support to ensure sustainable compliance. Director, Sous Chef, Lead Cooks will review prior day's logs and perform visual inspection to confirm compliance and take corrective action immediately if found to not comply. Q3. How often will the area needing correction will be evaluated? A. Daily, weekly and Quarterly inspections to ensure thorough and substantial compliance. Ongoing per policy. Q4. Who on your staff will be responsible to ensure that all corrections are completed and monitored? A. Food and beverage Director, Sous Chef and Dining room supervisor. Executive Director, Associate Executive Director to support Food when Food and Beverage department leadership is absent. Q5. Date facility alleges compliance March 23rd, 2025

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. 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, interview and record review, 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 C 240.

Z 142 corresponds with the above C240. The Plan of Correction above for C240 will be implemented for the purposes of bringing Z142 into complaince.

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, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 240.

Refer to 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:

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: