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 ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 09/17/24 at 11:00 am, the facility kitchen was observed to need cleaning in the following areas: * Hood vents above stove/grill/deep fat fryer – greasy/dusty; * Stainless steel surrounding stove/grill/deep fat fryer – significant accumulation of grease drips; * Deep fat fryer – exterior with significant drips of grease/food debris; * Stove/grill – front and sides had drips/spills; * Shelf below grill – grease drips/debris; * Lower shelf on prep counter – debris/spills/food; * Flooring underneath equipment – build up of debris/black matter; and * Dry storage flooring – food debris, black matter under shelving next to utility sink, sugar packets and repairs needed over the access to the crawl space which was on the floor near the utility sink. The following areas included improper food storage: * Food containers in refrigerator not labeled/dated/sealed securely; * Open packages of frozen breaded food product and tater tots in upright freezer; * Dry storage: - Open bags of flour, rice, sugar and panko crumbs creating risk of cross contamination and/or rodent/pest infestation. (Containers with securely sealed lids would be an appropriate option.); - Scoop stored in bag of flour, creating a cross contamination risk; and - Resident food items (snacks) stored in kitchen dry storage, not readily accessible to residents. The areas of concern were observed and discussed with Staff 1 (Director of Food Service) on 09/17/24. The findings were acknowledged.

OAR 411-054-0030 (1)(a) Resident Service Meals, Food Sanitation Rule 1. Immediate actions taken to correct the rule violation includes: i. Serenity administration review the time the hood vents was professional clean which is 8/14/2024 by American Hood Cleaning, please see attached receipt. Although we have schedule services with them for every 6 months but due to the deficiency noted, we have scheduled extra cleaning services with American Hood Cleaning on 10/18/2024. Staff cleaned stainless steel surrounding stove/grill/deep fat fryer, deep fat fryer-exterior, stove/grill-front and sides had drips/spills, shelf below grill, flooring underneath equipment to removed accumulated grease drips, food debris, and all black mayyeron 9/17/2024. ii. The flooring to dry storage crawl space which was next to the utility sink were repaired on 10/16/2024 iii. All unlabel food were discarded iv. Facility administration provided air-tight containers for flour, rice, sugar, panko crumbs and was implemented on 10/07/2024 to prevent cross contamination V. Staff removed all scoop stored in bag of floors and also removed resident stored food items stored in the kitchen dry storage on 9/17/2024. 2. The system will be corrected so that violation will not happen again through daily kitchen and food service observation audit created and implemented on 10/17/2024. Kitchen staff were provided inservice on how to utilized daily kitchen and food service observation audit to prevent further deficiency. Please see attached daily kitchen and food service observation audit. The administrator will meet weekly with Kitchen Manager to perform kitchen area walk through and review daily kitchen and food service observation audit for the week to discuss any deficiency and resolve it. 3. The administrator will be responsible to see that the plan of corrections are implemented and evaluated

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: