Print Inspection: KIT014223

OAR 411-054-0025 (1) Facility Administration: Operation (1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals. This Rule is not met as evidenced by: Based on observation and interview, it was determined the licensee failed to ensure adequate administrative oversight of facility operations regarding kitchen sanitation practices, which posed a risk to the safety of residents. Findings include, but are not limited to: During the annual kitchen inspection, conducted 09/10/26 through 09/15/26, administrative oversight to ensure adequate food sanitation practices in the facility kitchen was found to be ineffective based on the severity of the citation. Refer to C240.

1. What actions will be taken to correct the rule violation for each example/resident? The Management Company reviewed the results of the survey with the Administrator and discussed the citations and what was required to mediate the IJ and other citations on 9/10/26. The Manger walked the Administrator and the cook through the citations and all that needed to be remedied in order to be put back into substantial compliance and what was required when we received the Kitchen Survey Citation report as well as how to complete the plan of correction 9/12/26. The Manager or designee is reviewing the weekly audits that the Administrator is completing as well as completing walkthroughs of the kitchen during onsite visits. The Administrator or designee has been completing weekly Sanitation audits starting on 9/14/26. The Administrator or designee has been completing weekly audits on proper textures of residents with altered texture diets on 9/14/26. Administrator or designee will report the results of the above audits to QAPI monthly for 3 months or until deficient practice has resolved. The Administrator will work in partnership with the RD and then work with the IDT Managers on any areas identified in the RD visits. Administrator or designee will report the results of the RD visit to QAPI monthly for 3 months or until deficient practice has resolved.

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 a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. The unsanitary condition, lack of knowledge and training and poor food safety practices posed an immediate threat to residents’ heath and safety. Findings include, but are not limited to: Observation of the facility’s main food preparation kitchen, two additional house kitchens, food storage areas, and the lunch meal services was completed on 09/10/26 from 10:30 am through 3:00 pm, and the following was identified: 1. Main Kitchen: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, and/or black matter was visible on or underneath the following: * Reach-in cooler and refrigerator; * Interior of cabinets and drawers; * Prep space cutting board; * Prep space metal racks; * White bulk bins - lids and exteriors; * Industrial can opener and housing; * Interior of the ice machine; * Flooring and walls under counters and the three-sink area; * Kitchen drain; * Removable hood vents; * Walls behind the countertop work areas places; * Behind and under the stove and ovens; * Dry storage shelving; and * Flooring in dry storage area. b. The following areas needed to be repaired: * The dish machine was not working; * The down spouts for the three-compartment sink reached deep into the floor drain, not allowing the needed space for an air gap and back-flow prevention: * Multiple protective coverings for on the interiors of cabinets and drawers were pealed peeled, ripped, and torn and were not a smooth and cleanable surfaces; * Multiple cutting boards were heavily scored and stained; and * Wood shelving in the dry storage area had chipped, worn, and missing paint , and did not have smooth and cleanable surfaces. c. Multiple food items were observed in the reach-in coolers that were not labeled with open dates. Multiple items were in the reach-in cooler or refrigerator that were expired or past their discard date. d. The facility was not using pasteurized shell eggs when preparing cook-to-order egg dishes. e. Raw shell eggs were stored next to containers of ready-to-eat food items, causing the potential for cross contamination. f. The facility’s main dishwasher for sanitizing dishes was not operational. The facility was using a three-compartment sink to clean all dishes, which the surveyor observed was set up incorrectly. Staff 3 (Cook on Duty/Designated Person in Charge) was not able to demonstrate effective sanitation practices using 3 a three-compartment sink system. The facility kitchen staff were not ensuring dishes were soaking in the sanitize solution for the required contact time and were not aware of the required contact time for sanitation. g. Staff 3 was observed discarding her gloves once she was finished handling raw chicken, and she was observed immediately opening the oven without washing her hands. h. Staff 3 was interviewed about residents who required mechanical soft texture diets. Staff 3 reported no residents at the facility needed mechanically altered texture diets. She indicated the cooks did not mechanically alter the menu items and that the caregivers cut up the meats, if needed, at the respective houses. The facility had two residents who, per the diet order sheets printed and posted in the houses, needed mechanical soft texture diets. Staff 3 was not aware of the need to further mechanically alter meat and proteins for mechanical soft diet orders. Staff 4 (Cook) was able to accurately describe appropriate textures for a mechanical soft diet, but was also not aware of any residents who needed mechanical soft texture diets. Staff 4 denied ever preparing mechanical soft textures at this facility. i. Both Staff 3 and 4 were interviewed about resident food allergies. Both staff denied knowledge of any resident at the facility with a food allergy. The surveyor reviewed the diet order sheet posted on the facility refrigerator, which indicated a resident with a shellfish allergy. Both Staff 3 and 4 were unaware of the allergy. Staff 4 stated the facility did not serve shellfish. The surveyor observed a box of frozen shrimp stored in the facility freezer. j. Multiple food items were stored on the floor in the dry storage room. k. Dishwashing racks were stored on the floor. i. Staff 2 (Kitchen Manager) had to leave the facility prior to survey entrance because he was ill. At approximately 11:00 am, Staff 2 was observed inside the main kitchen. The surveyor interviewed Staff 2, who confirmed he was ill with gastrointestinal illness symptoms, but had returned to the facility because of the survey. Surveyor reinforced that he must be excluded from the kitchen until 24 hrs post any symptoms. 2. Outdoor Food Storage Area: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, and/or black matter was visible on or underneath the following: * The interior and exterior of reach-in coolers and freezers; * The flooring where freezers and coolers were stored; and * The threshold between the outside area and the interior door. b. The following areas needed to be repaired: * The reach-in freezer showed evidence of frost build-up, and a towel was stored in the bottom of the freezer to soak up moisture; and * The reach-in cooler storing vegetables had a broken/damaged seal and a large amount of condensation and moisture build-up. c. Perishable food items were stored on the floor. d. Perishable food items were stored outside, exposed to moisture and the elements, presenting an opportunity to attract rodents, pests, and animals. e. An open and repackaged bag of raw chicken breast was stored above multiple boxes of fish, posing a risk for contamination. f. There was expired food in the reach-in refrigerator storing dairy products. 3. Kitchen Area in House 2: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, and/or black matter was visible on or underneath the following: * The reach-in cooler and refrigerator; * The interiors of cabinets and drawers; and * The interior of the ice machine; b. The following areas needed to be repaired: * Multiple protective coverings on the interiors of cabinets and drawers were peeled, ripped, and torn and did not have a smooth, cleanable surface; * Wood shelving in the dry storage area with had chipped, worn, and missing paint, creating a surface that was not smooth and cleanable; and * The lighting in the kitchen was very dim. c. There were food items in the dry storage area that were not closed, creating the potential for contamination. d. Multiple food items in the reach-in refrigerator were not labeled with open dates. Multiple resident-specific foods were not properly labeled. e. One resident of this house had a mechanical soft texture diet order. Care staff were not able to accurately describe mechanical soft textures. The resident was served dry chicken in bite-sized pieces. The chicken was not ground, was not fork tender, and did not have a gravy or sauce, as the facility’s posted mechanical soft texture guide indicated. Care staff acknowledged most meat items were served bite-sized to this resident. Staff reported they had not witnessed the resident choking or having swallowing difficulties. 3. Kitchen Area in House 3: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, grease, and/or black matter was visible on or underneath the following: * The reach-in cooler and refrigerator; and * The interiors of cabinets and drawers. b. The following areas needed to be repaired: * Multiple protective coverings on the interiors of cabinets and drawers were peeled, ripped, and torn and did not have a smooth and cleanable surface; and * Wood shelving in the dry storage area with had chipped, worn, and missing paint creating a surface that was not smooth and cleanable. c. There were food items in the freezer that were open to potential contamination. d. Multiple food items were stored in the reach-in refrigerator without open dates and/or expired, and multiple resident-specific foods were not properly labeled. e. One resident residing in this house had a mechanical soft texture diet order. Care staff were not able to accurately describe mechanical soft textures. The resident was served dry chicken in bite-sized pieces. The chicken was not ground, was not fork tender, and did not have gravy or a sauce, as the facility’s posted mechanical soft texture guide indicated. Care staff acknowledged most meat items were served bite-sized to this resident. Staff reported they had not witnessed the resident choking or having swallowing difficulties. f. There was a resident residing in this house that had a food allergy that was listed on the posted diet sheet. Multiple care staff reported they had no knowledge of any residents in the house having food allergies. g. A trash can was observed with visible food debris inside the can and without a lid. The trash can was not in active use. There was an open container of recycled soda cans under the counter that did not have a lid to deter or prevent the attraction of insects or pests. h. Food was found stored on the floor in the dry food storage area. i. The clean dish rack for drying sanitized dishes was observed next to the sink, with no splash guard to protect the clean dishes from potential splash contamination. At approximately 12:07 pm on 09/10/26, the surveyor contacted the Community Based Care Supervisor and shared concerns about the unsanitary condition of the kitchen, the unsafe food storage and hygiene practices by staff, the failure of the Person In Charge to demonstrate adequate knowledge, the failure to know and provide appropriate mechanical soft textures and food allergens, and the lack of sufficient oversight of the food service system. A situation was identified where there was a failure of the facility to comply with the Department’s rules that was likely to cause residents serious harm. An immediate plan of correction was requested on 09/10/26 at 12:15 pm. The surveyor reviewed the safety concerns and sanitation areas with Staff 1, and she acknowledged the areas identified in need of immediate attention/correction. The facility submitted a plan of correction on 09/10/26 at 2:45 pm, which was accepted by the surveyor. The surveyor exited the facility at 3:00 pm. On 09/15/26, from 10:15 am to 12:00 pm, the surveyor toured the areas with Staff 5 (Management Company Representative), Staff 1, and Staff 2, and observed significant improvement of the identified areas. The surveyor reviewed documentation of staff training on food textures and allergies and interviewed multiple care staff, who were able to accurately discuss residents on altered texture diets, what they should look for to ensure correct textures are served, and what residents had food allergies. The surveyor verified that food storage concerns were addressed. At that time, it was determined the facility could safely resume food service operations.

1. What actions will be taken to correct the rule violation for each example/resident? All residents are at risk for being impacted by this deficient practice. The New Friends of Florence Residential and Memory Care kitchens were closed immediately from 9/10/26-9/15/26 at lunch time; at this time the ED and the Management company planned out all meals that were previously approved by the surveyor and they were outsourced which could include a cold item prepared from a store in coordination by the ED/Management company. The New Friends of Florence Residential and Memory Care kitchens were reopened after the surveyor's inspection for dinner service on 9/15/26. The Manager and Administrator disposed of all food that was not dated, sorted incorrectly to include stored on the floor, and the food stored outside near the freezer areas, and all non-pasteurized eggs on 9/12/26. The Manager, Administrator, and cooks cleaned all of the kitchens to include behind and under all appliances 9/13/26. All Fridges and freezers were thoroughly cleaned on 9/13/26 to include all seals and any debris was removed. The refrigerator that had stored the vegetables was evaluated and deemed that it could not be used after attempts to repair. Vegetables were stored properly in the main refrigerator in house 1. The above noted refrigerator was taken out of use on 9/13/26. A new refrigerator was ordered and arrived on 09/25/26. The Manager evaluated the Kitchen garbage cans on 9/14/26 in all three houses and thoroughly cleaned the garbage can in House one and replaced the garbage cans in House 2 & 3. The Maintenance Director placed contact paper in all three houses' pantries to allow for cleanable surfaces on 9/14/26. The Sanitizing Dish Machine was installed and functioning by 9/11/26. The Maintenance Director adjusted the down spouts for the three-compartment sink in order to be in compliance on 9/11/2026. The RD provided an in-service on modified diet to include mechanical soft diets, sanitation on 3 bin compartments processed along with general sanitation rules for the kitchen in accordance to OAR-333-150-0000 on 9/11/2026. The Manager and ED provided an in-service food placement and storage upon receipt from the vendor or store, modified diet to include mechanical soft diets, sanitation on 3 bin compartments processed along with general sanitation rules for the kitchen in accordance to OAR-333-150-0000, where to find diets and allergies, posted in each kitchen, in order section of chart and on service plan. Notify ED if you are concerned that you have approached the dietary manager and are not receiving results on 9/12-14/2026. All staff will be in-serviced by the Dietary Manager or designee on the proper techniques for handwashing when in a kitchen and handling food. The Administrator or designee has been completing weekly Sanitation audits starting on 9/14/26. The cooks in house 1 are preparing each altered texture diet and delivering it to the houses with residents with orders for altered texture diets on 9/11/26. The Administrator requested review of the two residents with Mech soft diets by the PCP and SLP referrals; these orders and referrals were received on 9/22/26. The Administrator or designee has been completing weekly audits on proper textures of residents with altered texture diets starting on 9/14/26. Administrator or designee will report the results of the above audits to QAPI monthly for 3 months or until deficient practice has resolved. All staff will be provided with the kitchen employee exclusion from work and sign and acknowledge it. Cooks and Maintenance cleaned the Outdoor storage area getting rid of all debris and any unnecessary items on 9/14/26. Any food improperly stored in the refrigerators and freezers was disposed of by the Manger on 9/13/26. The Maintenance Director evaluated the lighting in the kitchen in all houses and was able to make some adjustments to decrease the dim lighting 9/11/26. Maintenance Director evaluated all of the shelves and drawers and replaced or placed contact paper in areas needed to allow for a cleanable surface The Manager purchased a new rolling 3 drawer bin to store items and have additional cleanable storage areas on 9/14/26. The maintenance Director will complete a weekly audit of all kitchens to look for items requiring repair. The maintenance Director will report the results of the above audits to QAPI monthly for 3 months or until deficient practice has resolved. The RD’s next visit will be October 5th 2026 . Dietary Manager or designee overseeing daily, weekly, and monthly kitchen tasks and will follow up on any items requiring further attention Dietary Manager or designee will report out any items requiring further attention from his kitchen cleaning reports to QAPI monthly for 3 months or until deficient practice has resolved.

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 POC for C240.