Brookdale McMinnville City Center Memory Care

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 08/19/25 at 10:35 am, the facility kitchen was observed to need cleaning in the following areas:

* Shelves below coffee station – spills/drips;

* Interior of ice maker – pink matter build up;

* Floor drains under three compartment sink and in dishwashing area – build up of black matter;

* Commercial stand mixer – splash guard with food splatters;

* Operating fan near food service line – dusty;

* Dishwashing area – black matter build up on wall behind spray hose sink, dried debris on top of dishwashing machine, wall behind dishwasher yellow matter, shelf holding dish racks splatters/spills;

* Dry storage – floor beneath racks, debris/cobwebs;

* Commercial can opener – blade finish worn/black matter build up;

* Flooring throughout the kitchen including underneath cooking equipment, corners and areas close to cove base – build up of black matter/debris/stains; and

* Two door reach in refrigerator, bottom shelf – dried food debris.

Other areas of concern included:

* Colored cutting boards – finish worn and scored;

* Two door reach in refrigerator – salads and orange slices uncovered;

* Walk in refrigerator and freezer – containers/packages of shredded cheese, cooked sausage, cheese slices, diced chicken and mango slices not labeled and/or dated; and

* Lack of facial hair restraint.

The areas of concern were observed and discussed with Staff 1 (Dining Room Coordinator) and discussed with Staff 2 (Executive Director) on 08/19/25. The findings were acknowledged.

Based on observation and interview, 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.

The findings of the kitchen inspection, conducted 07/25/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
The findings of the first revisit to the kitchen inspection of 07/25/24, conducted 09/26/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview, and record review, it was determined the facility failed to prepare and serve food in accordance with Oregon Food Sanitation Rules. Findings include, but are not limited to:The kitchen was toured at 9:50 am on 07/25/24. The following was identified:a. Food spills, splatters, debris, dust, grease, pink grime, and/or black matter were observed in the following main kitchen areas: * The white lip inside the ice maker;* The ceilings throughout the kitchen;* The legs of stainless steel shelving throughout the kitchen;* The top of the warewasher;* The metal venting housing and the vents above the hot pass;* The drawer with ice cream scoops and tongs;* The sides and interiors of the gas ovens;* The interior and exterior of the small oven to the right of the gas ovens;* The pipe to the right of the small oven;* The knobs of the warming area to the right of the beverage refrigerator, on the gas oven, and on the hot pass station;* The exterior of the Robot Coupe mixer;* Electrical outlets throughout the kitchen;* The shelf-mounted can opener by the toaster;* The garbage can exteriors;* The vent in the freezer;* Both kitchen doors and their frames; and* Both rack holders in the dining room.b. Food spills, splatters, debris, and dust were observed in the following memory care kitchenette areas: * The top, interior, and sides of the refrigerator and freezer;* The cabinet door frames and interiors; and* The walls and posts in the kitchenette area;c. Items in the memory care kitchenette were not dated and labeled. d. The refrigerator in the memory care kitchenette lacked a thermometer.e. The following areas in the main kitchen were in need of repair:* The caulking behind the handwashing sink;* The wall behind the metal shelving to the right of the hot pass had paint missing;* Wall edges throughout the kitchen had exposed metal and missing paint;* The gas oven was not operable; and* The large stand mixer was rusted and chipped above the bowl, with potential for contaminating food in the bowl.f. Plastic utensils were stored in open containers on the bottom shelf below the hot pass with potential for contamination.g. Staff 3 (Cook) did not have a current food handler's permit.h. There were oranges with visible mold in the walk-in refrigerator of the main kitchen.The need to ensure Oregon Food Sanitation Rules were followed was discussed with Staff 1 (ED) and Staff 2 (Dining Services Director) on 07/25/24. They acknowledged the findings.

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 C240.

The findings of the kitchen inspection, conducted on 06/21/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first re-visit to the kitchen re-licensure survey of 06/21/23, conducted 08/24/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean, protocols and practices were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:On 06/21/23 at 11:15 am, the facility kitchen was observed to need cleaning in the following areas: a. Food spills, splatters, debris and/or black/brown matter was observed on or underneath the following:* Lower shelves throughout the kitchen including below the toaster, steam table, steamer and shelf storing pots and pans; * Equipment included: - Doors on reach in refrigerator; - Small refrigerator doors near steam table; - Oven doors; - End of the steam table; - Rolling cart shelves; - Wall behind the stove/grill; - Convection oven doors; - Lid on bin holding oatmeal; - Ceiling above steam table; - The lid to the oatmeal bin, behind the mixer; - Light fixture near back door; and - Flooring throughout kitchen and underneath equipment.Two garbage cans were uncovered when not in use near the ice machine and the dishwashing area. Improper food storage:* Uncovered/undated items in walk in refrigerator including: - Two baked pies; - Tray of individual portions of pudding; * Undated items included: - Ham, chopped salad and croissant sandwich;* Bag of onions sitting on the floor in dry storage area;* A sheet pan of cookies on rolling cart (next to steam table) were uncovered;* Scoops/cups were stored in granulated sugar storage bin and three containers of cereal; and* A stack of three boxes and a single box of food were sitting directly on the floor in freezer.b. One staff not wearing beard restraint.c. Uncovered individual servings of pudding on top of cart with trays delivered to the Memory Care Community unit dining room.The areas of concern were discussed with Staff 1 (Dining Services Director) and Staff 2 (Executive Director) on 06/21/23. The findings were acknowledged.

Based on observation and interview, it was determined the facility failed to follow licensing rules of Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240.

The findings of the re-licensure survey, conducted 09/19/22 through 09/20/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the re-licensure survey of 09/20/22, conducted 01/11/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day



The findings of the second revisit to the re-licensure survey of 09/20/22, conducted 04/19/23, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

3. Resident 2 was admitted to the facility in August 2022 with diagnoses including dementia. The resident's service plan, dated 09/02/22, and interviews with care staff between 09/19/22 and 09/20/22 indicated the resident required full assistance of two staff for transfers with use of a gait belt. The resident required extensive assistance for ADLs. The resident could make needs known but was forgetful.Review of incident investigations and progress notes from 06/19/22 through 09/19/22 showed the following: An incident report was completed regarding a skin tear to the resident's upper right arm on 09/05/22. A thorough investigation was not completed regarding the skin tear. The incident report/investigation did not include information on how staff ruled out abuse and neglect, staff response at the time of the incident, description of what occurred, and follow up action taken. The facility was asked to report the skin tear to the local SPD office, and confirmation was provided prior to the survey exit.The need to ensure resident incidents were thoroughly investigated to rule out abuse and neglect was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 09/20/22. The staff acknowledged the findings4. Resident 3 was admitted to the facility in August 2021 with diagnoses including Alzheimer's disease. The resident's service plan, dated 07/14/22, and interviews with care staff between 09/19/22 and 09/20/22 indicated the resident required full assistance from staff for care after a recent decline over the last few months. The resident previously was independent with transfers. The resident would not initiate care and staff anticipated the resident's needs. Review of incident investigations and progress notes from 06/19/22 through 09/19/22 showed the following: Incident reports were completed for unwitnessed, non-injury falls on 07/21/22, 07/30/22, and 09/15/22. The incident reports/investigations did not include information on how staff ruled out abuse and neglect. The investigations did not consistently include information regarding staff response at the time of the incident, description of what occurred, follow-up action taken, and administrator review. The need to ensure resident incidents were thoroughly investigated to rule out abuse and neglect was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 09/20/22. The staff acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause and unwitnessed falls were promptly investigated to rule out suspected abuse and/or neglect and were reported to the SPD as needed for 4 of 4 sampled residents. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 09/2016 with diagnoses including dementia and stroke.The resident's clinical record from 06/30/22 through 09/19/22, including progress notes, temporary service plans, and incident reports, was reviewed, and interviews with staff were conducted.On 09/14/22 staff completed an incident report for a skin tear on the resident's right forearm. The incident was not investigated to rule out abuse and/or neglect, nor was it reported to the local SPD office.The surveyor requested the RN report the incident on 09/20/22. Confirmation was provided of the reports prior to survey exit.The need to investigate injuries of unknown cause to rule out abuse and/or neglect, and to report the incident to the local SPD office if abuse and/or neglect could not be ruled out, was discussed with Staff 1 (ED) and Staff 2 (RN) on 09/20/22. They acknowledged the findings. The surveyor received confirmation the facility reported the incident on 09/20/22 prior to survey exit.2. Resident 4 was admitted to the facility in 08/2022 with diagnoses including dementia.The resident's facility record was reviewed, including progress notes, temporary service plans, and incident reports dated from 08/15/22 through 09/18/22, and interviews with staff were conducted.A 09/04/22 progress note indicated staff discovered a skin tear on the resident's lower right arm on 09/03/22. Staff documented on 09/06/22 the resident "did not remember how it happened." There was no documented evidence the facility investigated the injury of unknown cause to rule out abuse and/or neglect, nor did they report the injury to the local SPD office.The surveyor requested the RN report the incident on 09/20/22. Confirmation was provided of the report prior to survey exit.The need to thoroughly investigate injuries of unknown cause was discussed with Staff 1 (ED) and Staff 2 (RN) on 09/20/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause and unwitnessed falls were promptly investigated to rule out suspected abuse and/or neglect and were reported to SPD as needed for 1 of 2 sampled residents (#6) reviewed with incidents. Findings include, but are not limited to:Resident 6 was admitted to the facility in 12/2021 with diagnoses including dementia.Progress notes reviewed from 11/20/22 through 01/11/23 noted the following:*11/21/22 Resident was placed on alert charting for a non-injury fall;*11/25/22 Discoloration was noted on the top of the resident's left buttock;*12/09/22 Resident was placed on alert charting for a non-injury fall; and*12/14/22 Discoloration was noted on the resident's buttocks.Incident reports were completed for 11/21/22 and 12/09/22 noting unwitnessed non-injury falls. There was no documented evidence of investigations for the discoloration, injuries of unknown cause, that were noted on the resident on 11/25/22 and 12/14/22. The incident reports/investigations were either not completed or did not include information on how staff ruled out abuse and neglect. The investigations did not consistently include information regarding staff response at the time of the incident, description of what occurred, follow-up action taken, and Administrator review.Thoroughly investigating injuries of unknown cause and non-injury unwitnessed falls to rule out abuse and neglect and reporting as necessary to SPD was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 16 (Health and Wellness Director) on 01/11/23 at 1:20 pm. Staff acknowledged the findings.The surveyor requested Staff 16 report the incident on 11/21/22 and 12/09/22 to the local SPD. Confirmation of the reports was provided prior to the end of the day.

1. Incidents on 11/21/2022 and 12/09/2022 were provided to local SPD on 1/11/2023. Education was immediately provided to Med Tech's and caregivers at stand up and at shift change 1/13/2023. 2. Staff received education on incidents of unknown origin, documentation and reporting requirements on 1/25/2023. Executive Director, Health and Wellness Director, Clinical Coordinator and Resident Care Coordinator will review OR Abuse Reporting & Investigation guide to be completed by 2/10/2023. Incidents from the past 30 days have been reviewed to assure reporting as required by rule.3. Resident incidents will be discussed at daily stand-up meeting and reviewed in detail during routine clinical meeting 3-5 times per week to assure follow-up investigation, and/or APS reporting occurred as needed. Executive Director will regularly review incident documentation to evaluate for effective follow up and assure reporting has occurred. 4.The Executive Director is responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 1 of 4 sampled residents (#3) whose service plans were reviewed. Findings include, but are not limited to:Resident 3 was admitted to the facility in August 2021 with diagnoses including Alzheimer's disease. Observations of the resident, interviews with staff, and review of the service plan dated 07/14/22 showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas: * Behaviors including uncontrolled weeping/sadness;* Transfers and ambulation;* Walker and wheelchair use;* Full feeding assistance, straw use and supplements; and* Falls and safety interventions. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 09/20/22. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat residents' behaviors had written, resident-specific parameters and/or non-pharmacological interventions for staff to attempt prior to administering a PRN psychotropic medication for 3 of 4 sampled residents (#s 1, 3 and 4) who were prescribed a PRN psychotropic medication. Findings include, but are not limited to:Review of 09/01/22 through 09/19/22 MARs and physician orders revealed that Residents 1, 3 and 4 were prescribed a PRN psychotropic medication for anxiety and/or agitation. The following was identified:1. There were no resident-specific parameters on the MARs indicating how each resident exhibited signs and symptoms of anxiety and/or agitation.2. Resident 3's MAR did not include any non-pharmacological interventions for staff to attempt prior to administering the PRN psychotropic.The need to include a description of how each resident exhibited signs and symptoms of anxiety and/or agitation, as well as non-drug interventions for staff to attempt before administering a PRN psychotropic medication, was discussed with Staff 1 (ED) and Staff 2 (RN) on 09/20/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:Refer to C 231.

Based on 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 231.
Based on 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 231.
See POC 231

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 260 and C 330.

Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 4 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2, and 3's service plans offered some information about the resident's interests, but the facility had not fully evaluated the resident's:* Current abilities and skills;* Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary.There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist the resident with more individualized activities.Observations on 09/19/22 and 09/20/22 showed multiple small group activities being led by facility staff. Residents 1 and 3 were not consistently invited to activities or provided adaptations to participate in the activity.The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (Program Director/Activities) on 09/20/22. The staff acknowledged the findings.