Brookdale Roseburg

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).

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 Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the main kitchen and dining room kitchenette areas on 05/19/25 from 11:00 am through 1:30 pm revealed the following: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Kitchen drains * Interior of microwaves in main kitchen and all unit kitchenettes * Interior of unit ovens * Interior of reach in freezers in units * Industrial can opener housing * Floors under worktables * Stainless steel shelving holding pans * Stainless steel shelving by spices/binders * Box fan cage and blades near prep space * Exterior of convection oven and steamer * Fan cages in walk in cooler * Griddle top open grease reservoir area * Outside food storage area floor/shelves and canned goods with accumulation of dust/dirt/debris. b. Kitchen staff observed handling/preparing food and/or clean dishes without hair effectively restrained. c. Food observed stored in walk in cooler uncovered and exposed to potential contamination. Dry baked goods observed stored in baking rack in kitchen with food products open and exposed to potential contamination. d. Multiple potentially hazardous food items were noted stored in walk in cooler and/or reach in cooler that were not dated when opened. Multiple food items were found past the manufactures use by dates in unit refrigerators. e. Staff member in Saphire unit was observed reheating resident food in microwave. Staff was not able to correctly state proper reheat temperatures. Cook and Designated Person In Charge was also not able to correctly identify the proper reheat temperature. f. Refrigerator for holding resident food in Saphire unit did not contain a thermometer to ensure resident food was held at appropriate cold food temperatures. g. Care staff was observed entering kitchen area and did not wash hands or restrain hair upon entering. h. Multiple rags for surface cleaning/sanitation were observed stored out of the sanitation buckets on random counters/areas throughout the kitchen. i. Staff 2 was not able to correctly review proper cooling process to handle leftovers. The facility was observed to have a large number of leftovers in the refrigerators. The facility did not have an effective process to ensure food was properly cooled to ensure safe. Staff 2 Cook/PIC, toured kitchen with surveyor and acknowledged the areas identified. At approximately 1:30 pm, the surveyor and Staff 1 (Business Office Manager/Facility Designee) and Staff 3 (Health and Wellness Director) reviewed areas of concern. Staff 1 and 3 acknowledged the above areas needed to be cleaned and practices that needed addressed.

1) All areas of the kitchen including, but not limitied to, areas specified in the statement of deficiencies were cleaned at time of survey and then will be deep cleaned by all kitchen staff by compliance date and maintained by community staff following community cleaning schedule. New thermometer props ordered for each kitchenette Staff inserviced on cleanliness and dating and covering foods, and proper temperatures, per state regulations on 5/23/25. 2) Daily cleaning schedule is in place for neighborhood kitchenettes and for main kitchen and will be reviewed weekly. 3) Kitchen cleanliness will be monitored on a weekly basis. Food preperation will be monitored on a weekly basis. 4) The Executive Director, Dining Services Manager, and or designee will be responsible for monitoring continuned compliance.

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).

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.

: 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 above.

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.

Concerns were identified and the facility was provided with technical assistance in the following areas: H 1517: OAR 411-004-0020(2)(d): Individual Privacy: Own Unit (d) Each individual has privacy in his or her own unit. This was regarding no lock on the apartment side of the door to shared bathrooms.

The findings of the re-licensure survey, conducted 06/24/24 through 06/26/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Technical assistance was provided for Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, record review and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the main facility kitchen food storage areas, food preparation, and food service on 4/4/23 revealed splatters, spills, drips, dust and debris noted on: - Can opener blade and casing; - Interior and exterior of microwave; - Industrial mixer; - Exterior of grill, stove, ovens, sides of equipment, knobs and handles; - Grease trap of grill with large dirt/grease build up; - Floors throughout kitchen area, under/between equipment/shelves; - Floors under racks in walk in cooler; - Fan cages and ceiling of walk in; - Box fans in dish room and prep area; - Walls throughout kitchen area; - Plastic shelving storing dry goods in main kitchen area; - Baking rack; - Open shelving; and - Vents and fire sprinklers. The following items/areas in the main kitchen were in need of repair: - Metal racks storing dishes heavily rusted; - Wood shelving storing dishes with exposed pressed wood; - Hand washing sink with active leak causing standing water underneath; and - Steamer with active leak causing standing water underneath equipment. * Multiple items stored in freezer were not labeled/dated when opened or removed from original packaging.   * Dishwashing racks were observed stored on the floor. * Desserts for noon meal were transported to units uncovered. At approximately 1:30 pm, Staff 2 (Dining Director) and the Surveyor toured the kitchen. Staff 2 acknowledged the above findings. Observations of the unit kitchenette food storage areas, food preparation, and food service revealed splatters, spills, drips, dust and debris noted on/in: - Interior and exterior of drawers and cupboards; - Interiors of microwaves; - Interiors of ovens; - Entry latches/doors to kitchenette area; and - Freezers. * Plastic cups/mugs were noted to be ready to serve resident drinks that had stains and scoring. * Dishware was noted to be put away wet leaving noticeable water residue in the cups and in the cupboard. * Scoops were observed stored in bulk coffee containers. * Trash cans did not have lids for when not in use. * Thermometer probes were not small diameter for thin foods and/or were not operating correctly. * Staff were observed to touch ready to eat foods (buttered bread) with potentially contaminated gloves. * Plates/dishes of food from prior meals stored in unit refrigerator with no labels or dates. * Bulk foods (cereal/chips/etc) not securely closed after use. At 2:45 pm the areas in need of cleaning, repair and attention were reviewed with Staff 1 (Executive Director). She acknowledged the findings.

1) All areas of the kitchen including, but not limitied to, areas specified in the statement of deficiencies were cleated at time of survey and then will be deep cleaned by all kitchen staff by compliance date and maintained by community staff following community cleaning schedule. New metal racks were ordered and will be in place prior to complaince date. New thermometer props ordered for each kitchenette. Staff inserviced on cleanliness and dating and covering foods, per state regulations. 2) Daily cleaning schedule is in place for neighborhood kitchenettes and for main kitchen and will be reviewed weekly.   3) Kitchen cleanliness will be monitored on a weekly basis. Food preperation will be monitored on a weekly basis. 4) The Executive Director, Dining Services Manager, and or designee will be responsible for monitoring continuned compliance.

Based on observation, record review 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.

Refer to deficiencieces C240 and POC.

Based on record review and interview, it was determined the facility failed to ensure 13 of 27 staff reviewed who prepare and serve food had active food handlers certificates. Findings include but are not limited to: On 4/4/23 at approximately 1:30 pm, surveyor reviewed employee records for active food handlers cards. There were 8 employees who did not have a food handlers card on file and 4 that were found to be expired. At 2 pm, Staff 1 (Executive director) verified there were multiple staff that did not have active food handlers certification. Staff 1 verified that those staff duties did include preparing and serving food to residents.

1) All staff whose duties include preparing and servicng food to residents, with expired or no food handlers cards will go through training and records will be up to date, with food handlers cards. 2)Training binders will be audited monthly to ensure all staff have up to date food handlers cards and all new staff will obtain during training. 3) Monthly and at new hire. 4) The Executive Director, Business Office Manager and or designee will be responsible for monitoring continued compliance.

The findings of the kitchen inspection, conducted 4/4/23, 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 re-licensure kitchen inspection of  04/04/23, conducted on 07/07/23, 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.