Brookdale Redmond Assisted Living

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 ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 06/08/26, between 12:00 pm and 2:45 pm, the facility kitchen was observed to need corrections in the following areas: 1. Cleaning and/or Repair: * Ovens/Grill/Stovetop – had carbon build-up; * Freezer – had black spots on fan; * Fridge – had black/white spots on fan and shelving; * Dish machine – had gauge not working; * Mixer – had food splatters; * Fridge – had food debris on handles/door. 2. Sanitation: * Pantry – had opened containers/uncovered food; and * Non-food contact surface sanitizer – was without sufficient chemical/monitoring system. At approximately 1:30 pm Staff 5 (Cook) demonstrated the pH of quaternary ammonia for nonfood contact surface sanitation was below requirements in the main kitchen. Staff 4 (Med Tech) demonstrated sufficient pH for quaternary ammonia from the adjacent kitchenette in the MCC. Staff planned to use the solution from the MCC kitchenette until the repair was made to the chemical dispenser in the main kitchen. The areas of concern were discussed with Staff 2 (Executive Director) and Staff 3 (Associate Executive Director) at approximately 2:45 pm on 06/08/26. Staff acknowledged the findings.

On 06/08/26, between 12:00pm and 2:45 pm, the facility kitchen was observed to need corrections in the following areas: 1. Cleaning and/or Repair: * Ovens/Grill/Stovetop – had carbon build-up; - Cleaned and added to weekly scheudle * Freezer – had black spots on fan; - Cleaned and added to monthly schedule. * Fridge – had black/white spots on fan and shelving; Cleaned and added to weekly schedule * Dish machine – had gauge not working. Fixed. Checked weekly * Mixer – had food splatters; - Cleaned and added to daily schedule and * Fridge – had food debris on handles/door. - Cleaned and added to weekly schedule 2. Sanitation: * Pantry – had opened containers/uncovered food; Will be checked daily and * Non-food contact surface sanitizer – was without sufficient chemical/monitoring system. At approximately 1:30 pm Staff 5 (Cook) demonstrated the pH of quaternary ammonia for nonfood contact surface sanitation was below requirements in the main kitchen. Staff 4 (MT) demonstrated sufficient pH for quaternary ammonia from the adjacent kitchenette in the MCC. Staff planned to use the solution from the MCC kitchenette until the repair was made to the chemical dispenser in the main kitchen. - High temp Multi-quat purchased along with high temp test strips. All Items will be monitoried by the ED and Dining Services Manager.

Based on interview and record review, conducted during a site visit on 01/23/24, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to: During an interview on 01/23/24, Staff 1 (Administrator) stated the facility is currently working with the district team to ensure that all 22 Activities of Daily Living (ADLs) are listed, for each resident in the tool. On 01/23/24, a record review (off site) of the facility's ABST report, dated 10/02/23, showed only 17 ADLs were listed for each resident. The occupancy and census for the facility was 67 on 01/23/24. The findings of the investigation were reviewed with and acknowledged by Staff 1(ED) on 01/23/24, and Staff 4 (regional director of operations) on 02/06/24. It was determined the facility failed to fully implement an Acuity-Based Staffing Tool. Verbal Plan of Correction: The district team is working to include all 22 ADLs in the tool. Projected date of compliance unknown.

The findings of the on-site investigation, conducted 12/18/23 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on observation, record review, and interview, it was determined the facility failed to ensure the kitchens were maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility kitchen, food storage areas, food preparation, and food service on 11/20/23 revealed splatters, spills, drips, and debris noted on:   - Stand mixer; - Food processor; - Reach-in refrigerator; - Interior and exterior of the microwave; - Interior and exterior of oven and range, including oven handles; - Interior of hot cart for food service; - Stove hood; - Walls throughout the kitchen; - Flooring throughout the kitchen; - Floor drains; - Ceiling throughout the kitchen including grates and sprinkler heads; - Doors, flooring, fans, and shelving of walk-in refrigerator and freezer; - Dry storage area flooring, shelving, and food containers; - Dishes and cookware stored on open shelving and racks; - Open shelving and metal rack shelving; - Bakery racks; - Carts; - Underneath shelving and equipment throughout kitchen; - Triple pot sink area; and - Dishwashing area including flooring, drains, walls, and equipment. * The tray-line cutting board was damaged, creating uncleanable surfaces. * There were undated and unlabeled foods in all refrigerators. * Open packages were noted in the dry food storage area. * Box of food was on the floor in the walk-in freezer. * Dish washing racks were stored on the floor. Staff 1 (Executive Director) and the Surveyor toured the kitchen on 11/20/23. The food storage concerns and areas in need of cleaning and repair were reviewed with Staff 1. He acknowledged the findings.

- Stand mixer will be cleaned. Added to daily task list. - Food processor will be cleaned. Added to daily task list.- Reach in freezer will be cleaned. Added to weekly task list. - Microwave will be cleaned. Added to daily task list. - Oven will be cleaned. Added to monthly task list. - Hot cart will be cleaned. Added to daily task list. - Stove hood will be cleaned. Added to monthly task list. - Walls will be cleaned. Added to weekly task list. - Flooring will be cleaned. Added to daily task list. - Floor drains will be cleaned. Added to monthly task list. - Ceiling will be cleaned. Added to monthly task list. - Walk in freezer will be cleaned. Added to monthly task list. - Dry storage flooring will be cleaned. Added to daily task list. - Dry storage shelving will be cleaned. Added to monthly task list. Dry storage food containers will be cleaned. Added to daily task list. - Dishes and Cookware will be stored on covered racks - Shelving will be covered. - Bakery racks will be cleaned. Added to weekly task list. - Carts will be cleaned. Added to daily task list. - Underneath shelving will be cleaned. Added to weekly task list. - Dishwashing area drains walls and equipment will be cleaned. Added to daily task list. - Tray line cutting board will be replaced. Item has been ordered. - Labelling and dating open containers: training to be provided to kitchen staff. Will be monitored daily by Kitchen manager, ED, and AED. - Open packages in the dry storage area: Closeable containers will be purchase for dry goods. - Box of food on floor in walk in: Staff will be trained on proper food storage. 1

Based on observation, record review, and interview, it was determined the facility failed to ensure the kitchens were maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the facility kitchen, food storage areas, food preparation, and food service with Staff 3 (Dietary Service Manager) on 01/24/24 identified splatters, spills, drips, build up of black matter, and debris on:   - Hand washing sinks; - Stand mixer; - Food processor; - Stainless steel counters and prep areas; - Walls throughout the kitchen; - Flooring throughout the kitchen; - Ceiling throughout the kitchen including vents, sprinkler heads, with debris hanging above food prep area; - Flooring and fans of walk-in refrigerator and freezer; - Dry storage areas flooring and food containers; - Dishes and cookware stored on open shelving and racks; - Open shelving and metal rack shelving; - Blade and casing of the can opener; - Carts; - Oscillating floor fan blowing into food prep area; - Underneath shelving and equipment throughout kitchen; - Triple pot sink area; and - Dishwashing area including flooring, drains, walls, sinks, caulking, and equipment. * The shelving below the tray line was damaged creating un-cleanable surfaces. * The wall panels above the walk in refrigerator were loose creating areas for build up of debris. * There were undated and unlabeled foods in all refrigerators. * A box of food was on the floor in the walk-in freezer. * There were open, uncovered, and undated foods in the dry storage area. * The prep area hand washing sink was directly next to clean utensil and dish storage and lacked a splash guard. * The dishwasher was observed to not remove gloves or wash hands between handling dirty and clean dishes. * Dietary staff were observed without hair and beard restraints. * Dry, soiled wiping towels were observed on the tray line cutting board. There were no sanitizer buckets prepared or in use. When testing the auto dispensed Quaternary sanitizer, the ppm were above the recommended levels. * The high temperature warewashing machine thermometers lacked numbers to determine if it was operating at the correct temperature. The food storage findings and areas in need of cleaning and repair were reviewed with Staff 2 (Associate Executive Director) on 01/24/24. She acknowledged the findings.

- Hand washing sinks; Cleaned and added to daily check list. - Stand mixer; Cleaned and added to daily checklist. - Food processor; Cleaned and added to daily checklist. - Stainless steel counters and prep areas; Cleaned and added to daily checklist. - Walls throughout the kitchen; - Flooring throughout the kitchen; Cleaned and added to daily checklist. - Ceiling throughout the kitchen including vents, sprinkler heads, with debris hanging above food prep area; Cleaned and added to weekly checklist. - Flooring and fans of walk-in refrigerator and freezer; Cleaned and added to monthly checklist. - Dry storage areas flooring and food containers;  Cleaned and added to daily checklist. - Dishes and cookware stored on open shelving and racks; Staff educated on dish storage. - Open shelving and metal rack Cleaned and added to weekly checklist. shelving; - Blade and casing of the can opener; Cleaned and added to daily checklist. - Carts; Cleaned and added to daily checklist. - Oscillating floor fan blowing into food prep area; Fan removed. Staff educated on not using fan. - Underneath shelving and equipment throughout kitchen; Cleaned and added to weekly checklist. - Triple pot sink area; Cleaned and added to daily checklist. - Dishwashing area including flooring, drains, walls, sinks, caulking, and equipment. Cleaned and added to daily checklist. * The shelving below the tray line was damaged creating un-cleanable surfaces. Shelf repaired. Monthly inspection of kitchen furniture by ED and DSM. * The wall panels above the walk in refrigerator were loose creating areas for build up of debris. Repaired. * There were undated and unlabeled foods in all refrigerators. Further training provided on dating and labeling open containers. * A box of food was on the floor in the walk-in freezer. Further training provided on sanitary food storage. * There were open, uncovered, and undated foods in the dry storage area. Further training provided on sanitary food storage and dating/labelling open containers.   * The prep area hand washing sink was directly next to clean utensil and dish storage and lacked a splash guard. Further training provided on clean utensil storage. * The dishwasher was observed to not remove gloves or wash hands between handling dirty and clean dishes. Kitchen staff retrained on cross contaminational practises. * Dietary staff were observed without hair and beard restraints. Staff retrained on beard and hair restraint use.   * Dry, soiled wiping towels were observed on the tray line cutting board. There were no sanitizer buckets prepared or in use. When testing the auto dispensed Quaternary sanitizer, the ppm were above the recommended levels. Training provided on towel and sanitary bucket use. PPM log impleneted and traing provided. added to daily checklist. * The high temperature warewashing machine thermometers lacked numbers to determine if it was operating at the correct temperature. Dial gauges replaced by ecolab. All items will be monitored by ED and DSM.

Based on interview and observation, 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.

refer to C 240

The findings of the kitchen inspection, conducted 11/20/23, 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 revisit to the kitchen inspection of 11/20/23, conducted 01/24/24, 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.

The findings of the second revisit to the kitchen inspection of 11/20/23, conducted 04/11/24, 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 interview and record review, it was determined the facility failed to ensure it had a trained and designated Infection Control Specialist. Findings include, but are not limited to: In an interview on 02/16/23 Staff 1 (ED) stated the facility did not have a designated Infection Control Specialist. On 02/06/23 the need to designate an Infection Control Specialist, who had completed all required training, was reviewed with Staff 1. He acknowledged the findings.

C 295 1. The Executive Director will complete the Infection Control Specialist Training by 3/3/2023 2. The community has identified an additional associate who has complete required training to ensure coverage. 3. The Executive Director or designee will maintain compliance with Infection Control Specialist training as changes in training and guidelines occur.   4. The Executive Director and/or designee is responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to ensure MARs included specific instructions for PRN medications for 3 of 6 sampled residents (#s 1, 5 and 6) whose medications were reviewed. Findings include, but are not limited to: 1. Residents 2's 01/01/23 through 02/06/23 MARs were reviewed. Resident 2 had physician's orders for: *Enulose as needed for constipation; *Miralax as needed for constipation; and *Senna as needed for constipation. There were no resident specific parameters directing non-licensed staff on the administration of the three bowel medications. The need for resident specific parameters for PRN medications to guide non-licensed staff was reviewed with Staff 1 (ED) and Staff 2 (RN) on 02/07/23. They acknowledged the findings. 2. Resident 5's 01/01/23 through 02/06/23 MARs were reviewed. Resident 5 had physician's orders for: *Acetaminophen 650 mg as needed for pain; *Methocarbanol 500 mg as needed for pain; and *Oxycodone 5 mg as needed for pain. There were no resident specific parameters directing non-licensed staff on the administration of the three pain medications. The need for resident specific parameters for PRN medications to guide non-licensed staff was reviewed with Staff 1 (ED) and Staff 2 (RN) on 02/07/23. They acknowledged the findings. 3. Resident 6's 01/01/23 through 02/06/23 MARs were reviewed. Resident 6 had physicians' orders for: *Acetaminophen 650 mg as needed for pain; *Ibuprofen 200 mg as needed for pain; *Senna 8.8 mg as needed for bowel care; *Magnesium Hydroxide 30 ml as needed for bowel care for constipation; *Polyethylene Glycol 17 mg scoop as needed for constipation; and *Sodium Phosphates Enema as needed for constipation. There were no resident specific parameters directing non-licensed staff on the administration of the two pain medications and four bowel medications. The need for resident specific parameters for PRN medications to guide non-licensed staff was reviewed with Staff 1 (ED) and Staff 2 (RN) on 02/07/23. They acknowledged the findings.

C 310 1.  The Medication Administration Record for Resident 1, 5 and 6 were reviewed and updated to include special instructions for as needed medications. 2.  Remaining resident medication orders will be reviewed to assure presence of special instructions for as needed medications.  The clinical team has been trained by district team members on proper resident specific parameters for as needed medications. 3.  Medication orders will be monitored through the triple check process and during the quarterly medication review process.  Executive Director and/or designee will randomly audit 5 resident MARs a week for 60 days to assure ongoing compliance. 4.  The Executive Director and/or designee is responsible for this plan of correction..

The findings of the re-licensure survey, conducted 02/06/23 through 02/08/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations. 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. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the revisit to the re-licensure survey of 02/08/23, conducted on 06/13/23, 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 and 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 food was prepared, and 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 facility kitchen, food storage areas, food preparation, and food service on 11/21/22 revealed splatters, spills, drips, and debris noted on:   - Can opener blade and casing; - Stand mixer; - Food Processor; - Reach in refrigerator; - Interior and exterior of the microwave; - Walls throughout the kitchen; - Flooring throughout the kitchen; - Floor drains; - Ceiling throughout the kitchen; - Doors, flooring, fans, and shelving of walk-in refrigerator and freezer; - Dry storage area flooring, shelving, and food containers; - Hand washing sinks, including bowl, walls, and dispensers; - Dishes and cookware stored on open shelving and racks; - Open shelving and metal rack shelving; - Bakery racks; - Carts; - Underneath shelving and equipment throughout kitchen; - Triple pot sink area; and - Dishwashing area including flooring, walls, and equipment.   * Full garbage cans throughout the kitchen were uncovered. * The reach in refrigerator did not have a thermometer to monitor the temperature of protein based foods. * There were undated and unlabeled foods in all refrigerators. * Raw eggs were stored above ready to eat foods. * A condiment labeled "Refrigerate after opening" was stored in the dry storage area. * A dented can and open packages were noted in the dry food storage areas. * A box of empty soda cans was stored in the dry storage, creating a possible pest issue. * Brooms and dust pans were stored directly next to food in the dry storage. * Open shelving under the tray line was damaged, creating un-cleanable surfaces. * Dish washing racks were stored on the floor. Visible debris was noted on the clean side of the dish machine. * Staff were using a Quaternary solution for sanitizing. There was no evidence of testing the solution to ensure it was between 150 and 200 parts per million. When tested, it was above 400 parts per million. * Staff were observed to not change gloves between tasks while handling ready to eat foods. * Staff did not wash hand upon entry to the kitchen. * The facility did not have a small diameter probe thermometer to measure thin foods. Staff 1 (Executive Director) and the Surveyor toured the kitchen. The areas in need of cleaning and repair were reviewed with Staff 1. He acknowledged the findings.

- Can opener blade and casing. Can opener will be cleaned and casing will be repaird. Can opener cleaning will be added to weekly cleaning tasks ; - Stand mixer. Will be cleaned immediately and added to weekly, deep cleaning tasks ; - Food Processor. Will be cleaned immediately and added to weekly deep cleaning tasks ; - Reach in refrigerator. Will be cleaned imeediately and added to weekly deep cleaning tasks ; - Interior and exterior of the microwave. Will be cleaned immediately and added to daily cleaning tasks ; - Walls throughout the kitchen. Will be cleaned and added to weekly deep cleaning tasks ; - Flooring throughout the kitchen. Will be cleaned and added to weekly deep cleaning tasks ; - Floor drains. Will be cleaned immediately and added to weekly deep cleaning tasks ; - Ceiling throughout the kitchen. Will be cleaned immediately and added to weekly deep cleaning tasks ; - Doors, flooring, fans, and shelving of walk -in refrigerator and freezer. Will be cleaned immediately and added to weekly deep cleaning tasks ; - Dry storage area flooring, shelving, and food containers. Will be cleaned immediately and added to weekly deep cleaning tasks ; - Hand washing sinks, including bowl, walls , and dispensers. Will be cleaned immediately and added to daily deep cleaning tasks ; - Dishes and cookware stored on open shelving and racks. Will be cleaned immediately and added to weekly deep cleaning tasks ; - Open shelving and metal rack shelving. Will be cleaned immediately and added to weekly deep cleaning tasks ; - Bakery racks. Will be cleaned immediately and added to weekly deep cleaning tasks ; - Carts - Underneath shelving and equipment throughout kitchen. Will be cleaned immediately and added to weekly deep cleaning tasks ; - Triple pot sink area. Will be cleaned immediately and added to weekly deep cleaning tasks ; and - Dishwashing area including flooring, walls , and equipment. Will be cleaned immediately and added to weekly deep cleaning tasks. * Full garbage cans throughout the kitchen were uncovered. Lids will be purchased and used.. * The reach in refrigerator did not have a thermometer to monitor the temperature of protein based foods. Thermometer will be replaced and temp log established. * There were undated and unlabeled foods in all refrigerators. This has been addressed in kitchen meeting and will be montiored daily by Kitchen manager, Executive Director, and Associate Executive Director. * Raw eggs were stored above ready to eat foods.This has been addressed in kitchen meeting and will be montiored daily by Kitchen manager, Executive Director, and Associate Executive Director. * A condiment labeled "Refrigerate after opening" was stored in the dry storage area.This has been addressed in kitchen meeting and will be montiored daily by Kitchen manager, Executive Director, and Associate Executive Director. * A dented can and open packages were noted in the dry food storage areas. This has been addressed in kitchen meeting and will be montiored daily by Kitchen manager, Executive Director, and Associate Executive Director. * A box of empty soda cans was stored in the dry storage, creating a possible pest issue.This has been addressed in kitchen meeting and will be montiored daily by Kitchen manager, Executive Director, and Associate Executive Director. * Brooms and dust pans were stored directly next to food in the dry storage.This has been addressed in kitchen meeting and will be montiored daily by Kitchen manager, Executive Director, and Associate Executive Director. * Open shelving under the tray line was damaged, creating un-cleanable surfaces. Repair scheduled for 12/15/22 * Dish washing racks were stored on the floor. Visible debris was noted on the clean side of the dish machine. This has been addressed in kitchen meeting and will be montiored daily by Kitchen manager, Executive Director, and Associate Executive Director. * Staff were using a Quaternary solution for sanitizing. There was no evidence of testing the solution to ensure it was between 150 and 200 parts per million. When tested, it was above 400 parts per million. Testing solution acquired and implemented with log twice daily * Staff were observed to not change gloves between tasks while handling ready to eat foods. Staff did not wash hand upon entry to the kitchen. This has been addressed in kitchen meeting and will be montiored daily by Kitchen manager, Executive Director, and Associate Executive Director. * The facility did not have a small diameter probe thermometer to measure thin foods. New probe thermometers purchased and implemneted.

The findings of the kitchen inspection, conducted 11/21/22, 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 revisit to the kitchen inspection of 11/21/22, conducted 01/25/23, 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.