Brookdale River Road

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, sanitary manner or with required food inventory levels in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include but are not limited to: Observation of the facility kitchen, dining room and activity kitchenette on 12/02/24 from 10:30 a.m. through 1:30 pm revealed the following deficient practices: a. An accumulation of food spills, splatters, food debris build-up, loose food and debris, dust, dirt build-up and/or uncleanable surfaces was visible on the following: Ovens-Interior and Exterior; Windowsill ledge behind large metal rack; Multiple metal racks in kitchen; Racks in Cooler/Freezers-various; Handwashing sink faucet area; Wall poster outside of dry storage; Flooring Corners and edges; Cooler/Freezer bottom shelves; Top of dish machine; Light switch in ware washing area; Knife Rack; b. The following areas needed repair: Caulking in ware washing area with black matter debris build-up Hole in wall below knife rack; Walls with scrapes/dings/peeling-missing paint in various areas; Light switch damaged; Standing/pooling water under dish machine from possible leaking sprayer faucet; Cooler/Freezer racks with missing/peeling coating and rusted areas creating non-cleanable surfaces. c. The following areas needed replacement: Multiple metal racks with non-cleanable surfaces storing food items; Heavily scored sauté pans; Chipped, frayed, or rusty cooking utensils; d. Sanitation in the dishwashing process: Dish machine was run several times by surveyors and Staff 2 (Dining Services Coordinator) and was not able to reach correct sanitation concentration for chlorine levels. Upon investigation, sanitizing chemical was empty. Staff 2 changed out sanitizer, however dish machine continued to not register correct concentration after running another several times. Facility maintenance staff was contacted and was eventually able to get the dish machine sanitation concentration to 200 ppm as required. Facility was not able to determine when the dish machine was last correctly sanitizing dishes. Facility was not able to demonstrate effective monitoring system was in place for the dish machine to ensure dishes were effectively sanitized. Facility chlorine test strips were noted to be expired. e. Food Supply Dry goods, Perishable goods, Freezer goods not at required inventory levels. Staff 2 validated a large order would be placed that day and facility was not typically this low. Staff 2 acknowledged current food on hand did not meet 7 days of dry/staple foods nor 2-3 days of perishables required. Staff 2 did state they could run to store down the street if/when needed. f. Dating, labeling and/or expired food items Various food items observed stored in reach in coolers that were not dated, labeled or past the 7 days allowed per rule. Cakes for a staff party was stored with resident food. g. Miscellaneous areas noted Food equipment not covered/protected from potential contamination when stored (mixer bowl/whisk), coffee filters were stored open to potential contamination, scoop observed stored with handle touching food beverage item, dining room utensils observed pre-set and exposing food contact areas, uncovered food/beverages in dry storage, cooler, and freezer. Staff 2 toured kitchen with surveyors and acknowledged above areas in need of attention. At 1:30 surveyors reviewed with Staff 1 (Administrator) and Staff 2 (Dining Services Manager) the concerns found and they acknowledged the need for correction.

1. Community team began cleaning areas identifed in during survey immedaitely and all areas and/or equipment identified during survey will be cleaned or replaced by 12/31/24. Vendors have been contracted for all areas identified to be in need of repair and repairs will be completed or replaced by 1/20/25. Dry, perishable, and freezer goods have been replenished 2. A comprehensive cleaning list with daily/weekly/monthly tasks was been updated and appropriate staff were educated on its use on or before 12/10/24. Staff were educated on proper labeling, food storage, and equipment storage on or before 12/10/24. This included proper utensil setting when pre-setting the tables. 3. The Executive Director will complete a weekly walk for the next 60 days through to ensure kitchen cleanliness, proper food and equipment storage, and adequate food supply. The Dining Service Coordinator will monitor cleaning checklist complete and complete a weekly audit to ensure proper food and equipment storage, food supply and ktichen cleanliness a minimum of twice weekly as standard operations. 4. The Dining Services Coordinator and the Executive Director are responsible for this plan of correction

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 interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to: The facility's ABST was reviewed on 04/30/24. There was no documented evidence all 22 required ADLs were addressed separately on the ABST staffing tool the facility was using. The need to have all required ADLs listed separately on the ABST was discussed with Staff 1 (ED) and Staff 2 (District Director of Operations) on 04/30/24. They acknowledged the findings.

As we continue to partner with DHS on reviewing our ABST tool, we will continue to staff According to our Brookdale acuity based staffing tool. 2. Our home office team will continue to establish proper communication with DHS regarding The ABST tool and the 22 elements that make up the ABST tool, we will continue to staff at or above staffing levels currently identified in our tool.  We will continue our bi-weekly reporting to the department until we have received DHS approval on our ABST. 3.  This will be evaluated by the Health and Wellness Director/Resident Care Coordinator to ensure that proper staffing levels are scheduled according to the 22 elements to ensure the scheduled and unscheduled needs of the residents are being met. 4. The Executive Director is responsible to ensure that our staffing levels are appropriate as defined by our staffing tool

Concerns were identified and the facility was provided with technical assistance in the following areas: H1517 (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit.

The findings of the re-licensure survey, conducted 04/29/24 through 05/01/24, 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 and OARs 411 Division 004 Home and Community Based Services Regulations. 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 first re-visit to the re-licensure survey of 05/01/24, conducted on 02/05/25, 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 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 facility kitchen was conducted on 11/07/23 from 10:30 am through 2:00 pm and found the following:   a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:   * Refrigerator and oven in activity room; * Floors and walls under dish machine; * Reach-in coolers and freezers; * Metal racks storing spices; * Metal shelves storing pots/pans/dishes; * Industrial can opener and housing; * Steamer with scale build-up and dirty on interior and exterior; * Industrial mixer; * Interior of plate warmer; * Wood knife holder; * Walls and door thresholds with food debris/splatter; and * Handles of reach-in coolers and freezers. b. The following areas were in need of repair:   * Large open area in janitor room next to mops; * Large open gap by air duct in janitor room; * Caulking behind hand washing sink and ware washing area with black mold-like substance; * Piece of wood flooring missing by entry way threshold; * Walls in kitchen with pealing/chipped paint; * Light switch with crack and chip in outlet; * Visible mineral/scale build-up in ware washing machine; and * Stand-up freezer with large accumulation of ice/frost buildup. c. Scoops/spoons observed in bulk food containers with handles touching food surfaces. Coffee filters stored uncovered and open to potential contamination. d. Multiple cutting boards and cutting surfaces were found heavily stained and scored. Utility cart noted to be damaged with burn rings from coffee or hot beverage containers, making cart an unsmooth surface. Multiple pans/utensils with damage and wear needing to be replaced. e. Two containers of cottage cheese were found past their manufacturer's use-by date. Multiple food items found in reach-in refrigerators without proper labels and/or dates as required. f. Multiple food packages were found open in dry storage. g. Facility did not have a small diameter thermometer probe for thin foods. h. Multiple cooking/prep dishes were not stored inverted as required and were observed to have visible debris in them.   i. Kitchen staff observed during tray line service to use single service gloves incorrectly. On multiple occasions ready-to-eat items were handled with gloves that had been used for other tasks, including handling pen to write down room numbers on containers. At approximately 2:00 pm on 11/07/23, surveyors reviewed above areas with Staff 2 (Dining Service Coordinator) and Staff 1 (Administrator), who acknowledged the identified areas.

A. All areas in kitchen needing cleaning including food spills/splatters, loose food, trash debris, dirt, dust and or black matter to be cleaned as follows: *Refridgerator and oven in activity room to be cleaned by 12/15/23 *Floors and walls under dish machine, reach in coolers and freezers, metal spice racks, shelving and can opener to be cleaned by 12/15/23 *Steamer scale build up to be cleaned by 11/10/23 *Industrial mixer,plate warmer, knife holder, walls and door thresholds and handles of reach in coolers and freezers to be cleaned by 12/015/23 In prevention of a reoccurence of this violation: a comprehensive cleaning list with daily/weekly/monthly task will be updated, implemented and monitored on a weekly basis by the Dining Services Coordinator and or a designee starting on 12/10/23.    B. Large open area in janitor room next to mops will be repaired by placement of a plastic cover by maintenance technician by 12/1/23. *Large open gap by air duct in janitor to be repaired by  Watson Mechanical  11/30/23. *Repair of caulking behind hand washing sink and ware washing area and piece of wood flooring missing to be repaired by inhouse maintenance Tech by 12/20/23. *Peeling and chipped walls in kitchen and cracked light switch to be repaired by Maintenance Tech by 12/20/23 *Visible mineral build up in ware washing machine and ice/frost in freezer to be cleaned by 12/20/23.  All kitchen staff educated in proper deep cleaning of ware washing machine to be done by 11/15/23 and is on the weekly cleaning list and monitored weekly by the Dining Service Coordinator and or designee. C.Scoops/spoons were removed and coffee filters stored in covered area on 11/07/23.  All kitchen staff educated in proper placement of items during a kitchen staff meeting and a sign posted as a reminder by 11/15/2023. D.Stained cutting boards, utility cart and pots and pans to be replaced by 01/06/2023. E./F A weekly audit to ensure food is properly labeled and in  compliance with use dates and food packages in dry storage are closed to be done by Dining Services Coordinator and or designee.  All kitchen staff trained in proper labeling and storage during a kitchen staff meeting by 11/15/23 G.A small probe thermometer to be purchased by 11/30/23 H.Cooking/prep dishes to be stored properly wihout debris by 11/30/23 I. Kitchen staff trained in the correct use of single service gloves during a kitchen staff meeting by 11/15/23. The Executive Director will complete a review of kitchen to monitor cleanliness during routine facility walk through and conduct random audits of meal service to monitor for proper food handling practices. The Dining Services Coordinator and the Executive Director are responsible for this plan of correction.

The findings of the kitchen inspection, conducted 11/07/23, 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 re-visit to the kitchen inspection of 11/07/23, conducted 01/12/24, 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, conducted during a site visit on 08/02/23, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 1 of 1 sampled resident (#1). Findings include, but are not limited to: CS was unable to interview Resident 1 who no longer resided in the facility. During an interview on 08/02/23, Staff 1 (Executive Director) stated, "The call light response time is between 5-10 minutes." Staff 1 acknowledged the long response times on the call light report printed. A record review of the call light report for Resident 1 from April 2023, showed occurrences where the response time exceeded 10 minutes. On 04/08/23 the response time was 20 minutes 39 seconds. On 04/25/23 the response time was 24 minutes 23 seconds. It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident On 08/02/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: Staff 1 will continue to run reports for the call lights and having staff meetings if s/he sees a pattern that exceeds their timeframe.

Based on interview and record review, conducted during a site visit on 08/02/23, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to: During an interview on 03/28/2023, Staff #1 (Executive Director) stated their ABST was the same tool they had been using provided by their home office, called the resident services summary report. A review of the facility's ABST showed the tool did not have all 22 activities of daily living (ADL's) outlined individually for each resident and the amount of staff time needed to provide care. The facility's ABST had multiple ADLs grouped together in subcategories. The ABST stated on day and swing shift, 1 MT and 3 CG were required and on NOC shift, 1 MT and 2 CG were required. On 08/02/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: Staff 1 will contact the OPA and CAC for ABST to further understand the tool within the month.

The findings of the on-site investigation, conducted 08/02/2023, 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 CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse Notes on Abbreviations: "The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself. "Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate. "Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate. "If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and accepted sanitation standards were in accordance with the Food Sanitation Rules OARs 333-150-0000. Finding include, but are not limited to: On 11/30/22 at 10:30 am, the facility kitchen was observed to need cleaning in the following areas: * Vents within the hood over the stove had accumulation of grease/dust; * The wall beside the stove had accumulation of grease/dust; * The back of the stove/grill had grease buildup; * The end of the stove near the spice shelf had grease/splatters; * The grill top had grease buildup; * The lower shelf below the spice shelf/prep area had dried food debris; * The lower shelf below the steam table had dried food debris; * Drains below the coffee/juice counter and in the dish washing area had accumulation of black matter; and * The floor throughout the kitchen and dish washing area had scattered food debris. The garbage can near the two compartment sink in the kitchen was uncovered when not in use. The dry storage area had the following items observed directly on the floor: * Cardboard box of foam containers; * Bag of potato chips, raw potato, Ziploc bag of chips, box of Crystal Lite, box of cornbread mix; and * Large black plastic bag of towels. A bag of granulated sugar was open and not sealed closed. A scoop was observed in the flour bin. Two cardboard boxes of lids were directly on the floor near the large sugar bin. The above areas of concern were discussed with the Staff 1 (Executive Director) on 11/30/22. The findings were acknowledged.

Vents within the hood over the stove had accumulation of grease/dust. - The vents over the hood have been cleaned of grease and dust. A cleaning schedule has been updated with the expectation that the vents will be cleaned weekly. The ED or designee will be responsible for overseeing that the corrections are completed and monitored. The wall beside the stove had accumulation of grease/dust. - The wall beside the stove has been cleaned of grease and dust. A cleaning schedule has been updated with the expectation that the wall will be cleaned daily. The ED or designee will be responsible for overseeing that the corrections are completed and monitored. The back of the stove/grill had grease buildup. - The back of the stove/grill has been cleaned of grease. A cleaning schedule has been updated with the expectation that the back of the stove will be cleaned daily. The ED or designee will be responsible for overseeing that the corrections are completed and monitored. The end of the stove near the spice shelf had grease/splatters; The end of the stove near the spice shelf has been cleaned of grease and splatters. A cleaning schedule has been updated with the expectation that the end of the stove near the spice shelf will be cleaned daily. The ED or designee will be responsible for overseeing that the corrections are completed and monitored. The grill top had grease buildup - The grill top has been cleaned of grease. A cleaning schedule has been updated with the expectation that the grill top will be cleaned daily. The ED or designee will be responsible for overseeing that the corrections are completed and monitored. The lower shelf below the spice shelf/prep area had dried food debris - The lower shelf below the spice shelf/prep area has been cleaned of dried food debris. A cleaning schedule has been updated with the expectation that the lower shelf below the spice shelf/prep area will be cleaned daily. The ED or designee will be responsible for overseeing that the corrections are completed and monitored. The lower shelf below the steam table had dried food debris - The lower shelf below the steam table had dried food has been cleaned of dried food debris. A cleaning schedule has been updated with the expectation that the lower shelf below the steam table had dried food will be cleaned daily. The ED or designee will be responsible for overseeing that the corrections are completed and monitored. Drains below the coffee/juice counter and in the dish washing area had accumulation of black matter - The drains below the coffee/juice counter and in the dish washing area have been properly cleaned. A cleaning schedule has been updated with the expectation that the drains below the coffee/juice counter and in the dish washing area will be cleaned weekly. The ED or designee will be responsible for overseeing that the corrections are completed and monitored. The floor throughout the kitchen and dish washing area had scattered food debris. - The floor throughout the kitchen and dish washing area have been properly cleaned. A cleaning schedule has been updated for the floor throughout the kitchen and dish washing area to be cleaned daily. The ED or designee will be responsible for overseeing that the corrections are completed and monitored. The garbage can near the two compartment sink in the kitchen was uncovered when not in use. - The garbage can lids have been located and are on the trashcans now when not in use. A sign will be posted on all trashcans to remind staff to replace the trash can lids when not in use. ED or designee will be responsible for overseeing that the corrections are completed and monitored. The dry storage area had the following items observed directly on the floor: Cardboard box of foam containers, bag of potato chips, raw potato, Ziploc bag of chips, box of Crystal Lite, box of cornbread mix; and large black plastic bag of towels - All boxes and food items that were on the floor have been thrown away. The plastic bag of towels have been removed and the towels are on a shelf with other cleaning supplies. A cleaning schedule has been updated stating be daily checks of the floor in the storage area to ensure there is not anything that has been placed or fallen to the the floor. The ED or designee will be responsible for overseeing that the corrections are completed and monitored. A bag of granulated sugar was open and not sealed closed. - The sugar has been disposed of, any bags of sugar will now be placed into a sealed container and labeld properly. The ED or designee will be responsible for overseeing that the corrections are completed and monitored. A scoop was observed in the flour bin. - The scoop has been removed from the flour bin. There will be a sign posted on the flour bin to remind staff that the scoop is not to be left in the bin. The ED or designee will be responsible for overseeing that the corrections are completed and monitored. Two cardboard boxes of lids were directly on the floor near the large sugar bin. - The lids have been removed from the floor. The storage place has changed to a shelf to ensure they are not on the floor in the future. The ED or designee will be responsible for overseeing that the corrections are completed and monitored.

The findings of the kitchen inspection, conducted 11/30/22, 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 11/30/22, conducted 2/16/23, 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.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 10/6/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: 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