Print Inspection: RL013471

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure menus were prepared at least one week in advance and made available to all residents, residents were informed in advance of menu changes and meal substitutions were of similar nutritional value. Findings include, but are not limited to: During the survey, 08/03/26 through 08/05/26, several unsampled residents expressed concerns about the menu and serving process. a. Weekly menus were not made available to all residents at least one week in advance and the following was identified: * On 08/04/26 at 12:44 pm a weekly menu was observed posted in the dining room. It displayed only three days’ worth of meals, the day/date was not visible, and when the display was brought to the facility’s attention, it was dated 06/14/26, 51 days ago. b. On 08/03/26 at 3:58 pm the facility provided the weekly menu for 08/02/26 through 08/08/26. The menu was developed by Brookdale Senior Living’s Optimum Life Cuisine dining program. For residents who chose to eat in the dining room, daily menus sheets were placed on the table prior to the meal being served. For residents who chose to eat in their rooms, the lunch and dinner menu sheets were provided to them on the same day prior to each of those meals. Review of the menu sheets and the weekly menu indicated the facility made multiple changes and omissions to the weekly menu without advanced notice to the residents and were as follows: * 08/02/26 Lunch: * Bacon, egg, and Brussel sprouts salad replaced with romaine salad; * Noodles Romanoff and roasted curried cauliflower: eliminated; * Cranberry whip replaced with chocolate pudding; and * Sugar free cherry Jello replaced with reduced sugar ice cream. * 08/02/26 Dinner: * Orange with sweet bell peppers rice and steamed corn: eliminated; * White chocolate macadamia cookies replaced with chocolate chip cookies; and * Reduced sugar vanilla white chocolate chip cookie replaced with pineapple chunks. * 08/03/26 Lunch: * Anna potatoes (a thinly-sliced baked potato dish) was replaced with a baked potato; * Oven-roasted potatoes and glazed beets: eliminated; * Peaches and cream pie and no sugar added peach pie replaced with oatmeal cookies and fresh fruit bowl. * 08/03/26 Dinner: * Baked custard and reduced sugar French vanilla mousse were replaced with “ice cream of the day” and fresh fruit bowl. * 08/04/26 Lunch: * Baked potato and creamed asparagus: eliminated; and * Reduced sugar pineapple upside down cake replaced with fresh pineapple. * 08/04/26 Dinner: * Minestrone soup replaced with chicken noodle soup; * Chickpea salad: eliminated; and * Rum cake and reduced sugar frosted yellow cake replaced with lemon pudding and mandarin oranges. * 08/05/26 Lunch: * Kale salad replaced with mixed green salad; * Beef ribs with teriyaki glaze replaced with beef stroganoff; * Sweet potato casserole: eliminated; * Roasted Brussel sprouts replaced with “Chef’s Vegetables” (in this case the “California blend” of broccoli, cauliflower and carrots); and * Buttermilk cake and no sugar added pound cake were replaced with fruit Jello, apricot halves and no sugar added ice cream. * 08/05/26 Dinner: * Vegetable lasagna with alfredo sauce replaced with chicken alfredo and pasta; * BLT (bacon, lettuce, tomato) plate replaced with tuna plate; * Pickled beets salad replaced with “Chef’s Vegetables”; * Rocky road ice cream and no sugar added vanilla ice cream replaced with fruit Jello, apricot halves and no sugar added ice cream. The facility failed to inform residents of menu changes in advance. c. Review of the 08/02/26 through 08/05/26 menu items included the following substitutions that were not of the same nutritional value: * Bacon, egg, and Brussel sprouts salad replaced with romaine salad; * Peaches and cream pie and no sugar added peach pie replaced with oatmeal cookies and fresh fruit bowl; and * Reduced sugar pineapple upside down cake replaced with fresh pineapple; * Rum cake and reduced sugar frosted yellow cake replaced with lemon pudding and mandarin oranges; * Kale salad replaced with mixed green salad; and * Buttermilk cake and no sugar added pound cake were replaced with fruit Jello, apricot halves and no sugar added ice cream. During an interview on 08/05/26 at 1:10 pm, Staff 8 (Dining Services Director) acknowledged weekly menus were not posted in the main dining room for residents to review and some menu substitutions were not of equal nutritional value as the dietitian-approved community menus. He also stated he had not been notifying residents when he had to make substitutions prior to meal service. The need to ensure menus were prepared at least one week in advance and made available to all residents, and residents were informed in advance of menu changes and meal substitutions were of similar nutritional value were discussed with Staff 1 (ED), Staff 3 (District Director of Operations), Staff 4 (District Director of Clinical Services), and Staff 10 (RCC) on 08/05/26 at 3:18 pm. They acknowledged the findings.

1. Menu for the current week was posted and made available to the residents on day of exit. Menus will be posted on all three floors moving forward and distributed individually to resident one week in advance. 2. Dining Services Mgr. was reeducated on 8/11/26 as to rule requirements regarding posting menus, notifying residents of substitutions and being of similar nutritional value, community policy and systems used to develop menus. Cooks were reeducated on 8/20/26 as to menu changes, substitutions and requirement to notify residents in advance. Concierge was trained on their role in distributing the weeks menus to residents and posting of menu on each floor. Menu changes will be discussed at routine stand-up meetings and posted in advance at the entrance to the dining room for resident awareness. 3. Dining Services Mgr in coordinatoin with the Exec. Dir. will hold monthly menu chat to gain feedback from residents on communication & community process for posting. Executive Director will conduct random audits for the posted weekly menu in conjunction with community walk-throughs for 60 days. 4. The Executive Director and Dining Services Director will be responsible for completion and monitoring.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). This Rule is not met as evidenced by: