The Springs at Willowcreek

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. Facility also failed to ensure menus were predominately displayed for residents with altered texture diets were served meals in a palatable manor and in accordance with the menus. Findings include, but are not limited to:

Observation of the main kitchen and individual house kitchens were reviewed on 05/30/25from 10:30 am through 2:00pm 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:

* Walk in cooler fan grates
* Exterior of Ninja blender
* Interior of plastic bins storing measuring cups, spoons and scoops
* Hinge of portable tray line shelf

b. The following areas needed repair:

* Screen door in the main kitchen area left a 1 ½ inch gap at the bottom of the door when in the closed position leaving space for insects/pests to enter. Main door was observed open the majority of survey with this gap allowing potential pest entry to kitchen
* Knobs to one of the portable steam lines where broken off.

c. Surface sanitizer buckets were tested upon entry to the main kitchen area. No parts per million (PPM) of sanitizer registered on the strips. The buckets were changed by staff and a fresh one was mad that also registered 0 ppm. The chemical was not observed flowing thru the hose to the mixing valve until ran for several seconds. Mixture was then tested and was registering 100ppm. Facility staff including staff 2 (Executive Chef) were not able to verbalize the correct concentration for the sanitizing solution used. Logs were reviewed and it was documented the staff documented the sanitizing solution earlier that day at 125 ppm. The facility was utilizing quaternary ammonia for surface sanitation which needs to be between 200 and 400 ppm for effective sanitation. Facility was unsure how long the dispenser of surface sanitizer was not dispensing the correct sanitation amounts. Surveyor brought this to the attention of Staff 2 who discussed the correct concentration needs to staff members.

d. Multiple food items were found stored in the walk-in cooler that did not have a date opened or prepared and/or past the seven days as required. One item was found multiple days past the manufactures use by dates.

e. A cook was observed to touch multiple servings of ready to eat Salmon for lunch with their bare hands while transferring from the baking pan to the tray line pan.

f. Care staff members in multiple houses were observed serving and/or assisting residents with their meals without protective barriers to prevent cross contamination from care giving duties with meal service tasks.

g. Kitchen staff drinking/beverage cups were not off the approved style making hand contact to lip surfaces of the cup likely which is prohibited per rule.

h. Food and beverage items were not appropriately covered and protected from potential contamination when delivered to resident rooms.

i. Menus were not predominately posted in the houses for residents/visitors to review.

j. A resident in house E was observed to be served all pureed food items in 1 dish all mixed together. It did not look appetizing. Caregiver was asked why they were doing it that way and they said they had just always done it that way. Staff 2 acknowledged this was not an appropriate way to present the food products for palatability and provided education to the staff member.

k. Multiple prepared pureed meals were observed in the walk in cooler. Staff 2 was interviewed and indicated the facility’s practice was to puree the days meal for meal service the next day. This meant that residents receiving the pureed meal were a day behind the rest of the residents and that the residents were always getting reheated “leftovers” from the day before. Staff 2 verified the residents on puree diets were not served freshly cooked food like the other residents. This practice was related to allowing staff the ability to serve puree residents before other residents related to assistance needed with meals. This practice was not related to resident request or choice.

At 1:30 pm, surveyor reviewed above areas with staff 2 and staff 1 (Facility Designee) who acknowledged areas in need of attention.

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 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.

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.

This Rule is not met as evidenced by:

The findings of the kitchen inspection, conducted 06/27/24, 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 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.
The findings of the revisit to kitchen inspection of 06/27/24, conducted on 10/03/24, are documented in this report. The facility was found to be 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 maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:Observation of the main kitchen and five cottage kitchenettes on 06/27/24 at 10:30 am through 2:00 pm revealed the following deficiencies: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:* Fan next to three compartment sink and fan in kitchenette Building E;* Fans in reach in cooler;* Can opener and housing;b. The following areas were found in need of repair:* Screen door to main kitchen area with 1/2-1 inch gap. Door observed open allowing entry point for pests/insects. Multiple flies were observed in kitchen area.* All cottages noted with kitchenette cabinets and/or drawers with damage. Protective coating worn, chipped causing non-cleanable surfaces. Some drawers or cabinets missing front covers or not opening correctly.* Cottage F and A with severe water damage to cabinets under sink. Large holes in walls under sinks where pests could enter. Visible build up of black matter/debris where water damage occurred. c. Container of strawberry cream cheese noted stored in cabinet not refrigerated. Food product was warm to touch. It did not contain a date as to when it was opened. Staff 1 (Administrator) discarded item.d. Multiple kitchen staff and caregiving staff were observed to wash hands for less than the 20 seconds required to effectively remove dirt/debris stopping at 10 seconds. Some were observed to immediately rinse hands after applying soap and failing to lather up hands/finger/etc with soap prior to rinsing in order to effectively clean hands.e. Staff were observed to serve resident meals to rooms with food and beverages uncovered failing to protect from potential contamination during transport.f. Care staff were not wearing aprons when serving and/or assisting residents with meals.g. Multiple kitchenettes did not have lids for trash cans to cover garbage when not in use.h. Multiple small saute pans with noted build up of black carbon debris on cooking surface and/or scratches in non stick coating.Staff 1 (Administrator) and Staff 2 (Maintenance Director) toured kitchen and kitchenettes with surveyors and they acknowledged areas needing to be addressed.

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.

The findings of the kitchen inspection, conducted 06/01/23, 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 revisit to the kitchen inspection of 6/1/23, conducted 8/9/23, 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, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:Observation of the kitchen on 06/01/23 at 10:15 am through 2:30 pm revealed the following deficiencies: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:* Small and industrial mixers;* Storage container next to beverage dispenser;* Blender;* Crock pot;* Fan next to three compartment sink and fan in kitchenette Building E;* Air conditioner in window;* Carpet on floor in freezer;* Knobs on both ovens and interior of oven on end; and * Toaster.b. The following areas were found in need of repair:* Hole in wall behind steamer;* Screen door not latching;* Can opener dull with metal shavings observed;* Multiple cutting boards stained and heavily scored;* Cooking pan damaged, stained and not level on stovetop;* Sanitizer for three compartment sink not working; and* Hole on floor under sink with an uncleanable surface.c. Food items including bananas, juice and jello stored on the floor in walk-in.d. Food items in walk-in stored incorrectly: pork was being stored on top of pre-made toast, chicken stored over shellfish and beef. Staff 1 (Administrator) and Staff 2 (Person in Charge) were unaware of proper storage to prevent potential contamination.e. Staff food stored in and around reach-in refrigerator in main kitchen. Staff coffee and rice cooker for staff being used in Building E.f. Cheese found in reach-in fridge that had been opened with no date.g. Reach-in freezer had food that was not frozen and did not provide adequate circulation.h. Upright freezer was packed with food and did not allow adequate circulation. Also had dings and scratches. i. The following was observed in the kitchenettes: * Scoops found in bins and/or ice trays in Buildings B, D and E;* Vents and/or sprinklers dusty in Buildings B and D;* Ice build-up in freezer of Building A;* Interior of microwaves stained and/or damaged in Buildings A, B and E;* Fridge temperatures in Buildings A and B were both found to be at 50 degrees, exceeding proper temp of 41 degrees and below. Protein rich foods were tested and temperatures for both milk and ranch dressing were 48 degrees in Building A and ranch dressing was 48 degrees in Building B. Instructed Staff 1 to discard all protein rich items in Building A, and ranch and mayonnaise in Building B as those items were at risk for potential sources of foodborne illnesses;* Multiple food items in fridges not properly covered, labeled and/or dated in Buildings A, D, E and F;* Wall behind trash can in Building F was chipped with a rough surface and the electrical conduit was lacking a seal; * Caulking behind hand washing sink with visible mold like debris in Building F;* Lower cabinet drawer missing front piece in Building A; and* Thermometer stored in a cabinet in Building D without any protection from possible contamination.j. Staff 2 was unable to demonstrate required knowledge for cooling, proper cooking temperatures, proper reheating temperatures, proper holding temperatures, proper sanitation of surfaces/pots/pans, and how foodborne illnesses were transmitted and how to prevent them, including cross contamination.k. Facility did not have pasteurized shell eggs for soft-cooked egg items. Staff 1 and Staff 2 were unaware of requirement that facility had pasteurized shell eggs and verified they served over easy and over medium fried eggs. l. Staff did not sanitize thermometers after potential contamination nor were they observed to check the temperature of foods after preparing and during serving process to ensure proper temperatures were reached and maintained. Staff 2 was asked to check the food temperature prior to serving. m. Staff did not know how to use the test strips available to validate concentration of sanitizer used for surface sanitation buckets and three compartment sinks. During the tour it was identified via test strip that the sanitizer system was not working and staff working were not aware. Kitchen staff were unaware of how long their surface sanitizing methods were not working. Staff 3 (Maintenance Director) was alerted and able to repair prior to exiting. n. Multiple staff were observed to potentially contaminate hands and food items while preparing and serving food and washing dishes when they did not wash or sanitize hands when switching from dirty to clean tasks. A kitchen staff was observed to touch food items while wearing potentially contaminated gloves. o. Staff preparing food was observed to rinse knife in sink with water and shake excess water off with no splash guard to protect prepping area next to sink. Staff was not observed to effectively wash and sanitize this piece of equipment after use.p. Staff 2 preparing food did not have hair effectively restrained as required.q. Staff serving food was observed to place all serving utensils in one bucket while moving food cart from building to building and pulled them out for serving food without cleaning, a potential source for allergen exposure. In an interview, Staff 2 (Person in Charge) toured the kitchen with surveyors and acknowledged the identified areas needing cleaning and repair, stock being stored on the floor, improper storage of food in walk-in, and use of test strips for proper sanitizing.Staff 1 (Administrator) and Staff 3 (Maintenance Director) toured kitchen and kitchenettes with surveyors and they acknowledged areas needing to be addressed.

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 C 240.

The findings of the re-licensure survey, conducted 06/06/22 through 06/08/22, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.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 first re-visit to licensure survey of 06/08/22, conducted on 07/13/22, 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 and OARs 411 Division 57 for Memory Care Communities. 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 06/08/22, conducted on 09/26/22, 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 and OARs 411 Division 57 for Memory Care Communities.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:Review of facility records on 06/07/22 identified the following deficiencies:There was no documented evidence fire and life safety instruction was provided to staff on alternating months.On 06/07/22 the need to provide fire and life safety instruction to staff, in accordance with the OFC was discussed with Staff 1 (Administrator), Staff 4 (Director of Plant Operations) and Staff 5 (Maintenance Assistance). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:Review of facility records on 06/07/22 identified the following deficiencies:There was no documented evidence that annual training on fire safety was provided to residents. This included residents in the memory care units, whose cognitive abilities allowed engagement in such instruction, and residents in the facility's RCF.On 06/07/22 the need to provide and document fire and life safety instruction for residents, at least annually, in accordance with the OFC was discussed with Staff 1 (Administrator), Staff 4 (Director of Plant Operations) and Staff 5 (Maintenance Assistant). They acknowledged the findings.

Based on observation and interview, 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 510.

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were properly labeled and maintained in a locked storage unit, and failed to ensure exterior pathways were maintained in good repair and did not contain drop offs to prevent tripping hazards for residents. Findings include, but are not limited to:On 06/06/22, an interior and exterior tour of the facility identified the following deficiencies:* Outdoor courtyard/patio areas contained drop off's, up to an inch and a half in depth, creating a possible trip hazard for residents;* Cleaning chemicals were observed accessible to the residents in unlocked cabinets in the kitchenette of cottage "B"; and* Multiple buckets were observed in resident courtyards that contained deicer and were not properly labeled. On 06/06/22, ensuring all toxic materials were properly labeled and maintained in locked storage to avoid access by residents, and the need to ensure all exterior pathways were maintained in good repair, was discussed with Staff 1 (Administrator), Staff 4 (Director of Plant Operations), and Staff 5 (Maintenance Assistant). They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in a locked storage unit, and failed to ensure exterior pathways were maintained in good repair and did not contain drop offs to prevent tripping hazards for residents. This is a repeat citation. Findings include, but are not limited to:On 07/13/22, an interior and exterior tour of the facility with Staff 1 (Administrator) and Staff 5 (Maintenance Assistant) identified the following deficiencies:* Outdoor courtyard/patio areas contained drop off's, up to three inches in depth, creating possible tripping hazards for residents in cottages A, B, D and E; and* Cleaning chemicals were observed accessible to the residents in unlocked cabinets in the kitchenette of cottages A and B.On 07/13/22, the need to ensure all toxic materials were maintained in locked storage to avoid access by residents, and the need to ensure all exterior pathways were maintained in good repair, was discussed with Staff 1 and Staff 5. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:On 06/06/22, a fireplace was observed in the common area of cottage "E". The fireplace was located where residents could come into incidental contact with it. The glass surface of the fireplace, measured with the surveyor's thermometer, was above 150 degrees F. Surveyor informed Staff 1 (Administrator), Staff 4 (Director of Plant Operations), and Staff 5 (Maintenance Assistant) that the fireplace could not exceed 120 degrees F. Staff 5 reported they would turn off the fireplace and Staff 1 reported they would put a memo out to staff to not utilize the fireplace until a cover could be obtained.On 06/07/22, the fireplace in cottage "E" was observed to be on and the glass surface temperature, measured with the surveyor's thermometer, was again above 150 degrees F. Surveyor informed Staff 5 to turn turn off the gas to the fireplace until a fireplace cover could be obtained. The fireplace and gas was later observed as turned off on 06/08/22.On 06/06/22, the need to ensure the surfaces around the fireplace did not exceed 120 degrees F was discussed with Staff 1 (Administrator), Staff 4 (Director of Plant Operations), and Staff 5 (Maintenance Assistant). 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 C 420, C 422, C 510 and C 540.
Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 510.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled direct care staff (#s 6, 7, 8 and 13) completed the required number of hours of annual training. Findings include, but are not limited to:Training records were reviewed with Staff 19 (Business Office Manager) on 06/07/22 and identified the following: * Staff 6 (CG), hired on 04/15/19, Staff 7 (MT), hired on 08/26/19, Staff 8 (CG), hired on 11/22/04, and Staff 13 (CG), hired on 05/30/06, lacked documentation of completing the required ten hours of annual training related to provision of care in community-based care or the required six hours related to dementia care. The need to ensure all required in-service training hours and requirements were completed annually was reviewed with Staff 1 (Administrator) and Staff 19 on 06/08/22. They acknowledged the findings.