The findings of the kitchen inspection, conducted 05/31/23, 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 05/31/23, conducted 08/22/23, are documented in this report. The facility was found 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 05/31/23 at 11:15 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:

* Flooring under mats with dirt/debris build up;

* Flooring in corners, edges, between and under equipment;

* Ice machine interior;

* Wall behind ice machine;

* Ceiling vents;

* Drains throughout kitchen;

* Industrial can opener and housing;

* Top of juice and coffee machine;

* Industrial mixer and table;

* Deli refrigerator door;

* Thermometer in deli fridge;

* Mixer, food processor, food processor container handle;

* Interior and exterior of bulk food bins and lids of bins;

* Shelves of baking racks;

* Floors under two baking racks with trash and food debris;

* Inside and edges of warming drawer; and

* Handle of bussing cart.

b. The following areas were found in need of repair:

* Metal shelving in cabinet cooler with peeling/missing coating exposing rusted metal;

* Sealing stripping on cabinet cooler peeling/missing and cracked;

* Trash can lids were cracked, heavily scored and dirty;

* Caulking behind hand washing sink with visible mold like debris;

* White caulking in dish washing area had spots with mold growth; and

* Open shelving under steam table with missing or damage to shelves caused an un-cleanable surface.

c. Cutting board on deli cart were found heavily stained and scored. Brown serving/cutting surface area on tray line had chipped edges;

d. Container of dressing stored in deli fridge without date/label. Container was also dirty with dried dressing on top and sides.

e. Sauté pans were found heavily scored and non-stick area flaking/scratching off. Plastic scoopulas and spatulas were found heavily stained and/or scored.

f. Facility did not have test strips available to validate concentration of sanitizer used for surface sanitation buckets and three-compartment sinks.

e. Staff were observed to prepare RTE (ready to eat) food items with bare hands and not with gloves as required. Staff were observed to potentially contaminate hands while serving food and did not wash or sanitize hands when switching from dirty to clean tasks. A server touched a dry rag on tray line several times during service. This rag was used to wipe area with food products, touch pans, etc. No hand washing step was observed after handling this potential contaminated rag and then touching food during plating.

f. Multiple kitchen staff preparing and/or serving food did not have hair and/or facial hair effectively restrained as required.

g. Memory care unit kitchenette was observed and the refrigerator was found to not have a thermometer to ensure food items were kept at appropriate temperatures. The reach in refrigerator was noted to have dirt, food debris/spills on the interior. Meat product was found stored next to produce (celery) in a drawer. Kitchenette cabinet next to entry door was found damaged and the handle on a cabinet outside by the entry door was found to have dried brown frosting like substance.

h. Kitchen staff were observed to place all food items served for lunch (roasted pork with peppers, steamed vegetables  with broccoli, carrots and cauliflower, and rice pilaf) into a blender with water and the outcome was poured into a bowl and served to resident on a pureed diet. Meal was not visually appealing and serving all food items in one container mixed/blended together did not meet expectations for palatable.

The surveyors reviewed above areas with Staff 2 (Dining Services Manager) and s/he acknowledged the identified areas.  At 2:00 pm the surveyors reviewed the areas in need of cleaning, repair and poor practices with Staff 1 (Administrator). S/he acknowledged the areas.

1.All areas identified A-H have been addressed and reviewed.

2. Willamette Springs will implement new Kitchen cleaning checklist and inspections. Facility will conduct twice monthly trainings in detail to items that were identified in survey.

3. New checklist will be monitored daily, weekly, bi monthly and quarterly based on individual need to maintain compliance.

4. Dining Services, Maintenance Director and Executive Director.

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 POC in this document for C240 for Plan of Correction fo142