Timber Town 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 maintain the kitchen in good repair and in a sanitary manner in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observations of the four house kitchens on 03/10/26 from 10:15 am through 2:30pm revealed the following deficiencies: 1. House 4 and main food preparation kitchen: 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: * Stove top under back two burners; * Interior of microwave; * Interior of cabinets and drawers; and * Window screen. b. Multiple cabinet interior shelving edges were heavily worn, exposing porous wood surfaces yielding a non-cleanable surface. The back wall where pots and pans were stored was noted with heavy scoring/scratches that had exposed drywall, causing a non-smooth and non-cleanable surface. c. Clean and sanitized dishes were stored directly next to the dirty dish washing and/or hand washing sink, exposing clean dishes to potential splash contamination. d. An unlabeled/unidentified energy drink can was stored next to resident food products. e. Activities staff was observed to enter into the kitchen area during food/meal preparation without a hair restraint, and did not wash her hands. She then opened a cabinet and a drawer to retrieve a bowl and utensil for a resident. 2. House 3: 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: * Interior/exterior of cupboards/cabinets/drawers storing clean dishes and/or food; and * Interior of cabinet storing garbage can. b. Multiple cabinet interior shelving edges were heavily worn, exposing porous wood surfaces yielding a non-cleanable surface. c. A container of salsa was dated 03/03/26 without a use-by date. This was day seven and should have been discarded or a clear use-by date documented to ensure the product was safe for consumption. d. At 10:52 am, multiple containers of oatmeal were noted in the reach-in refrigerator with visible fresh condensation on the lids. Surveyor touched the outside of the container, and it was warm to the touch. The internal temperature of the food product was tested and read 97 degrees Fahrenheit. Staff were interviewed and indicated staff was finished serving by 8:40 am indicating that the food product was not at 70 degrees after 2 hrs. Staff were interviewed regarding cooling process and indicated they had not checked the temperature of the food product prior to putting it in the refrigerator. Staff indicated they had never checked the temperature when putting away food to ensure proper temperature thresholds were met during the proper cooling time frames. Staff indicated they feel the outside of the containers to ensure they are not too hot before putting in the fridge. Multiple containers of leftover food items were noted in the refrigerator also with noticeable condensation on the lids indicating they were not properly cooled down before lidded and placed in the refrigerator. e. There was no dedicated hand-washing sink. Dirty dishes were observed in both sides of the sink. f. Clean and sanitized dishes were observed stored directly next to the handwashing/dishwashing, sink exposing clean dishes to potential splash contamination. g. A small container of white powdery substance (sweetener) was observed uncovered and open to potential contamination h) Multiple containers of butter dated 03/06/26 were observed stored in a cabinet unrefrigerated. Some containers did not contain a date so it was unknown how long they were stored unrefrigerated. 3. House 2: 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: * Interior/exterior of cupboards/cabinets/drawers storing clean dishes and/or food; * Interior of cabinet storing trash can; and * Interior of ice machine with black and shiny biological matter build-up. b. Multiple cabinet interior shelving edges were heavily worn exposing porous wood surfaces yielding a non-cleanable surface. c. Multiple containers of leftover foods observed with large amounts of visible condensation on the lids indicating they were not properly cooled before covering and placing in the refrigerator. d. There was no dedicated hand-washing sink. Dirty dishes were observed in both sides of the sink. e. A container of butter dated 03/03/26 was observed stored in cabinet unrefrigerated. Some containers did not contain a date so it was unknown how long they were stored unrefrigerated. f. Handheld can opener observed to have heavy rust accumulation on the blade and needed replacement. 4. House 1: 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: * Interior/exterior of cupboards/cabinets/drawers storing clean dishes and/or food; * Interior of reach-in freezer pull out drawer seal; * Interior of microwave; and * Interior of cabinet storing trash can. b. Multiple cabinet interior shelving edges were heavily worn, exposing porous wood surfaces yielding a non-cleanable surface. c. Multiple food items stored past seven days and should have been discarded (washed lettuce, deli ham). Open cheese slices were removed from the manufacturer’s package and did not contain a use-by date for safety. A container of staff lunch was stored with resident food items causing a potential cross contamination concern. d. Multiple containers of left over foods observed with large amounts of visible condensation on the lids, indicating they were not properly cooled before covering and placing in the refrigerator. A container of oatmeal half full was noted to be warmer to touch and temperature was found at 79 degrees Fahrenheit at 11:18 am, more than three hours after service. e. A handheld can opener observed to have heavy rust accumulation on the blade and needed replacement. f. An undated container of butter was observed stored in a cabinet unrefrigerated. g. There was no dedicated hand-washing sink. Dirty dishes were observed in both sides of the sink. At approximately 1:45 pm, surveyor reviewed above items/areas with Staff 1 (ED), who acknowledged the need for correction.

Plan of correction for accumulation of food, spills, splatters, loose food and trash debris, dirt, dust- 1. Deep clean of all kitchens will be completed by 3/23/26. Weekly night shift duties list updated to include clean cupboards and drawers, clean microwave. Ice machine will be deep cleaned by 3/23/26 and there on monthly. 2. Updated cleaning duties sheets and maintenance routine schedules. 3. Resident Care Coordinators will do weekly walk throughs to ensure tasks are being completed. Administrator will sign off on monthly ice machine cleaning. 4. Administrator, maintenance director and resident care coordinators will be responsible for monitoring and corrections. Plan of correction for items that were found needing repair or replacement- 1. All areas cited for worn interior cabinet shelving will be covered in a rubber material to ensure they are cleanable and do not present safety or sanitation concerns. Rusty can openers in two houses. Back wall noted with scoring/scratches with exposed drywall has been repaired. 2. Kitchen Manager will check these weekly during walk throughs and report any concerns to maintenance. New can openers placed in two houses cited 3. Weekly 4. Kitchen Manager Plan of correction for staff related issues- 1. On 4/10/26 all staff will receive thorough training on food cooling procedures, open dates and when and how food is to be stored. Designated sinks posted with appropriate signage. Every kitchen will be rearranged to meet splatter criteria by 3/20/26. Spreadable butter replaced all regular butter on 3/18/26. 2. Kitchen Staff will do daily walk throughs while stocking to ensure all items above are maintaining compliance. Kitchen inspections will be completed bi-annually by administrator. 3. Daily and in depth bi-annually 4. Kitchen Staff and Administrator. Proper staff food storage; labeling of all food items with clear use-by dates to ensure safe consumption; adherence to proper food cooling and storage procedures; maintenance of a dedicated handwashing sink accessible at all times; prevention of splash contamination by ensuring clean dishes are properly protected; proper refrigeration of temperature-sensitive items lacking dates or exceeding the seven-day use period; and installation of appropriate signage to clearly designate handwashing sinks.

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).

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 new hired staff (#s 11, 17, 22 and 23) demonstrated competency in assigned duties within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 10/09/24 at 11:50 am with Staff 1 (Administrator) and Staff 2 (Assistant Administrator). The following was identified: There was no documented evidence Staff 11 (MT), Staff 17 (CG), Staff 22 (CG), and Staff 23 (CG), hired 07/14/24, 07/18/24, 07/28/24, and 07/26/24, respectively, completed training in one or more of the following areas: - Role of the service plan in providing individualized care; - Providing assistance with ADL’s; -Changes associated with normal aging; - Identification, documentation and reporting of changes of condition; and - Conditions that require assessment, treatment, observation and reporting The need for staff to complete all required training within 30 days of hire was discussed with Staff 1 and Staff 2 on 10/09/24 at 11:50 am. They acknowledged the findings.

Pre-Service Training I acknowledge that some of our staff did not complete their pre-service training as required. To address this, I have implemented the following corrective actions: • Mandatory Pre-Service Training: All new hires will complete the mandatory pre-service training before starting their duties. This training includes residents’ rights, abuse reporting, infection control, fire safety, and emergency procedures, etc. • Make-Up Sessions: I have scheduled make-up sessions for current staff who missed any part of their pre-service training. 30-Day Training I understand the importance of the 30-day training requirement. To ensure compliance, I have: • Comprehensive 30-Day Training Program: Developed a comprehensive 30-day training program that includes detailed modules on dementia care, medication administration, and other resident-specific needs. • Training Coordinator: Assigned a training coordinator to monitor and document the completion of these training sessions. Competency Packet To ensure our staff are competent in their roles, I have: • Competency Evaluation Packet: Created a competency evaluation packet that includes observation checklists, written tests, and practical assessments. • Regular Competency Evaluations: Scheduled regular competency evaluations for all staff and documented the results in their personnel files. New Program Implementation To enhance our training and compliance tracking, I have implemented a new program that assists in keeping track of all staff members’ Continuing Education Units (CEUs) and facilitates easy auditing and review of mandatory pre-service, 30-day, and annual trainings. Our updated staff training requirements clearly outline the steps new staff members must take to ensure compliance. Assigned Roles • Training Coordinator: Bryan Lyman has been assigned as the staff trainer. He will sign off on all competency trainings while working with new staff members for 40 hours on the job, including competency for the medication room. • Data Entry: Cheyenne, our Administrative Assistant, will complete the data entry of all staff into the med-trainer program. • Competency Review: The RN will review and sign off on each med-tech training competency form to ensure thorough training in all areas of the medication room. • Final Sign-Off: I (Administrator) will sign off on the competency packet and pre-service trainings to ensure that staff are not working on the floor until all training is complete. Immediate Corrective Actions • Staff Training: Ensure that Staff 11, 17, 22, and 23 complete the required training immediately. Document their completion of training in the following areas: o Role of the service plan in providing individualized care. o Providing assistance with Activities of Daily Living (ADLs). o Changes associated with normal aging. o Identification, documentation, and reporting of changes of condition. o Conditions that require assessment, treatment, observation, and reporting. Identification of Other Affected Staff • Review training records of all staff hired within the last six months to ensure compliance with the 30-day training requirement. Identify any other staff who may have missed required training and ensure they complete it promptly. Systemic Changes • Training Program Review: Revise the training program to include a checklist and tracking system to ensure all new hires complete required training within 30 days. • Competency Evaluation: Implement a competency evaluation process where new hires must demonstrate their skills and knowledge in the required areas before they can work independently. • Documentation: Maintain detailed records of all training sessions, including dates, topics covered, and staff attendance. Monitoring and Sustaining Compliance • Regular Audits: Conduct monthly audits of training records to ensure ongoing compliance. Assign a staff member to be responsible for these audits. • Feedback Mechanism: Establish a feedback mechanism where staff can report any issues or gaps in their training. Timeline • Immediate Actions: Complete the training for Staff 11, 17, 22, and 23 within the next 7 days. •Systemic Changes: Implement the revised training program and competency evaluations within 30 days. • Ongoing Monitoring: Begin monthly audits starting from the next month. Supporting Documentation • Training Completion Records: Include signed and dated training records for Staff 11, 17, 22, and 23. • Audit Reports: Provide a sample audit report showing the review of training records. I am committed to maintaining high standards of care and compliance with all state regulations. I appreciate your guidance and support in helping us improve our training and competency evaluation processes. I take this matter very seriously and am committed to ensuring that all our care staff meet the required training and competency standards.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

Based on interview and record review, it was determined the facility failed to conduct fire drills per OFC and to instruct staff in fire and life safety topics on alternate months from fire drills. Findings include, but are not limited to: Facility fire drill and fire and life safety records from 03/2024 to 09/2024 were requested and reviewed with Staff 1 (Administrator) on 10/08/24 at 10:21 am. The facility’s fire drill records lacked the following documentation: - Problems encountered, and comments relating to residents who resisted or failed to participate in the drills; and - Documentation fire and life safety instruction for staff was consistently completed on alternating months from the fire drills. The need to ensure fire drills were conducted per OFC, and staff were trained in fire and life safety procedures on alternate months from fire drills was discussed with Staff 1 on 10/08/24 at 12:05 pm. They acknowledged the findings.

Plan of Correction for OAR 411-054-0090 (1-2) Immediate Actions Taken 1.Review of Current Procedures: I immediately reviewed our current fire drill and fire safety training procedures to identify gaps and areas for improvement. 2.Staff Meeting: On 10/09/24, I held a meeting with all staff to discuss the citation and emphasize the importance of compliance with OAR 411-054-0090. 3.Documentation Update: I updated our fire drill record sheet to include sections for documenting problems encountered and comments relating to residents who resisted or failed to participate in the drills. Corrective Actions 1.Fire Drills: o Schedule: I have implemented a new schedule for unannounced fire drills to be conducted every other month at different times of the day, evening, and night shifts. o Documentation: Each fire drill record will now include: ? Date and time of day ? Location of simulated fire origin ? Escape route used ? Problems encountered and comments relating to residents ? Evacuation time period ? Staff members on duty and participating ? Number of occupants evacuated o Fire Alarm Activation: I will ensure the fire alarm system is activated during each fire drill unless otherwise directed by the Fire Authority having jurisdiction. Staff Training: o Alternate Month Training: I have implemented a schedule for fire and life safety instruction to be provided to staff on alternate months from fire drills. o Training Curriculum: I have developed comprehensive training materials covering fire and life safety procedures, evacuation methods, and responsibilities during fire drills. o Documentation: Detailed records of all training sessions will be maintained, including: ? Content covered ? Staff attendance with signatures ? Scheduled make-up sessions for staff who missed the initial training to ensure compliance within the month. Ongoing Monitoring and Compliance 1. Monthly Audits: I will conduct monthly audits of fire drill and training records to ensure compliance with OAR 411-054-0090. 2. Feedback Mechanism: o Feedback Forms: I will distribute feedback forms to staff after each fire drill and training session to gather structured feedback. These forms will include sections for observations, issues encountered, and suggestions for improvement. o Suggestion Box: I will place a suggestion box in a common area accessible to all staff, allowing them to anonymously submit feedback and suggestions at any time. I will review the submissions weekly. o Monthly Safety Meetings: I will hold monthly safety meetings with representatives from different shifts and departments to discuss feedback, review fire safety procedures, and plan for upcoming drills and training sessions. Minutes of these meetings will be documented. o Follow-Up Actions: I will assign specific staff members to address the issues and suggestions raised during the meetings. A log of actions taken in response to feedback will be maintained, including descriptions of the issues, actions taken, dates of completion, and responsible persons. o Communication with Staff: I will regularly update staff on changes made based on their feedback through staff meetings, email newsletters, and bulletin board notices. I will also acknowledge and thank staff for their contributions to improving fire safety. By implementing these corrective actions, I aim to ensure the safety of all residents and staff and maintain compliance with state regulations. I am committed to addressing this citation comprehensively and continuously improving our fire safety procedures.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission; and failed to re-instruct residents on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending, per the Oregon Fire Code (OFC). Findings include, but are not limited to: Facility fire drill and fire and life safety records from 03/2024 to 09/2024 were requested and reviewed with Staff 1 (Administrator) on 10/08/24 at 10:21 am. During the review of the fire drill records, Staff 1 reported the facility does not have documentation that residents were instructed on general fire safety procedures within 24 hours of admission, and the facility does not have a system for annual re-instruction of general safety procedures. The need to instruct residents of general fire safety procedures, and re-instruct residents at least annually per the OFC requirements was discussed with Staff 1 on 10/08/24 at 12:05 pm. She acknowledged the findings.

Fire and Life Safety Training-Residents Corrective Actions: Develop a Comprehensive Fire Safety Training Program o Details: I will create a detailed training curriculum that covers all aspects of fire safety, including evacuation procedures, the use of fire extinguishers, and emergency contact information. o Responsible Persons: Kelsea Burkhart (RCC), Kirsten Summers (Activities Director), and Holly Woods (Admin Assistant). o Evidence: A written training curriculum will be provided. Schedule and Conduct Mandatory Fire Safety Training Sessions o Details: I will organize regular training sessions, ensuring that all residents attend. These sessions will include visual aids, demonstrations, and practice drills to enhance understanding. o Responsible Persons: Kelsea Burkhart (RCC), Kirsten Summers (Activities Director), and Holly Woods (Admin Assistant). o Evidence: Attendance records and training session materials will be maintained. Distribute Fire Safety Information Materials o Details: Admin Staff will provide residents with brochures, posters, and handouts that summarize key fire safety tips and procedures. o Responsible Persons: Kelsea Burkhart (RCC), Kirsten Summers (Activities Director), and Holly Woods (Admin Assistant). o Evidence: Copies of the distributed materials will be kept. Implement a Fire Safety Drill Schedule o Details: I will establish a regular schedule for fire drills to ensure residents are familiar with evacuation routes and procedures. o Responsible Persons: Kelsea Burkhart (RCC), Kirsten Summers (Activities Director), and Holly Woods (Admin Assistant). o Evidence: A fire drill schedule and logs will be maintained. Documentation and Record Keeping o Details: I will implement a documentation system for all fire safety training sessions and drills. o Responsible Persons: Administrator and Admin assistants. o Evidence: Standardized forms and secure storage of records will be used. Monitoring and Evaluation 1. Regular Audits o Action: I will conduct quarterly audits of fire safety training records. o Responsible Persons: Administrator. o Details: I will review training records to ensure compliance with the training schedule and documentation requirements, addressing any discrepancies immediately. o Evidence: Audit reports and records of corrective actions taken will be maintained. Feedback Mechanism o Action: I will establish a feedback mechanism for residents and staff. o Responsible Persons: Administrator and Admin Assistants. o Details: I will collect feedback on the effectiveness of the training sessions and make necessary adjustments to improve the program. o Evidence: Feedback forms and records of adjustments made will be kept with the safety committee meetings.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents (5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

Based on observation and interview, it was determined the facility failed to ensure an electronic code that must be entered to use an exit door was clearly posted for residents, visitors, and staff use. Findings include, but are not limited to: The facility ground consisted of four cottages. During the acuity interview, Staff 4 (RN) stated the facility considers itself a “locked unit” due to housing residents with severe behavioral disorders. The facility was toured on 10/07/24 at 1:30 pm. It was noted each cottage required a manually entered code to use the exit door. During the survey, observations were made of residents leaving cottages by asking staff to enter the code. Facility staff confirmed the residents do not know the code, and the code was not visibly displayed. The need to clearly post an electronic code for residents, visitors, and staff to use, if a code is needed to use an exit door, was discussed with Staff 1 (Administrator) and Staff 2 (Assistant Administrator) on 10/10/24 at 12:00 pm. They acknowledged the findings. No further information was provided.

Warren Bird stated to me that there is nothing for me to do a plan of correction for with the current exceptions that are in place. I have attached the exceptions for your review.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

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 four cottage kitchen areas (1, 2, 3, 4) and food storage (Pantry) were reviewed on 04/24/24 from 10:45 am through 2:30 pm and identified 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: * Cracks in concrete floor in pantry; * Range top in house 2; * Ceiling vent in house 1; and * Screen and windowsill in house 3. b. Staff 3 (Cook) was observed to not follow 3 compartment method when sanitizing utensils/equipment used for meal prep. Staff were wiping dishes with a sanitized rag from sanitizer bucket after washing and rinsing utensils/equipment, pots and pans. Staff were not submerging and soaking items as required. S/he acknowledged the facility did not   have availability to effectively sanitize pots, pans and knives. c. During observations in cottages, surveyor noted dishwashing cycles to be on quick wash cycles. Staff interviewed in three of the four houses stated they washed the dishes for resident meal service on the one-hour cycle (quick wash) for the dishwasher. Staff interviewed were not able to validate the cycle effectively sanitized the dishes. Staff 1(Administrator) and Staff 2 (Person in Charge/Assistant Administrator), acknowledged the facility did not have a clear process for ensuring residential dishwashers were effectively sanitizing dishes and that all staff knew which cycles were effectively sanitizing dishes and ensuring that was the cycle used. d. Scoops were observed stored in bulk ice containers. Staff 1 and 2 acknowledged there was not a current system to ensure refrigerators with ice makers were cleaned and maintained in order to ensure ice produced was done in a clean and sanitary way to ensure safety of residents. e. During interviews with staff in all houses the following was identified: *Staff were not aware of proper cooling procedures for left overs; *Staff were not checking temperature of food products to ensure temperatures were at 41 degrees or below within 6 hrs; *Multiple staff were also not sure of temperatures required for reheating and the s urveyor was unable to validate food was reheated to 165 degrees Fahrenheit as required. f. Multiple food items were observed not dated when opened and/or did not have use by dates. In house 4, a container of sauce was found passed 7 days and should have been discarded. g. The Pantry building was constructed to have large breaks in flooring which had accumulated dust/dirt and debris and the wall junctures were not coved as required. The pantry building stored a large amount of bulk dry storage food items, and multiple reach in freezers and/or refrigerators. h. Surveyor observed multiple meal trays delivered to resident rooms uncovered/protected from contamination. The findings were reviewed with Staff 1 and Staff 2 at 2:00 pm, Staff acknowledged the areas .

A.The Administration team has developed a comprehensive cleaning schedule and task list to maintain the outdoor pantry's cleanliness and orderliness. The maintenance team has been tasked with thoroughly cleaning the kitchen vents to prevent dust, grime, and grease accumulation. The kitchen manager will conduct regular kitchen inspections 1x per month in every kitchen. A detailed deep cleaning list was developed by the Kitchen Manager that includes routine cleaning of all range tops, screens, and windowsills. The RCC team will monitor daily and ensure compliance and competency with our care team. To address the chips and cracks in the pantry, a work order has been issued to our maintenance team. Concrete crack filler and epoxy concrete paint will be applied to repair the damage. The maintenance team will incorporate monthly inspections of the pantry flooring into their routine duties to ensure its upkeep and compliance. Monthly inspections by the kitchen manager will ensure proper upkeep of the pantry and kitchen areas were completed by. B. Timber Town Living has purchased a commercial-grade tub to ensure all staff are able to utilize a three-compartment sink that is sufficiently sized to allow for the complete submersion and sanitization of all cookware, such as pots, pans, and knives. The RCC's will ensure that the staff are knowledgeable about proper utiliztion of the sanitizing bucket in every staff members onboarding and orientation. The kitchen manager has provided a separete tub that can be utilized for wiping down surfaces as a way to redirect this habit to the appropriate bucket. The RCC's and the Lead Care Givers will ensure the daily compliance of properly sanitizing dishes. All concerns will be reported to the kitchen manager. C. The Timber Town Living maintenance team will utilize a waterproof electric thermometer to verify the dishwasher's temperature. Monthly checks will be conducted by the maintenance team to ensure the water reaches the appropriate temperature for sanitization, and the results will be meticulously recorded in a maintenance log. Signage will be prominently displayed on all dishwashers, providing staff with clear instructions on the proper cycle to use for dishwashing. D.To ensure employees do not place scoops in the ice makers, the scoops will be stored in a clearly marked ziploc bag in the freezer. After each use, staff members will return the scoops to the bag. Signage will be placed on all freezers and ice makers to remind employees to keep scoops out of the machines. Our maintenance team will fully defrost the ice makers montly, allowing the care team to thoroughly clean and sterilize all ice makers and ice maker trays. The facility administration team has added this deep clean schedule to the daily and monthly duties of the maintenance and care teams. The RCC's will monitor the care team daily and report to the kitchen manager of any concerns. E. The administrative team has developed a comprehensive training program to ensure all employees understand the proper cooling procedures. This training covers the handling, storing, refrigerting and reheating of leftovers. Signage has been placed in all kitchens to provide guidelines for proper cooling and warming methods and temperature danger zones. Additional supplies will be provided to the care team as needed throughout this transition. Additionally, the cooling process has been incorporated into the training and competency packet provided to all staff. G. The care team has been tasked with ensuring that all food items are properly labeled and discarded when they reach their expiration date. As part of their daily routine, the kitchen manager now conducts thorough kitchen inspections, paying special attention to the pantries and refrigerators to identify any outdated or improperly labeled food items. H.Timber Town Living's pantry was intentionally placed with expansion joints in the concrete to prevent cracks and buckling. Concrete expands and contracts as temperatures fluctuate and absorbs moisture, which can cause excess stress on the concrete. Without expansion joints, this movement can cause severe stress points that weaken the structure and may lead to early replacement or significant damage. Timber Town Living will submit an exemption to request that these joints be left in place in order to preserve the concrete. Timber Town Living has created a deep cleaning program for the cooks to properly clean out the expansion joints on a regular basis. Timber Town Living management will be doing daily rounds to ensure this is being done. Timber Town Living maintenance installed molding to every wall junction on 4/29/24. To ensure the prevention of food contamination, Timber Town Living has made an investment in food trays and covers. These items have been incorporated into Timber Town Living's training materials. All staff members have received comprehensive training on the proper procedure for delivering meal trays to residents' rooms.

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.

See C240

The findings of the kitchen inspection, conducted 04/23/24 thru 04/24/24, 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 revisit to the kitchen inspection of 04/24/24, conducted 07/10/24, 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.

The findings of the on-site investigation, conducted 07/25/23 through 07/25/23, 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 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

The findings of the on-site investigation, conducted 07/25/23 through 07/25/23, 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 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

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility's kitchens, food storage areas, food preparation, and food service on 03/16/23 revealed: * There was peeling paint inside the microwaves in Houses 2 and 4. * Cutting boards in all buildings were significantly scored and some had deep gouges; * The interior and exterior of cabinet doors and drawers in House 4 had drips, spills, splatters, and debris; and * There were areas on the cabinets in House 4 where the varnish had worn through and raw wood was exposed. The findings were reviewed with Staff 1 (Administrator). He acknowledged the findings.

1. Facility Maintanence has replaced both Microwaves in Houses 2 and 4. Facility Maintance has fixed the cabinets in house 4 that had raw wood exposed. Facility Cooks have deep cleaned the kitchens and outside pantries to ensure all food debris are clean and sanitary. Administration has provided all new cutting boards and got rid of the old ones.   2. Facility Administration has created a deep cleaning schedule for the kitchen staff to ensure deep cleans of kitchens and the outside pantry is being kept clean and orderly. Maintanence will routinly check the kitchens for chipped paint and repair as needed. 3. Facility Administration will monitor the kitchens Monthly to ensure compliance with cleaning and sanitation policies. 4. Kitchen Manager & Administration.

The findings of  the kitchen inspection, conducted on 03/16/23, 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 3/16/23, conducted 6/14/23, 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 unannounced complaint investigation conducted 10/25/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. No deficiencies were identified in relation to the complaint.

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 10/26/2022.  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

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 10/25/2022.  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

Based on interview and record review, it was confirmed that the facility failed to administer medications and prescribed. Findings include: In review of Resident # 1's medication administration records (MARs) and progress notes for August 2022 and Medication Incident Report for 08/26/22. Resident #1 received 6 doses of a medication that was put on hold. The facility failed to give medication as ordered in the MAR. The above information was acknowledged by Staff #1-2 on 09/08/22. In interviews on 09/08/22, Staff #1-2 stated that Resident #1 had a medication on hold, however, when cycle fill was put in on 08/20/22, a new card was placed in the resident 's basket. The morning med tech gave the medication because they did not check the medication against the MAR. . Plan of Correction: Policy and procedures for medication administration reviewed with staff, system re-evaluated and corrections made. Staff member was written up and pulled off the cart to part time med passer.

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 09/08/2022.  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