Timber Town Living

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.

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.

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.

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.

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.

See C240

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.

1. The Service planning team updated service plans to reflect all current care needs, preferences and equipment. Service planning team will direct the staff of any updates to these service plans.2.The service planning team consists of Administration staff, Nursing Staff and Care Staff. Service planning team is responsible for keeping the service plan up to date. The nurse will review the updated Service Plan to ensure that all care needs are addressed, and they provide clear direction to direct care staff. 3.The Nursing staff and Administrative staff will be evaluating service plans quarterly or upon changes of condition to ensure service plans are up to date and accurately reflect current care needs. 4. The Administrative team will review the system on a quarterly basis to assure compliance

1. Resident 3's service plan has been reviewed with the service planning team. Nectar thick liquids and cuing with meals have been reviewed with all staff. 2. Facility Administration obtained new containers of Thick-it with instructions and proper measuring utensils for each house to ensure proper and consistent measurements for thickened liquids. Staff will be trained and educated on how to properly utilize thickening agents and how to obtain the proper consistency as prescribed by the residents PCP. 3. Facility Med tech's will monitor daily to ensure that Residents needing thickened liquids will have them on a daily basis. Facility RN's will monitor on a quarterly basis and as needed to ensure staff are properly following each residents diet. 4. Facility RN's & Administrator will assure compliance.

1. MAR's have been reviewed to reflect the narcotic logs to ensure all meds that have been signed out of the narcotic book have been logged into the EMAR system. Medication Aides have received additional training by the Nursing Staff to ensure they are logging all narcotics that are being given in both the narcotic book and the EMAR. We have reached out to Eldermark to utilize the electronic narcotic count record system they have available through EMAR. Administration will be starting this process of training all staff once training is completed with the Administrative staff. 2. The Medication Tech's and Nursing Staff will be responsible to assure that all medications are being signed out of the EMAR system. The Medication Aides will be monitored by the Nursing Staff to assure compliance. 3. MAR will be evaluated by the Nursing Staff regularly for quality assurance. 4.Administration Team will be monitoring Monthly to assure staff are following established protocol