Homewood Assisted Living

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired direct care staff (#s 6, 8, 9, and 10) had completed orientation prior to beginning their job responsibilities. Findings include but are not limited to: Staff training records were reviewed with Staff 1 (ED) on 06/10/26 at 11:30 am. There was no documented evidence that Staff 6 (MT), hired 06/03/25, Staff 8 (CG), hired 01/26/26, Staff 9 (CG), hired 01/20/26, and Staff 10 (CG), hired 03/19/26, had completed orientation prior to beginning their job responsibilities in one or more of the following areas: * Resident rights and values of CBC care; * Abuse reporting requirements; * Fire safety and emergency procedures; * Written job description; * Infectious disease prevention; * Dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms; * Techniques for understanding, communicating, and responding to behaviors, and reducing the use of antipsychotic medications; *Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and * Specific aspects of dementia care and ensuring the safety of residents with dementia, addressing pain, providing food and fluids, preventing wandering and elopement, and use of a person-centered approach. The need to ensure staff had completed orientation prior to beginning their job responsibilities was discussed with Staff 1 and Staff 2 (Health Services Director) on 06/10/26 at approximately 12:30pm. They acknowledged the findings.

Employees 8 and 10 are no longer employed by the facility. The files for employees 6 and 9 were audited, and all missing or incomplete documents were corrected to comply with OAR 411-054-0070(3)-(4). The facility will audit all current employee files to ensure compliance with part C370 of the regulation, and complete or correct any missing pre-service or orientation documentation. A tracking spreadsheet has been implemented to monitor employee file compliance, including completion of required pre-service orientation. The Business Office Manager, under the supervision of the Executive Director or designee, is responsible for maintaining the spreadsheet to ensure ongoing compliance.

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 2 of 4 newly hired direct care staff (#s 6 and 8) had demonstrated competency in all assigned duties within 30 days of hire. Findings include but are not limited to: Staff training records were reviewed with Staff 1 (ED) on 06/10/26 at 11:30 am. There was no documented evidence that Staff 6 (MT), hired 06/03/25, and Staff 8 (CG) had demonstrated competency within 30 days of hire in one or more of the following areas: * The role of service plans in providing individualized resident care; * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; and *Conditions that require assessment, treatment, observation and reporting. The need to ensure direct care staff demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 and Staff 2 (Health Services Director) on 06/10/26 at approximately 12:30 pm. They acknowledged the findings.

Employee 8 is no longer employed by the facility. Employee 6 demonstrated competency in all assigned duties, and the signed evaluation has been added to her file. The facility will audit all direct care employee files to ensure competency evaluations are completed within 30 days of hire, as required by OAR Section C372. The facility will also ensure all staff and contractors who provide direct resident support complete the required LGBTQIA2S+ training. A tracking spreadsheet has been implemented to monitor employee compliance, including timely competency evaluations and required LGBTQIA2S+ training. The Business Office Manager, under the supervision of the Executive Director or designee, will maintain the spreadsheet. The Executive Director or designee will also collect and maintain documentation of contractors' LGBTQIA2S+ training.

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 document all required elements of fire drills in accordance with the Oregon Fire Code (OFC). Findings include but are not limited to: On 06/09/26 at 1:45 pm, six months of facility fire drill and fire and life safety records, from 12/2025 through 05/2026, were requested and reviewed with Staff 4 (Maintenance Director). The following was determined: Fire drill documentation was lacking the following required components: * Number of occupants evacuated; * Evacuation time period needed; and * Problems encountered and comments relating to residents who resisted or failed to participate in the drills. The need to ensure fire drills addressed all required components was discussed with Staff 1 (ED) and Staff 3 (Director of Maintenance) on 06/10/26 at approximately 12:50 pm. They acknowledged the findings.

On 6/26/26, the Director of Maintenance and Executive Director in-serviced staff on the facility's Emergency Action Plan (EAP) evacuation procedures. The next fire drill will include a simulated resident evacuation with documentation of the number of residents evacuated, evacuation time, and any issues encountered, including resident participation. Following the drill, an ad-hoc Safety Committee (including the Director of Maintenance, Executive Director, Health and Wellness Director, and at least one participating staff member) will review the results, conduct a root-cause analysis of identified issues, and revise evacuation procedures as needed. At the next all-staff monthly meeting, the Executive Director or designee will review the findings and provide training on any protocol changes. Future fire drills and evacuation exercises will continue to document any issues, with the Executive Director or designee reviewing results and implementing additional corrective actions or training as needed to ensure ongoing compliance with OAR section C420.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment during meal service. Findings include, but are not limited to: Observations of meal service were completed between 09/08/25 through 09/10/25 and revealed the following: * Multiple care staff responsible for resident care and meal service were observed to serve food and beverages to residents without donning a protective barrier over potentially contaminated clothing. * Multiple care staff retrieved items from the kitchen, touched residents, and touched wheelchairs/walkers, without performing hand hygiene prior to or between tasks. The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving meals to the residents was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 09/10/25. They acknowledged the findings.

1. Community will ensure that aprons are available for staff to wear during meal service. Clean aprons are to be used for one meal only and then are considered dirty. 2. Dirty aprons will be placed in a bin after each meal service. 3. NOC shift employees to wash dirty aprons during their shift to ensure clean aprons are always available. 4. Staff to be trained about wearing aprons during staff meeting that will be held on 9/25/25. 5. Staff to be trained on infection prevention/hand washing during staff meeting on 9/25/25. 6. Dining Services Manager to monitor and ensure that staff wash hands after touching different things.

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

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 in fire and life safety procedures at least annually. Findings include, but are not limited to: Fire and life safety records were reviewed and discussed with Staff 1 (ED) and Staff 4 (Director Maintenance) on 09/10/25 at 10:40 am. There was no documented evidence residents were educated in general fire and life safety procedures, evacuation methods, responsibilities and designated meeting places inside or outside the building in the event of an actual fire at least annually. The need to ensure fire and life safety instruction was provided to each resident annually was discussed with Staff 1, and Staff 2 (Health Wellness Director) on 09/10/25 at 12:07 pm. They acknowledged the findings.

1. Executive Director to create a checklist. Checklist includes: a. Topics that need to be covered annually b. Signature sections for both resident/staff member training c. Date for when it was completed. 2. Health and Wellness Director to go over training with resident during quarterly evaluations (every 90 days). This practice to be implemented 9/22/25 3. Executive Director to monitor this quarterly when quarterly reviews are due.

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 observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 06/15/23 at 11:10 am, the following areas were observed in need of cleaning: * The vent located on the ceiling above the coffee station and handwashing sink; * The ceiling light cover, directly in front of a vent and near the coffee station and the steam table;   * The ceiling area around a pipe that was attached to the ceiling between the steam table and the dishwashing area;   * The sides of the grill and stove; and   * Vents under the hood above the stove/grill. * One staff was observed without any hair restraint. The areas of concern were observed and discussed with Staff 1 (Dining Services Manager) and Staff 2 (Interim Executive Director) on 06/15/23. The findings were acknowledged.

C240 OAR 333-150-0000 Sanitation Rules The following areas will be cleaned of any grease, dirt, dust or other debris - The vent located on the ceiling above the coffee station and handwashing sink - The ceiling light cover, directly in front of a vent and near the near the coffee station and the steam table. - The ceiling area around a pipe that is attached to the ceiling between the steam table and the dishwashing area. - The sides of the grill and stove - Vents under the hood above the stove/grill These areas will be added to the daily cleaning schedule. The Dining Services Director will evaluate these areas during her weekly sanitation audit. Interim Executive Director and Dining Services Director will ensure these corrections are made and monitored. C240 OAR 333-150-0000 Sanitation Rules - One staff member was observed without any hair restraint Dining Services Manager will ensure all staff use effective hair restraints to prevent the contamination of food or food-contact surfaces. Dining Services Manager/ Cook, Manager on duty will ensure staff are following this rule daily. Interim Executive Director and Dining Services Manager will ensure the correction is completed and monitored.

The findings of the kitchen inspection, conducted 06/15/23, 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 first re-visit to the kitchen re-licensure survey of 06/15/23, conducted 08/24/23, 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 interview and record review, it was determined the facility failed to ensure fire drill records included documentation of all required elements and fire and life safety instruction to staff was provided on alternate months from fire drills. Findings include, but are not limited to: On 03/07/22, fire drill and fire and life safety training records from 10/26/21 to 02/28/22 were reviewed. The following deficiencies were identified: A. Fire drill records lacked documentation of the following required components: * The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the fire drills; and * Number of occupants evacuated. During an interview with Staff 4 (Maintenance) on 03/08/22 at 11:30 am, he stated the facility was not relocating or evacuating residents during fire drills. B. The facility did not provide fire and life safety instruction to staff on alternating months from fire drills. Documentation review and interview with Staff 4 on 03/08/22 confirmed the facility was not consistently providing fire and life safety instruction to staff on alternating months from fire drills. The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 6 (Riverwood ALF Administrator) and Staff 7 (Corporate) on 03/08/22 at 11:45 am. They acknowledged the findings.

1. Community will provide fire and life safety instructions for staff on alternating months of fire drills and ensure all required components are documented and recorded. 2. Community will continue to conduct monthly fire and life safety training per Prestige Senior Living policy and ensure to meet OAR 411-054-0090 and 411-054-0093. Staff will be trained at newly hired, the following topics every other month; elopment drill, prolonged power failure, earthquakes, extreme heat, wildfires, winter storms and extreme cold, chemical threats, floods, thunderstorms and lightening and bomb threats. Staff will be intereviewed and provided questionnaire form outside of monthly training to ensure each individual is aware and acknowledges importance  of safety escape route that is outlined in our fire and life safety plan. 3. This system will continue to be conducted and monitored each month to ensure staff are in compliance with our safety plan. 4. This system will be monitored monthly by Maintenance Director, Executive Director will be responsible for compliance.

The findings of the re-licensure survey conducted 03/07/22 through 03/09/22 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 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 03/09/22, conducted 05/12/22, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Regulations.