Homewood Assisted Living

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.

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

This Rule is not met as evidenced by:

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.

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.

This Rule is not met as evidenced by:

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 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.

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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second 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.

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.