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: 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 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 02/2025 through 07/2025 were reviewed with Staff 3 (Maintenance Director) on 08/13/25 at 1:30 pm. During the review of the fire drill records Staff 3 reported the facility did not have documentation that residents were instructed on general fire safety procedures within 24 hours of admission and the facility did not have a written record 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 (ED) on 08/13/25 at 3:52 pm. She acknowledged the findings.

In regards to OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents, "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…"- To address this deficiency, a full building evacuation drill was conducted on 08/20/25 with all staff on duty and residents in the building. An acknowledgement sheet of the training was signed by residents and staff. (Please see attached sheet.) For residents who were not present, a 1:1 training was completed. For staff that was not present during the drill, a training session was completed at the following All-Staff Meeting on August 27th, 2025. (Training Sheet Attached) Moving forward, the Health Service Director is going to go over the Fire and Life Safety protocol as well as perform a physical evacuation walk-through with new residents within 24 hours of move-in, while performing her move-in assessment. Once moved in, she will also make the life-safety training a part of her annual evaluation and have the resident(s) sign the paperwork upon completion. When conducting fire drills for the community, the residents will also be given a refresher course on the evacuation routes and procedures for the community, and be asked to sign on the fire drill training alongside the staff signatures. The Executive Director will be responsiblefor ensuring that these corrections are immediately implemented and monitored on an ongoing basis.

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:

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure its change of ownership survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 613.

See C613.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation. This Rule is not met as evidenced by:

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to keep all interior surfaces clean and in good repair. Findings include, but are not limited to: The interior of the building was toured on 08/13/25 at 1:20 pm. The following areas were in need of cleaning or repair: * Chipped paint on walls and corners in dining room area; * Extensive dark stains on carpet in hallways and common areas throughout the building, and in several resident rooms; * Marks and scuffs on multiple base boards throughout the facility; * Handrails were scratched or worn in multiple areas; and * Wood furniture showed marks and scratches on legs in dining room and common areas. In an interview on 08/13/25 at 2:50 pm, Staff 1 (ED) stated the facility had plans to remodel and upgrade all areas of the building, including carpets, painting, and wood fixtures. However, there was no documentation of contracts, bids, or specific time frames for the work to be completed. On 08/14/25, the need to maintain all interior surfaces clean and in good repair was discussed with Staff 1. She acknowledged the findings.

In regards to OAR 411-054-0300 (4) General Building: Doors, Walls, Cleanable, "…walls and interior surfaces clean and in good repair."- There is an overall remodel being planned on the interior of the building to address this deficiency. Completion date is still to be determined, but work on the floors is scheduled to begin on 10/13/25. Chipped paint on the walls and corners in the dining room will be touched up and repaired by the Maintenance Director in the meantime. Stained carpets will be replaced with new carpet or Laminate Vinyl Plank flooring during the remodel and the Maintenance Director has the current carpet on a rotating cleaning schedule, with weekly spot-cleaning and monthly deep-cleaning by hallway, to equal a full deep clean quarterly. The Marks and scuffs found on baseboards will be cleaned and touched up, along with the handrails along the walls. This will all be repaired/replaced during the remodel. In regards to the wood furniture showing marks and scratches on the legs, they will be cleaned and evaluated by the Maintenance Director, to determine if they need repair. Chairs will be replaced during the remodel.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must be kept clean and in good repair. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to keep all interior surfaces clean and in good repair. This is a repeat citation. Findings include but are not limited to: The interior of the building was toured on 12/04/25 at 10:18 am. The following areas were in need of cleaning or repair: * Extensive dark stains on carpet in hallways, in common areas throughout the building, and in several resident rooms; * Chipped paint on walls and corners in dining room area; * Marks and scuffs on multiple base boards in the dining room; and * Wood furniture showed marks and scratches on legs in dining room and common areas. In an interview on 12/04/25 at 10:50 am, Staff 1 (ED) stated the facility had not begun the scheduled remodel with upgrades to all areas of the building, including the carpets, painting and wood furniture. On 12/04/25 at 12:20 pm, the need to maintain all interior surfaces clean and in good repair was discussed with Staff 1. She acknowledged the findings.

In regards to OAR 411-054-0300 (4)(d-i) General Building: Doors, Walls, Cleanable, "…Interior Doors, Exit Doors, Walls and Ceilings, Elevators, The Interior of the facility must be free from unpleasant odors, 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 must be kept clean and in good repair". The overall remodel of Astor Place officialy began on 12/15/2025. Chipped paint on the walls and corners in the dining room will be repaired during this process. Stained carpets will be replaced with new carpet or Laminate Vinyl Plank flooring during the remodel and the Maintenance Director has the current carpet on a rotating cleani g schedule, with weekly spot-cleaning and monthly deep-cleaning by hallway, to equal a full deep clean quarterly. Marks and scuffs found on baseboards will be cleaned and touched up, along with the handrails along the walls. This will all be repaired/replaced during the remodel. In regards to the wood furniture showing marks and scratches on the legs, they will be cleaned and evaluated by the Maintenance Director, to determine if they need repair. Chairs will be replaced during the remodel. The Executive Director is including a copy of the Scope of Work being done during the remodel as well as the timeline for completion. There will also be a request for a timeline extension for completion, as the flooring will not be completed until the end of February 2026.

OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable (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 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. An ALF 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 must be kept clean and in good repair. This Rule is not met as evidenced by: