Print Inspection: CHOW010767

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. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to conduct fire drills every other month in accordance with the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to: Fire and life safety documentation from 11/2025 through 03/2026 was reviewed on 04/15/26 at 9:20 am with Staff 3 (Director of Plant Operations). The following deficiencies were identified: * The facility had conducted one fire drill in the assisted living unit, on 12/31/25. Staff 3 confirmed the facility had not conducted any other fire drills in the assisted living unit. * The facility provided documentation of one fire and life safety training for staff on 03/16/26. In an interview with Staff 1 (ED) on 04/16/26 at 11:20 am, she acknowledged the facility had not conducted fire drills every other month or provided fire and life safety instruction to staff on alternate months. The need to ensure fire drills and fire and life safety training were conducted per the OFC was reviewed with Staff 1 and Staff 2 (Regional RN) on 04/16/26 at 11:20 am. They acknowledged the findings.

The community has reviewed and implemented the Fire Drill & Life Safety Policy to ensure full compliance with state regulations. 1. Fire Drill Schedule & Compliance Fire drills are now scheduled every other month, on varying shifts (day, evening, night), in accordance with policy and OAR requirements. A structured annual calendar has been implemented and is monitored by the Director of Plant Operations and Executive Director. 2. Required Documentation The standardized TSL Fire Drill Forms will be used for every drill to ensure all required elements are documented, including: ? Date and time ? Location of simulated fire ? Primary and alternate escape routes ? Evacuation time ? Staff participation ? Number of residents evacuated ? Resident response and any issues encountered o Completed documentation will be: ? Maintained in the Fire Drill Binder ? Uploaded into TELS ? Copied to the Health Services survey binder 3. Staff Training Fire and Life Safety staff training will occur on alternating months between drills, per policy. Any staff who miss training will be assigned mandatory make-up training within 30 days. 4. Oversight & Monitoring The Director of Plant Operations will oversee drill execution and documentation. Monthly audits will be completed to ensure: ? Drills/trainings occurred as scheduled ? Documentation is complete and compliant The Executive Director will conduct quarterly reviews to ensure ongoing compliance and address any deficiencies immediately. 5. System Improvements A pre-drill preparation process has been implemented to ensure all documentation tools and scenarios meet regulatory requirements before each drill. Post-drill evaluations will be completed to identify and correct any procedural gaps. How we will ensure continued compliance: • Monthly audits by Plant Operations • Quarterly leadership review of fire and life safety compliance • Immediate corrective action taken if any drill, training, or documentation is missed or incomplete

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. This Rule is not met as evidenced by: