Print Inspection: CHOW009489

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 ensure fire drills were conducted in accordance with the Oregon Fire Code and that fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to: Fire and life safety records, reviewed from 08/2025 through 02/2026, showed fire drill documentation was lacking in the following areas: * The escape route used; * Number of occupants evacuated; and * Evidence of alternate routes used. Additionally, the records reviewed did not show fire and life safety training was provided to staff on alternate months from fire drills. On 02/19/26 at 01:20 pm Staff 1 (ED) and Staff 5 (Maintenance Director) confirmed that all required elements were not included on their current fire drill documentation records and life safety training had not been completed as required. The need to ensure all required components were addressed and documented for each fire drill, and that drills were conducted on alternate months from fire and life safety training, was discussed with Staff 1 and Staff 5 on 02/19/26.

Fire drills and Life Safety training will be completed on schedule per the OAR. Life safety Binder and Fire drill binder will be organized according to month due and monthly calendar schedules will be completed as reminders of due dates. (Maintenance Director) will hold all trainings on fire and life safety during new hire orientation every Tuesday and as needed. Maintenance Director will ensure that every current employee has had fire and life safety training. Fire drill form updated to include required questions pertaining to OAR which include *the escape route used; *Number of occupants evacuated; and *Evidence of alternate routes used. Fire and Life Safety is on an alternate month schedule in our TELS system to provide reminders and due dates to our Maintenance director.

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:

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 instruct residents within 24 hours of admission, and re-instruct at least annually, on 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, and failed to maintain a written record of fire safety training, including content of the training sessions and the residents attending. Findings include, but are not limited to: Review of fire drill and fire and life safety records from 11/01/25 through 02/17/26 revealed there was no documented evidence of resident instruction within 24 hours of admission or annual fire safety re-instruction. On 02/18/25 at 1:15 pm, Staff 1 (ED) confirmed the facility did not have a system for instructing residents within 24 hours of admission or re-instructing residents at least annually on fire and life safety expectations. The need to instruct residents within 24 hours of admission and re-instruct at least annually on fire and life safety procedures was discussed with Staff 1 and Staff 5 (Maintenance Director) on 02/19/25 at 1:20 pm. They acknowledged the findings.

All residents and their POA’s who currently reside at Windsong will have facility fire and life safety procedures explained and documented. RCC’s will review this quarterly with resident care plan meetings to ensure completion. All new residents will have fire and life safety training within 24 hours of admission from our Community relations director. Move in packets will contain our life and fire safety form for Community relations director to go over.

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 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to ensure all chemicals and other toxic materials were in a locked storage unit and exterior pathways were maintained in good repair. Findings include, but are not limited to: During a tour of the MCC on 02/17/26 at 12:45 pm, the following was identified: * Cleaning chemicals and disinfectants were observed accessible to the residents in unlocked cupboards within the dining room kitchenettes in both Aspen and Cedar units of the MCC; and * The interior and exterior courtyard pathways had multiple drop-offs along pathway edges, measuring up to approximately two inches in depth. The drop-offs presented a potential trip and fall hazard to residents using the pathways. The need to ensure all chemicals and other toxic materials were in a locked storage unit and exterior pathways were maintained in good repair was discussed with Staff 1 (ED) and Staff 4 (Resident Care Coordinator) on 02/19/26 at 3:50 pm. They acknowledged the findings.

Courtyard pathway edges that measured up to two inches in depth will be filled in with Mulch by Maintenance Director and monitored Monthly. All chemicals and other Toxic materials were removed immediately. Cleaning chemicals are now stored in locked housekeeping closets. Housekeeping will ensure that after using chemicals, they will return them to locked closets directly after.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up. This Rule is not met as evidenced by:

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C420, C422, and C510.

The issue identified during survey was reviewed by the Administrator immediately upon notification. All documentation and procedures related to the cited concern were reviewed to ensure compliance with Oregon Administrative Rules for Residential Care Facilities.The Administrator has reviewed the applicable Oregon Administrative Rules and facility policies to ensure administrative compliance. Staff and management were re-educated on regulatory requirements and facility policy to ensure ongoing adherence to state regulations.The Administrator or designee will conduct periodic reviews of relevant documentation and practices to ensure compliance with Oregon Administrative Rules. Any concerns will be addressed immediately through retraining or policy clarification.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) 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 when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure staff training requirements were met related to pre-service orientation for 3 of 3 newly hired staff (#s 11, 12, and 16), dementia training for 4 of 4 newly hired (#s 11, 12, 16, and 7), and demonstration of competency in job duties within 30 days of hire for 3 of 3 newly hired staff (#s 11, 12, and 16). Findings include, but are not limited to: Training records were reviewed on 02/18/26 at 11:20 am with Staff 6 (Business Office Manager). The following was identified: 1. There was no documented evidence that Staff 11 (MT), Staff 12 (CG), Staff 16 (CG), and Staff 7 (Cook), hired 12/18/25, 11/23/25, 11/18/25, and 01/12/26, respectively, had completed one or more of the following pre-service orientation and/or dementia training: * Resident rights and values of CBC care; * Fire safety and emergency procedures; * Family support and the role the family may have in the care of the resident; and * How to provide personal care to a resident with dementia, including an orientation to the resident’s service plan. 2. There was no documented evidence Staff 11 (MT), Staff 12 (CG), and Staff 16 (CG), hired 12/18/25, 11/23/25, and 11/18/25, respectively, demonstrated competency in one or more of the following areas within 30 days of hire: * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting. The need to ensure staff training requirements were completed within the requisite time periods was discussed with Staff 1 (ED) and Staff 6 on 02/18/26. They acknowledged the findings.

Training program through Oregon Care Partners has been established with the required training courses such as *Resident rights and values of CBC care; *Fire safety and emergency procedures. *Family support and the role the family may have in the care of the resident; and *How to provide personal care to a resident with Changes associated with normal aging. * Identification, documentation and reporting of changes of condition; and * Conditions that require assessment, treatment, observation and reporting. Staff who have not completed them have been assigned the training needed. BOM and ED will monitor completion of these training courses by using our monthly audit form. BOM updated Residents Rights forms have been reviewed and signed with staff. Resident rights forms have been added to our new hire orientation packets

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) 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 when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request. This Rule is not met as evidenced by:

OAR 411-057-0160(g) Outside Area (g) Access to secured outdoor space and walkways which allow residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance. Findings include, but are not limited to: During a tour of the secured interior and exterior courtyards of the Aspen and Cedar units on 02/17/26 at approximately 1:00 pm, it was observed that the doors allowing entry to and return from the courtyards in Cedar and Aspen units were locked. Residents were unable to access the secured courtyards or return indoors without staff assistance. Interviews conducted with multiple care staff on 02/18/26 indicated the courtyard doors in both Aspen and Cedar remained locked, and staff opened the doors for the residents when they requested to go outside. The need to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 1 (ED) and Staff 4 (Resident Care Coordinator) on 02/19/26 at 3:50 pm. They acknowledged the findings.

Interior and exterior doors to the secured courtyards have been unlocked to allow residents to enter and return without staff assistance. Interior and exterior doors will only be locked when there are unsafe weather conditions, and a sign will be posted by Maintenance Director. Maintenance will check doors daily to ensure they are unlocked and if needed lock due to unsafe weather, signage will be posted.

OAR 411-057-0160(g) Outside Area (g) Access to secured outdoor space and walkways which allow residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). This Rule is not met as evidenced by: