OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure 2 of 2 sampled residents (#’s 2 and 4) were treated with dignity and respect during meal service. Findings include, but are not limited to: Observations were conducted of dining service on 09/09/25 and 09/10/25. The following concerns were identified: 1. Resident 2 moved into the facility in 11/2020 with diagnoses including degeneration of the brain, dysphagia, and a history of weight loss. The resident was observed to require cueing and physical feeding assistance and received a mechanical soft diet and pre-thickened nectar thick liquids. * Staff 10 (MT), Staff 11 (CG) and Staff 16 (CG) were observed standing while assisting and feeding Resident 2. The resident was seated in a wheelchair in the dining room, while staff remained standing while feeding the resident, rather than positioning at eye level or sitting beside the resident. * Staff 10, 11, and 16 were observed to lean over and/or into the resident and Resident 2 was noted to lean away from staff, appearing to avoid contact. * Residents were observed to receive vanilla ice cream for dessert at lunch, however Resident 2 was not provided dessert. On 09/10/25 at 12:19 pm, Staff 11 reported the resident didn’t like ice cream and was unsure if an alternate dessert was available. Staff 9 (MT) reported there were alternate dessert options, and she would ask what was available. However, Resident 2 was not provided an alternate dessert. The need to ensure residents were treated with dignity and respect was reviewed with Staff 1 (Memory Care Administrator), Staff 2 (Administrator), and Staff 3 (RN) on 09/11/25 at 3:37 pm. They acknowledged the findings. 2. Resident 4 moved into the facility on 08/2025 with diagnoses including dementia. * On 09/10/25, lunch served to residents was a tuna sandwich, cucumber/tomato salad, and potato chips. Resident 4 did not eat the tuna sandwich. Staff 11 was observed removing a dirty plate from Resident 4, but did not ask the resident why he/she did not eat or if he/she needed an alternative. * Surveyor interviewed Resident 4 to ask why he/she did not eat the tuna sandwich. The resident stated, “I didn’t know what it was, so I ate that (pointing at a potato chip bag) instead”. The need to ensure residents were treated with dignity and respect during meal service was discussed with Staff 1 (Memory Care Administrator), Staff 2 (Administrator), and Staff 3 (RN) on 09/11/25 at 1:45 pm. They acknowledged the findings.

The facility failed to ensure 2 of 2 sampled residents (#’s 2 and 4) were treated with dignity and respect during meal service. *Staff will be provided training regarding assisting resident's with feeding so that they are treating resident's with dignity and respect. Staff training will also include explaining what is being served for meals, so if resident's don't like what is being served they can be offered an alternative off the alt menu. *Staff immediately made aware that the refridgerator in MC is stocked with alternate options for resident's with texture diet order's. *Staff training will be provided at all staff on 10/10/25. *New hire care partner skills checklists include assisting with eating. *Training will be reviewed bi-annually. *Administrator, MC Administrator, RCC and Business Services Director to oversee the compliance with QA audits to review documentation.

OAR 411-054-0027 (1) Resident Rights and Protection - General (1) GENERAL RIGHTS. The facility must implement a residents' Bill of Rights. Each resident and the resident's designated representative, if appropriate, must be given a copy of the resident's rights and responsibilities before moving into the facility. The Bill of Rights must state that residents have the right: (a) To be treated with dignity and respect. (b) To be given informed choice and opportunity to select or refuse service and to accept responsibility for the consequences. (c) To be given informed consent before any nontherapeutic examination, observation or treatment is provided. (d) To participate in the development of their initial service plan and any revisions or updates at the time those changes are made. (e) To receive information about the method for evaluating their service needs and assessing costs for the services provided. (f) To exercise individual rights that do not infringe upon the rights or safety of others. (g) To be free from neglect, financial exploitation, verbal, mental, physical, or sexual abuse. (h) To receive services in a manner that protects privacy and dignity. (i) To have prompt access to review all of their records and to purchase photocopies. Photocopied records must be promptly provided, but in no case require more than two business days (excluding Saturday, Sunday, and holidays). (j) To have medical and other records kept confidential except as otherwise provided by law. (k) To associate and communicate privately with any individual of choice, to send and receive personal mail unopened, and to have reasonable access to the private use of a telephone. (l) To be free from physical restraints and inappropriate use of psychoactive medications. (m) To manage personal financial affairs unless legally restricted. (n) To have access to, and participate in, social activities. (o) To be encouraged and assisted to exercise rights as a citizen. (p) To be free of any written contract or agreement language with the facility that purports to waive their rights or the facility's liability for negligence. (q) To voice grievances and suggest changes in policies and services to either staff or outside representatives without fear of retaliation. (r) To be free of retaliation after they have exercised their rights provided by law or rule. (s) To have a safe and homelike environment. (t) To be free of discrimination in regard to race, color, national origin, gender, sexual orientation, or religion. (u) To receive proper notification if requested to move-out of the facility, and to be required to move-out only for reasons stated in OAR 411-054-0080 (Involuntary Move-out Criteria) and have the opportunity for an administrative hearing, if applicable. This Rule is not met as evidenced by:

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a daily program of social and recreational activities that was based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to: During the survey, the memory care was home to 15 residents. The residents did not initiate any activities. Residents were observed wandering the unit and several residents spent time sitting in chairs near the staff charting area. From 09/08/25 through 09/11/25, observations were made, interviews were conducted, and the memory care activity calendar for September 2025 was reviewed. The following was revealed: The following scheduled activities were observed in the memory care: * 09/08/25 at 2:00 pm – “Root Beer Float Cart”; * 09/09/25 at 8:45 am – “Morning Meet”; and * 09/10/25 at 8:45 am – “Morning Meet”. During the survey, staff were observed to ask residents if they wanted to participate in an activity located in the assisted living, that included exercise, bingo, and music. On 09/11/25 at 11:06 am, Staff 2 (Administrator) confirmed the activities listed on the memory care activity calendar were not specific to the memory care. Therefore, the facility failed to ensure the memory care had a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs. The need to ensure a daily activity program was provided in the memory care for residents to address their mental, physical, and psychosocial needs was reviewed with Staff 1 (Memory Care Administrator), Staff 2, and Staff 3 (RN) on 09/11/25 at 3:37 pm. They acknowledged the findings.

The facility failed to ensure a daily program of social and recreational activities that was based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. *October activity calander was updated to reflect activities specific to the memory care based upon individual and group interests and physical, mental, and psychosocial needs of our resident's. *The activity calander is reviewed monthly before posting. *Administrator, MC Administrator, and Life Enrichment Director to oversee the compliance with monthly QA audits to review documentation.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities (c) A daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs, and creates opportunities for active participation in the community at large; (d) Equipment, supplies and space to meet individual and group activity needs; This Rule is not met as evidenced by:

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 observation and interview, it was determined the facility failed to maintain effective infection prevention and control protocols for multiple sampled and unsampled residents related to dining services. Findings include, but are not limited to: Multiple meals were observed in the memory care unit between 09/09/25 and 09/11/25. a. Staff were observed serving meals and beverages, touching residents, touching their own faces, and scratching noses, picking up dirty plates, serving desserts, and assisting residents with feeding without changing gloves or performing hand hygiene between all clean and dirty tasks. b. Direct care staff were observed serving meals and providing feeding assistance to sampled and unsampled residents without donning a protective barrier over potentially contaminated clothing. c. A dietary staff member was observed delivering food to the unit without covering fruit bowls on 09/09/25, the side of the tomato/cucumber salad on 09/10/25, and the ice cream desserts on both days. Also, direct care staff were observed delivering an ice cream dessert to a resident in the room without covering. The need to ensure the facility maintained infection prevention and control protocols to provide a safe, sanitary, and comfortable environment during meal service was reviewed on 09/11/25 at 1:45 pm with Staff 1 (Memory Care Administrator), Staff 2 (Administrator), and Staff 3 (RN). They acknowledged the findings.

The facility failed to maintain effective infection prevention and control protocols for multiple sampled and unsampled residents related to dining services. *Staff provided hand washing training at all staff on 9/10/2025. Reviewed hand washing policy. *Dietary staff immediately educated on infection prevention and control protocols to provide a safe, sanitary environment. Reviewed the importance of covering food while its being transported or served to a resident's apartment. *New hire dining assistant skills checklists updated 10/1/25 to include hand washing and transporting food. *Training will be reviewed bi-annually. *Administrator, MC Administrator, Dining Services Director and Business Services Director to oversee the compliance with QA audits to review documentation.

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:

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 3 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to: Resident 2 moved into the memory care community in 11/2020 with diagnoses including degeneration of the brain, dysphagia, and had a history of weight loss. The resident’s record, including current physician's orders and MAR/TAR, dated 08/01/25 through 09/08/25, were reviewed. The following was identified: Resident 2 had a physician's order for a health shake to be offered twice daily at 10:00 am and 3:00 pm. The resident’s record noted the health shake was not administered as ordered on 43 occasions. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Memory Care Administrator), Staff 2 (Administrator), and Staff 3 (RN) on 09/11/25 at 3:37 pm. They acknowledged the findings.

The facility failed to ensure physician orders were carried out as prescribed for 1 of 3 sampled residents (#2) whose orders were reviewed. *Community RN immediately updated the health shake instructions to ensure physician orders are carried out as prescribed. New instructions as follows; Please offer nectar thick health shake twice a day (one between breakfast and lunch and the second one between lunch and dinner) document percentage of health shake drank. If resident is sleeping, please reattempt to offer health shake when she wakes up. Thickened health shakes are provided by conservator. Please contact conservator and the health services team when she is down to one week of health shakes left. *QA audit will be completed weekly to review missed doses. *RN, administrator, MC administaror, and RCC to oversee the compliance with QA audits to review documentation.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders (f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order. This Rule is not met as evidenced by:

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will 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 ensure all interior materials and surfaces were kept clean. Findings include, but are not limited to: The facility was toured throughout the survey, 09/08/25 to 09/11/25, and the following was identified: Interior cleaning was needed in the following areas: * Gray carpet throughout the facility had black and brown stains and debris in multiple areas; and * Gray chairs across from the staff charting area had brown stains in multiple areas. During a facility tour on 09/11/25 at 4:45 pm, the need to ensure the interior of the facility was kept clean was discussed with Staff 1 (Memory Care Administrator). She acknowledged the findings.

The facility failed to ensure all interior materials and surfaces were kept clean. *Community is on a carpet cleaning schedule with Summit. Carpets were re cleaned on 9/12/25 and will be cleaned every other month and as needed. *ESD and housekeepers spot clean carpets and fabric chairs as needed. *QA audits will be completed weekly to review carpet and furniture to ensure the interior of the facility is kept clean. *ESD, Administrator, and MC Administrator to oversee the compliance with QA audits to review documentation.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (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 the 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. A RCF 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 will be kept clean and in good repair. This Rule is not met as evidenced by:

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure 2 of 2 sampled residents (#’s 2 and 4) were treated with dignity and respect related to meal service. Findings include, but are not limited to: Refer to C200.

Refer to C200.

OAR411-004-0020(1)(c) Individual Rights Settings: Privacy, Dignity (1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint. This Rule is not met as evidenced by:

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. This Rule is not met as evidenced by: Based on observation and interview, it was determined the facility failed to provide each individual privacy in his or her own unit for multiple sampled and unsampled residents who resided in shared units. Findings include, but are not limited to: During the acuity interview on 09/08/25, the survey team was provided with a resident roster which indicated there were three double occupancy rooms in the facility. Each of the double occupancy rooms had two residents sharing one unit. The semi-private rooms that were shared between two residents had no means to provide privacy for one of the two residents when someone entered or exited either of the bedroom areas or when ADL cares were provided outside of the bathroom. The need to ensure residents’ right to be afforded privacy within their own unit was discussed with Staff 1 (Memory Care Administrator) on 09/11/25 at 2:30 pm. She acknowledged the findings.

The facility failed to provide each individual privacy in his or her own unit for multiple sampled and unsampled residents who resided in shared units. *Community will install privacy curtains between each shared semi-private room to ensure residents’ right to be afforded privacy within their own unit. These will be installed by 11/10/2025. *Staff training will be provided by 11/10/2025 to ensure staff know how and when to use the privacy curtain to to ensure residents’ right to be afforded privacy within their own unit. *Instructions will also be added to each resident's growth and wellness plan by 11/10/2025. *ESD, Administrator, and MC Administrator to oversee the compliance.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit. 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 limited to: Refer to C200, C242, C295, and C513.

Refer to C200, C242, C295, and C513.

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 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C303.

Refer to: C303.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility. This Rule is not met as evidenced by:

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a daily meal program for nutrition and hydration was provided based upon the resident’s preferences and needs for 1 of 3 sampled residents (#2) whose service plans were reviewed. Findings include, but are not limited to: Resident 2 moved into the facility in 11/2020 with diagnoses including degeneration of the brain, dysphagia, and had a history of weight loss. During the survey Resident 2 was observed to require assistance with eating and drinking and could not initiate requests for food or fluids. The resident received a mechanical soft diet and nectar thick liquids. Resident 2’s service plan, dated 09/08/25, and “[Individualized] Hydration and Nutrition Plan”, dated 06/29/25, were reviewed. Observations were made and interviews with staff were conducted. The following was identified: Resident 2’s record noted the resident liked “…just about everything”, however on 09/09/25 and 09/10/25, during meal observations, Resident 2 did not eat the provided side dishes, consisting of cottage cheese and apple sauce, and did not receive ice cream for dessert. On 09/10/25 at 11:47 am, Staff 6 (CG) reported Resident 2 didn’t like apple sauce and would “sometimes” eat cottage cheese. Staff 6 additionally reported the resident preferred to eat one food at a time. On 09/10/25 at 12:19 pm, Staff 11 (CG) reported “[Resident 2] doesn’t like ice cream...it’s too cold.” The resident’s record noted for staff to “…offer/encourage/assist [Resident 2] with snacks [and] fluids between meals.” However, throughout survey there were no observations of staff offering, encouraging, or assisting Resident 2 with snacks or fluids in-between meals. The resident’s nutrition and hydration plan was not reflective of the resident’s current needs and preferences, and lacked individualized instruction related to resident preferences, snacks, and hydration. The need to ensure an individualized nutrition and hydration plan that was based on the resident’s preferences and needs was developed was reviewed with Staff 1 (Memory Care Administrator), Staff 2 (Administrator), and Staff 3 (RN) on 09/11/25 at 3:37 pm. They acknowledged the findings.

The facility failed to ensure a daily meal program for nutrition and hydration was provided based upon the resident’s preferences and needs for 1 of 3 sampled residents (#2) whose service plans were reviewed. *Resident's individualized nutrition and hydration plan will be updated by 11/1/2025 and will be reviewed quarterly. *Staff immediately made aware that the refridgerator in MC is stocked with alternate snack options for resident's with texture diet order's, as well as thickened liquids. *DSD, Administrator, MC Administrator, and RCC to oversee the compliance with QA audits to review documentation.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration (c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills. This Rule is not met as evidenced by:

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. Findings include, but are not limited to: Residents 1, 2 and 3’s current service plans, dated 08/14/25, 09/08/25, and 08/13/25, respectively, and “Getting to Know You” questionnaires were reviewed. There was no documented evidence the facility had evaluated and developed individualized plans based on each residents': * Past and current interest; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; and * Adaptations necessary for the resident to participate. The need to ensure each resident was evaluated for activities and an individualized activity plan was developed was discussed with Staff 1 (Memory Care Administrator) on 09/11/25. She acknowledged the findings.

The facility failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. *Each of the sampled resident's individualized activity plans will be developed and implemeted by 11/1/2025 and will be reviewed quarterly. *Life Enrichment Director, Administrator, MC Administrator re educated on fully completed and updated Getting to Know You Forms to to ensure each resident was evaluated for activities and an individualized activity plan was developed. *Life Enrichment Director, Administrator, MC Administrator, and RCC to oversee the compliance with QA audits to review documentation.

OAR 411-057-0160(2d) Activities (d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities. This Rule is not met as evidenced by: