Print Inspection: RL007564

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and preferences and provided clear direction regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 moved into the community in 05/2025 with diagnoses including dementia and unspecified sleep disorder. The resident’s clinical record was reviewed, including the 10/20/25 service plan, observations were made, and interviews were conducted. The following was identified: The 09/04/25 service plan was not reflective of the resident’s current care needs and did not give clear direction to the staff in the following areas: * Number of staff and amount of assistance required with dressing, toileting/incontinence care, and transfers; * Preference of hospital bed to sleep; * Use of side rails, hospital bed, and alternating pressure mattress; and * Frequency of weights. The need for the facility to ensure residents’ current service plans were reflective of current care needs and status and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Executive Director), Staff 2 (Director of Health Services), Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 1:55 pm. They acknowledged the findings. 2. Resident 2 moved into the community in 12/2012 with diagnoses including psoriatic arthritis mutilans and chronic obstructive pulmonary disease. The resident’s clinical record was reviewed, including the 10/20/25 service plan, observations were made, and interviews were conducted. The following was identified: The service plan was not reflective of the resident’s current care needs and did not give clear direction to staff in the following areas: * Fall history; * Use of walker for ambulation inside the apartment; * The resident’s inability to self-administer treatments; and * Hourly safety checks. The need for the facility to ensure service plans were reflective of the resident’s current care needs and status and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Executive Director), Staff 2 (Director of Health Services), Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 2:30 pm. They acknowledged the findings.

1. Resident 1 and Resident 2 Service Plans have been re-reviewed to ensure all information from their evaluation is reflected on their service plans and current care needs. 2. Resident Care Coordinator (RCC) and Registered Nurse (RN) will receive additional education on the New Admission Evaluation and SP steps. The RCC and RN will complete new move in evaluations and then the Administrator will audit to confirm these areas are reflected on the service plans. 3. All New Admission Service Plans, and 3 quarterly service plans will be audited as part of our monthly Quality Audit for 3 months, and if no errors are found then this will be audited quarterly, as well as needed when service plans occur. 4. Resident Care Coordinator, Registered Nurse, and Administrator will all be responsible to ensure completion of the processes and that corrections are monitored.

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained. 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's orders were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the community in 08/2025 with diagnoses including dementia with behavioral disturbance and chronic kidney disease. Resident 3’s MAR, dated 10/01/25 through 10/27/25, and current physician's orders, dated 09/23/25, were reviewed, and the following was identified: a. Resident 3 had a physician’s order for polyethylene glycol to give 17 grams by mouth every 24 hours as needed for constipation. Review of the MAR revealed the polyethylene glycol was scheduled to be given 17 grams by mouth daily. b. Physician's orders indicated rosuvastatin (calcium) oral tablet 25 mcg to be given by mouth one time a day. Review of the MAR revealed rosuvastatin was listed twice to be administered at 8:00 pm and 9:00 pm and was initialed as administered twice five times during the 10/01/25 through 10/27/25 period. In an interview with Staff 2 (Director of Health Services) on 10/29/25 at 9:55 am, she stated it was likely an error with the pharmacy. The need to ensure physicians' orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2, Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 2:25 pm. They acknowledged the findings. 2. Resident 1 moved into the community in 05/2025 with diagnoses including dementia and constipation. Review of the MAR, dated 10/01/25 through 10/27/25, and current physician's orders, dated 10/27/25, identified the following: Resident 1 had a physician's order to weigh resident daily on day shift before breakfast. From 10/01/25 to 10/24/25 and on 10/26/25 and 10/27/25, the MAR was marked as “Other/see nurses notes.” There was no corresponding documentation in the Progress Notes to indicate why resident was not weighed. In an interview on 10/28/25 at 11:05 am, Staff 2 (Director of Health Services) stated the daily weights should have been discontinued. The need to ensure physicians' orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2, Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 1:50 pm. They acknowledged the findings.

1. Orders have been reviewed for resident 3 and resident 1's primary care providers and orders have been clairified and updated. MARS on these residents were updated to align with Physician orders. 2. New Orders Triple Check system education will happen with the RCC, RN and Med Techs. Additionally,RCC, RN and Med Techs will be educated on how to appropriately document in the progress notes when marking "Other/see nurses notes" and the reason they need to complete the circle of documentation. Registered Nurse will Audit Point Click Care to verify that all "Other/see nurses notes" have follow up in the chart. We will utilize a triple check system where the RN, RCC, and Administrator check that the medication orders are put in correctly. 3. New orders will be audited M-F during our Clinical Meetings for the next month, then audited monthly as part of our Quality Audit. 4. Registered Nurse, Resident Care Coordinator, and Administrator will be responsible to see that corrections and systems are followed and monitored.

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 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters and instructions were included for PRN medications and failed to ensure the MAR included the correct dosage of medication for 2 of 3 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the community in 12/2012 with diagnoses including psoriatic arthritis mutilans and chronic obstructive pulmonary disease. The resident’s MAR, dated 10/01/25 to 10/27/25, was reviewed, and the following orders were noted: a. The resident had orders for two PRN medications for pain that did not have parameters for order of administration by unlicensed staff: * Acetaminophen 500 mg, two tablets every six hours; and * Hydromorphone HCl 4 mg tablet every four hours. b. The resident had three orders for PRN medications for constipation that did not have parameters for order of administration by unlicensed staff: * PEG 3350 powder 238 gm, mix 17 g in liquid; * Senna 8.6 mg, one tablet daily; and * Senna 8.6 mg, two tablets if no bowel movement in three days, not to exceed two tablets per day. In an interview with Staff 15 (MT) on 10/28/25 at 2:35 pm, s/he stated, “I would probably give the Senna,” if the resident complained of constipation, “but actually, I would text the nurse just to make sure.” The need to ensure resident-specific parameters and instructions for PRN medications were included on the MAR was reviewed with Staff 1 (Executive Director), Staff 2 (Director of Health Services), Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 2:30 pm. They acknowledged the findings. 2. Resident 1 moved into the community in 05/2025 with diagnoses including dementia and constipation. The resident’s MAR, dated 10/01/25 to 10/27/25, was reviewed, and the following orders were noted: a. The resident had orders for two PRN medications for pain that lacked parameters for order of administration by unlicensed staff: * Acetaminophen 325 mg two tablets daily as needed for pain; and * Morphine sulfate 20 mg/ml 0.25 to 0.5 ml every four hours as needed for pain. b. The resident had two orders for PRN medications for constipation that lacked parameters for order of administration by unlicensed staff: * Bisacodyl rectal suppository 10 mg rectally every 24 hours as needed for constipation; and * Polyethylene glycol 17 grams as needed for bowel care. c. The following medications lacked the specific dosage to administer: * Morphine sulfate 20 mg/ml 0.25 to 0.5 ml every four hours as needed for pain; and * Lorazepam 0.5 to 1 mg every four hours as needed for anxiety or shortness of breath. In an interview on 10/28/25 at 11:00 am, Staff 2 (Director of Health Services) confirmed the lack of PRN parameters for the pain and bowel medications, as well as the ranges of the dosage of medications on the October MAR. The need to ensure resident-specific parameters and instructions for PRN medications were included on the MAR and all medications had the correct dosage to administer was reviewed with Staff 1 (Executive Director), Staff 2, Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 1:55 pm. They acknowledged the findings.

1. All errors in parameters related to the bowel meds and to pain meds have been fixed with Resident 1 and Resident 2. 2. The Med Techs will be educated on clear parameters for PRN meds and education if an order is found to not have clear parameters. The Registered Nurse will review PRN orders for accurate Parpameters in MARS as a part of the new order review process. 3. We will audit new PRN medication orders M-F during clinical meetings for 4 weeks, if no issues are found we will audit PRNs monthly as part of our Quality Assurance process. 4. Registered Nurse, Resident Care Coordinator, and Administrator.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication. This Rule is not met as evidenced by:

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, failed to document other less restrictive alternatives were evaluated prior to the use of the device, and failed to instruct caregivers on the correct use and precautions related to the use of the device for 1 of 1 sampled resident (# 1) who used a supportive device with restraining qualities. Findings include, but are not limited to: Resident 1 moved into the community in 05/2025 with diagnoses including dementia and unspecified sleep disorder. Observations of the resident and interviews with staff indicated the resident had a quarter-length side rail on both sides of his/her bed. The side rails were in good repair and flush with the mattress. There was no documented evidence other less restrictive alternatives were evaluated prior to the use of the device. Staff reported the resident was primarily bedbound and received the hospital bed with side rails from the hospice provider. On 10/28/25 at 11:25 am, Staff 2 (Director of Health Services) confirmed an assessment of the side rails was not completed prior to survey entry. The need to ensure supportive devices with restraining qualities were assessed by an RN, PT, or OT and were included in the resident's service plan was discussed with Staff 1 (ED), Staff 2, Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 1:55 pm. They acknowledged the findings.

1. Resident 1 assistive devices assessment was completed by Registered Nurse while survey was still in the community. 2. The Registered Nurse and RCC will do full physical walk through to ensure all potentially restrictive devices are identified and have appropriate assessments in place. Moving forward, each new device, including hospital beds, will be assessmented by the Registered Nurse for restraining qualities. 3. Desiginated staff will complete weekly walk through for 1 month for any further assistive devices, and monthly for 1 quarter. The Administrator will pull device audit monthly during QA to ensure all assessments are in place and compliant. If no errors are found in three months, then this will be audited quarterly as part of our Service Plan system. 4. Registered Nurse and Administrator are responsible to verify completion and monitoring of system.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07 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 observation, 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 C 260, C303, C310, and C340.

1. Refer to above C260, C303, C310, C340 2. Refer to above C260, C303, C310, C340 3. Refer to above C260, C303, C310, C340 4. Refer to above C260, C303, C310, C340

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(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 meaningful activities that promote or help sustain the physical and emotional well-being of residents and activities were person centered and available during residents ' waking hours for sampled residents (#s 1 and 3) and multiple unsampled residents, and failed to ensure an individualized activity plan was developed for each resident, based on an activity evaluation, for 2 of 2 sampled residents (#s 1 and 3) who resided in the memory care unit. Findings include, but are not limited to: 1. Observations were made throughout the survey in the memory care unit and revealed a lack of meaningful activities for the residents. On 10/28/25 during observations in the memory care unit, an activity was scheduled at 11:00 am titled “Music Hour.” In an interview with Staff 10 (CG) at 11:15 am on 10/28/25, he stated “typically” during music hour they will put music on the television for the residents to listen to together. Observations at 11:15 am revealed a cat show on the television with two residents watching and another resident looking at a magazine in the common area. The scheduled activity did not take place. An interview with Staff 12 (CG) on 10/28/25 at 2:40 pm confirmed care staff were primarily responsible for conducting activities. Staff 12 stated there will be an activity title on the calendar “like reminiscing time”; however, she stated they did not have instructions on how to do the activity. The following activities were scheduled for 10/29/25 in the memory care unit: * 10:00 am – Reminiscing Time * 11:00 am – Card Game * 1:00 pm – Relaxation Afternoon Observations made on 10/29/25 revealed that none of the above activities took place as scheduled. Throughout the survey residents were observed remaining in their rooms or sitting at tables in the common area of the memory care unit coloring and/or watching television. The need to ensure the facility provided meaningful activities that promote or help sustain the physical and emotional well-being of residents, and to ensure that activities were person centered and available during residents' waking hours was discussed with Staff 1 (ED), Staff 2 (Director of Health Services), Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 2:30 pm. They acknowledged the findings. 2. Resident 1 and 3’s current service plans, dated 09/04/25 and 09/15/25, respectively, and “Activity Evaluation” questionnaires were reviewed. There was no documented evidence the facility had evaluated and developed individualized plans based on each resident’s: * Past and/or current interest; * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; and * Adaptations necessary for the resident to participate; and * Identification of activities for behavioral interventions. The need to ensure each resident was evaluated for activities and an individualized activity plan was developed was discussed with Staff 1 (ED), Staff 2 (Director of Health Services), Staff 6 (Regional Operations Specialist), Staff 7 (Regional Nurse), and Staff 8 (Regional Director of Operations) on 10/29/25 at 2:25 pm. They acknowledged the findings.

1. Activity calendar will be audited for implementation of resident directed activities. Staff has been educated on the importance of following through on the activities on the calendar and Resident Care Coordinator and Activities Director are checking for execution of the activities. Resident 1 and Resident 3's activity evaluations have been updated to reflect past/current interest, current ability and skill, emotional and social needs and patterns, physical ability and limitations and adaptations necessary for the resident to participate and identification of activities for behavioral intervention. 2. Staff education on the importance and method of completing each activity with checks by the Resident Care Coordinator, Administrator, or Activities Director occurring daily. Regional Director has come and taught staff about our Radiance program and how to implement and execute activities. Activity Director and Administrator audited all memory care activity evaluations to ensure they match each resident. Each new resident's Activity Evaluation will be completed by the Activity Director and double checked by Administrator. 3. Activity program execution will be evaluated as part of Quality Assurance each month, as well as spot checks completed daily by the Activities Director. New move in and quarterly activity evaluations will be completed by Activity Director and Administrator will review to ensure accuracy for 6 months. Then audited quarterly during Quality Assurance and Activity Focused audits. 4. Activities Director, Administrator, Resident Care Coordinator, Caregivers, and Medication Techs.

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: