Print Inspection: RL012255

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the immediate health, safety, or welfare of residents for 1 of 1 sampled resident (# 4) who smoked and used oxygen. Resident 4 smoked while wearing an oxygen cannula. This placed residents at risk and constituted an immediate threat to residents’ health and safety. Findings include, but are not limited to: Resident 4 was admitted to the facility in 09/2025 with diagnoses including chronic obstructive pulmonary disease. ? Resident 4's current service plan and evaluation, dated 03/05/26, noted the resident smoked, used oxygen as needed, and was alert and oriented. There was no indication of whether the resident was able or willing to remove his/her oxygen prior to smoking or what the resident did with his/her oxygen tank while smoking. During an interview on 06/02/26 at 2:36 pm, Resident 4 was observed in his/her room using a nasal cannula and oxygen concentrator. S/he stated that s/he had more difficulty breathing recently and used oxygen continuously.? On 06/03/26 at 2:30 pm, Resident 4 was observed driving his/her electric wheelchair to the outside corner of the building near a bench.? Resident 4 had a nasal cannula in place attached to a portable oxygen tank. S/he was observed removing the nasal canula but did not turn off the oxygen tank prior to lighting and smoking cigarettes. On 06/03/26, between 2:49 pm and 4:35 pm, multiple staff interviews were conducted regarding Resident 4’s smoking status while receiving oxygen via nasal cannula. Multiple staff reported they had observed or were aware that the resident had smoked while oxygen was in use. The tank of concentrated oxygen and tube next to an open flame created a fire hazard. This placed residents at risk and constituted an immediate threat to residents’ health and safety. On 06/03/26 at 4:33 pm, Staff 1 (ED) and Staff 2 (Resident Services Coordinator) were notified of the observation. Staff 1 and Staff 2 created an immediate plan of correction, educated the resident on the risks of smoking with oxygen, and updated Resident 4's service plan to require staff to assist resident in turning off tank prior to smoking and immediately notify the Administrator if the resident was observed smoking with oxygen on. An immediate plan of correction to address the reasonable precautions was requested from Staff 1 (ED) on 06/03/26 at 4:33 pm. The plan of correction was received and accepted by the survey team on 06/03/26 at 6:19 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation. In an interview on 06/03/26 at 6:19 pm, the need to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents was discussed with Staff 1 and Staff 2. They acknowledged the findings.

1. The two residents discussed have given their cigarettes to be locked in the med cart. When they go out to smoke the MT will give them one and remove the oxygen tank. Upon returning inside the MT will put the oxygen tank back on. If the residents want to stay outside when finished, they will press their pendant, and we will bring the oxygen out to them. Both residents have agreed, and this is already in place. This has been communicated by ISPs to the staff. 2. Every smoker that lives here that uses oxygen will be evaluated for safely removing their oxygen before they go out to smoke. This will apply to any resident whose smoking status changes or oxygen use changes. The safety of smoking and use of oxygen will be evaluated with service plan updates. If they are unsafe, we will implement the same plan for them. This will be communicated to staff through ISPs and has already been communicated to current staff. We will also put this into the treatment section of the MAR as a PRN once we confirm that the MD order will match. Care staff will be informed through the ISP as well to notify the MT if there is a concern for safety moving forward. There will be mandatory training for staff on safe smoking and oxygen procedures on Monday 6/8/26. 3. This will be discussed at shift huddle daily for 2 weeks. Then we will monitor monthly for 3 months then quarterly and PRN. 4. The ED or the RN will be responsible for ensuring this plan is completed and used as needed for future residents.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action (Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to notify the local Department office when an incident of abuse or suspected abuse occurred and failed to ensure investigations included all required components for 1 of 1 sampled resident (#4) who experienced misplacement of money. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 09/2025 with diagnoses including chronic obstructive pulmonary disease. The resident’s 03/01/26 through 06/01/26 record was reviewed, and the resident and staff were interviewed. The following was identified: Resident 4 went to the emergency room on 03/13/26. Upon his/her return to the facility, a progress note stated “[R]esident not happy. Went to [the] hospital last night due to being out of morphine. [S/he] came back this afternoon and realize[d] all [of] the money in [his/her]] wallet was gone and so was the money on [his/her] desk by [his/her] bed.” There was no documented evidence the facility immediately reported the incident to the local Department office. On 06/04/26 at 3:20 pm, Staff 1 (ED) confirmed he was unable to find evidence of reporting to the local Department office and was unable to find evidence of an investigation completed by the facility. The need to ensure all incidents of abuse, or suspected abuse, were reported to the local Department office and that the facility investigation included all required components was discussed with Staff 1 and Staff 6 (Business Office Manager) on 06/04/26 at 3:20 pm. They acknowledged the findings.

1. All current incident reports were reviewed for reportable incidents. 2. ED, Wellness Coordinator, and BOM attended the OHCA Abuse Prevention Summit 06/11/26. Reviewed the CBC Compliance Framework Guide regarding APS reporting and investigation with all staff 06/25/2026. 3. Daily Incident Report review at morning standup meetings with the Interdisciplinary Team. 4. Executive Director / Licensed Nurse

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’ needs and preferences and provided clear direction to staff for 3 of 5 sampled residents (#s 1, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 04/2008 with diagnoses including Alzheimer’s disease and type 2 diabetes mellitus. The resident’s 01/14/26 to 06/01/26 clinical record was reviewed, interviews with staff were conducted, and observations were made. The service plan, dated 02/13/26, was not reflective of the resident’s current care needs or lacked clear instructions to staff in the following areas: * Instructions for the use of an air mattress; * Instructions regarding oral care; * Instructions for sensory status, including hearing impairment; and * Fall interventions. During the survey, it was observed the resident used an air mattress while in bed and had hearing impairment, as evidenced by the need for staff to repeatedly ask simple questions to communicate with the resident. On 06/03/26 at 1:20 pm, during an interview, Staff 5 (MT) confirmed the resident had a hearing impairment. The service plan did not include any instructions regarding the use of the air mattress. The need to ensure residents’ service plans were reflective of their needs and provided clear direction to staff was reviewed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 10:55 am. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 09/2025 with diagnoses including chronic obstructive pulmonary disease. The resident’s 03/01/26 through 06/01/26 clinical record was reviewed, interviews with staff and the resident were conducted, and observations were made. The service plan, dated 03/05/26, was not reflective of the resident’s current care needs or lacked clear instructions to staff in the following areas: * Oxygen tank monitoring and reordering of supplies; * Power wheelchair cleaning and maintenance; and * Home health nursing services. The resident’s service plan stated the resident used oxygen as needed, though multiple staff and the resident stated during the survey oxygen was currently being used on a continuous basis. A home health nurse noted on multiple dates the resident had only one tank of oxygen remaining and supplies needed to be reordered. In an interview on 06/04/26 at 3:20 pm, Staff 1 (ED) stated the resident received automatic deliveries of oxygen. He acknowledged the resident appeared to be using more oxygen than s/he had in the past and, therefore, could be running low on oxygen prior to additional tanks being delivered. He acknowledged the service plan did not include instructions on who, when, or how oxygen should be ordered. The need to ensure residents’ service plans were reflective of needs and provided clear direction to staff was reviewed with Staff 1 and Staff 6 (Business Office Manager) on 06/04/26 at 3:20 pm. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 03/2026 with diagnoses including type 2 diabetes. The resident’s 03/20/26 to 06/02/26 clinical record was reviewed, interviews with the resident and staff were conducted, and observations were made. The service plan, dated 04/16/26, was not reflective of the resident’s current care needs and preferences or lacked clear instructions to staff in the following areas: * Skin conditions including ongoing sores on his/her bottom, a rash and the surgical site from the catheter; * Toileting, including assistive device, location, and technique for toileting; and * Bathing, including assistive device and preferences for time of day and gender of caregiver. During an observation on 06/02/26 at 1:30 pm, Resident 1 was assisted by one caregiver for toileting assist. The resident backed his/her power chair into the shower while the caregiver applied powder to the seat of commode and was instructed by the resident to place a towel on the hardware of the commode for skin protection during the transfer. Resident 1 indicated there was no room to use the toilet and this was the method s/he used for toileting. During an interview on 06/02/26 at 11:44 am, Resident 1 showed the surveyor s/he had a sliding transfer tub bench for showering but indicated one of the caregivers did not like to use it. During an interview on 06/03/26 at 10:45 am, Staff 11 (CG) stated they preferred to use the commode instead for access to wash the resident’s bottom. The service plan did not provide clear instructions on which assistive device to use. The need to ensure service plans provided clear direction regarding the delivery of services and were reflective of the resident’s needs and preferences was discussed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:04 pm. They acknowledged the findings.

1. 100% audit to be done and all issues fixed on current service plans. 2. IDT will take place weekly with all managers present. All managers will be trained on how to appropriately complete their section of the service plan 3. Weekly during IDT, Quarterly with SP updates, and with any significant change of condition 4. IDT team (ED,LN, Resident Care Coordinator, Medroom Manager, Life Enrichment, Maintenance Director).

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to consistently determine and document what action or intervention was needed for short-term changes of condition, communicate the action or intervention to staff on each shift, monitor the resident consistent with the resident’s evaluated needs, and document weekly progress until the condition was resolved for 2 of 5 sampled residents (#s 1 and 4) with changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2026 with diagnoses including type 2 diabetes. The resident's 04/16/26 service plan, 03/20/26 to 06/02/26 progress notes, and 03/27/26 through 05/30/26 outside provider visit notes were reviewed. For the following changes of condition, the facility failed to document the status of the condition at least weekly until resolved or failed to document whether the condition was resolved: * 03/20/26 – Rash to groin and pannus; * 03/20/26 – Surgical site from removal of suprapubic catheter; and * 03/21/26 – Three sores on the bottom. During an interview on 06/04/26 at 10:52 am, Staff 2 (Resident Services Coordinator) acknowledged the lack of monitoring at least weekly for the skin conditions, which included the status of the buttock wounds. The need to ensure the facility noted progress of the condition at least weekly until resolved was reviewed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:04 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 09/2025 with diagnoses including chronic obstructive pulmonary disease. The resident’s 03/01/26 through 06/01/26 clinical record was reviewed and interviews with staff and the resident were conducted. The following was identified: a. Resident 4 went to the emergency room on 03/13/26, and upon his/her return, a progress note stated, “[R]esident not happy. Went to [the] hospital last night due to being out of morphine. [S/he] came back this afternoon and realize[d] all [of] the money in [his/her]] wallet was gone and so was the money on [his/her] desk by [his/her] bed.” The resident experienced shortness of breath and staff documented the resident experienced an “anxiety attack” and required the use of PRN medication. There was no documented evidence that actions or interventions were determined and the resident was monitored through resolution of symptoms. b. On 05/07/26 an Interim Service Plan (ISP) was initiated stating the resident was experiencing depression and instructed staff to check on the resident three times per shift, ensure his/her laptop was working, and monitor for signs and symptoms of depression. There was no documented evidence of monitoring with weekly progress noted through resolution. In an interview on 06/02/26 at 2:36 pm, Resident 4 stated that his/her laptop was no longer working and s/he felt isolated at times as it was his/her primary source of entertainment. The need to ensure short-term changes of condition had interventions determined and documented, those interventions were communicated to staff on all shifts, and the resident was monitored, with progress noted weekly through resolution, was reviewed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 3:20 pm. They acknowledged the findings.

1. Residents' ISP and monitoring were updated to weekly again. This is the Mosaic policy and standard. 2. ED and LN will review alert charting daily to ensure all concerns have been placed in the monitoring section as needed 3. Daily review of progress notes, weekly for residents with change of condition or skin issues. 4. Clinical team. (ED, LN, Resident Services Coordinantor, Medroom Manager).

OAR 411-054-0045(2) Res Hlth Srvc: On- and Off-Site Health Srvc (2) ON-SITE AND OFF-SITE HEALTH SERVICES. The facility must assist residents in accessing health care services and benefits to which they are entitled from outside providers. When benefits are no longer available, or if the resident is not eligible for benefits, the facility must provide or coordinate the required services, as defined in facility disclosure information, for residents whose health status is stable and predictable. (a) On-site Health Services. The facility must coordinate on-site health services with outside service providers such as hospice, home health, or other privately paid supplemental health care providers, etc. (A) The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols are in place. (B) The facility nurse must review the resident's health related service plan changes made as a result of the provision of on-site health services noted in section (2)(a)(A) of this rule. (C) The facility must have policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care. (b) Off-site Health Services. The facility must coordinate off-site health services for residents who cannot or choose not to self-manage their health services. (A) The facility must assist the resident by coordinating appointments, with outside providers, that are necessary to support the resident's health needs. (B) Transportation for medical purposes must be arranged or provided for by the facility. (C) Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable. (D) The facility must provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider. (c) The facility is exempt from the coordination of outside health services for residents who are capable and choose to independently arrange and manage their health care needs. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure information and interventions provided by on-site outside providers were communicated to staff and service plans adjusted if necessary and, following a resident's visit to an outside medical provider, information obtained from said provider was included in the resident's record for 2 of 3 sampled residents (#s 1 and 4) who received outside services. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 03/2026 with diagnoses including type 2 diabetes and was identified during the acuity interview on 06/01/26 as receiving home health services. Review of outside provider notes from 03/27/26 through 05/30/26 identified the following recommendations: * 04/03/26 – A HH RN note recommended to “Reinforce checking briefs many times daily ... Frequent position changes every 15 [minutes] in chair or sitting.”; * 04/06/26 – A HH OT note indicated, “Due to wounds recommend hourly brief checks due to urine incontinence...Also recommend trash bag for transfers to reduce sheering.”; and * 05/21/26 – A HH nursing note indicated “greenish discharge” from the suprapubic catheter and instructed staff to, “Please push fluids and call 911 if [s/he] becomes disoriented or confused.” There was no documented evidence the facility communicated these recommendations to direct care staff or that the service plan was adjusted to ensure continuity of care. The need to ensure staff were informed of on-site outside provider information and interventions, and the service plan adjusted if necessary, was reviewed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:04 pm. They acknowledged the findings. 2. Resident 4 was admitted to the facility in 09/2025 with diagnoses including chronic obstructive pulmonary disease. The resident’s 03/01/26 through 06/01/26 clinical record was reviewed, interviews with staff and the resident were conducted, and observations were made. The following was identified: On 04/16/26, the facility received a fax containing “pre-procedure instructions” to prepare the resident for surgery on 04/21/26. The procedure was stated to require anesthesia and included a bronchoscopy (viewing of the bronchial tubes via a camera inserted into the mouth and down the throat into the bronchial tubes) and lung biopsy. The pre-procedure instructions included modifications to the resident’s medications and ability to eat and drink the night and morning prior to surgery. The April 2026 MAR showed medications were administered according to the pre-procedure instructions, including administration of PRN acetaminophen (for pain) and PRN morphine (for shortness of breath) at 8:00 am on 04/21/26. The resident was scheduled to arrive for the procedure at 9:15 am on 04/21/26. There was no indication in the resident’s facility record of whether the resident underwent the procedure on 04/21/26 or the resident’s status following the procedure. Staff 2 (Resident Services Coordinator), Staff 5 (MT), and Staff 13 (MT) stated in separate interviews on 06/03/26 they were unaware of whether the resident had undergone surgery on 04/21/26. The need to ensure any information obtained from an outside provider, following a resident’s visit with said provider, was included in the resident’s record was reviewed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:04 pm. They acknowledged the findings.

1. Service plans updated to reflect the recommendations of outside providers for both residents identified. 2. MT meeting to provide education on appropriate way to pull the providers recommendations and place them in an ISP for communication to care partners 3. All orders will be processed timely, using the 3rd check system. This will be reviewed weekly. 4. Clinical team. (ED, LN, Resident Services Coordinantor, Medroom Manager).

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 establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment related to incontinence and personal care for 2 of 2 sampled residents (#s 1 and 3) whose care was observed. Findings include but are not limited to: 1. Resident 1 was admitted to the facility in 03/2026 with diagnoses including type 2 diabetes. a. On 06/02/26 at 1:30 pm, Staff 10 (CG) was observed donning gloves to provide incontinence care and replace catheter tubing due to catheter leakage. No observations were made of Staff 10 performing hand hygiene prior to donning gloves. Staff 10 applied powder to the commode, placed a towel on the end of the commode, removed the soiled brief and assisted the resident to transfer onto the commode from the wheelchair. Staff 10 used a soiled draw sheet from the resident’s wheelchair to wipe up urine that had leaked onto the footplate of the wheelchair and placed the draw sheet in the trash can. Staff 10 removed the trash bag, replaced with a new trash bag, left the resident’s room to dump the trash and returned to the room with the same soiled gloves. Staff 10 was not observed changing her gloves or performing hand hygiene and began prepping the catheter tubing, wiped the tip with an alcohol pad, and then inserted the tube into its sleeve. The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:04 pm. They acknowledged the findings. b. Staff 11 (CG) was observed on 06/03/26, between 10:30 am and 10:50 am, to provide incontinence care to Resident 1. Staff 11 handled the resident’s clothing, brief, and urinal, emptied the catheter drainage bag into the urinal, and then emptied the urinal into the toilet. Staff 11 did not change gloves during these tasks. Staff 11 then applied a no-rinse foam cleanser to the resident’s abdominal fold area, cleaned the area with wipes, and applied cream after completing abdominal care. The resident was then turned to the side with staff’s direction. During the repositioning and turning process, Staff 11 wiped gloved hands with a wipe but did not change gloves before continuing care. Staff 11 proceeded to clean the resident’s buttocks and apply cream without changing gloves between clean and dirty tasks. Throughout the entire incontinence care process, Staff 11 did not change gloves. Upon completion of care, Staff 11 removed the gloves, but did not perform hand hygiene. The need to ensure infection prevention and control practices were followed during personal care was discussed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 10:55 am. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2008 with diagnoses including Alzheimer’s disease and type 2 diabetes mellitus. Staff 10 (CG) was observed on 06/03/26, between 11:00 am and 11:11 am, providing incontinence care to Resident 3. The resident was seated in a chair at the dining table near the kitchenette area in his/her room. Staff 10 initiated care by positioning the resident’s four-wheel walker in front of the resident and providing verbal direction to stand using the walker. Staff 10 then lowered the resident’s soiled brief and pants and instructed the resident to sit back down in the chair without placing a protective barrier or performing any cleansing. Staff 10 removed the soiled brief and pants and applied a clean brief while the resident remained seated in the chair. Staff 10 then instructed the resident to stand again and proceeded to clean the resident’s perineal and buttocks areas. Following incontinence care, Staff 10 continued to wear the same gloves while touching and adjusting the resident’s shoes and grooming the resident’s hair. Staff 10 did not change gloves between dirty and clean tasks or after completing incontinence care and before performing grooming tasks. Upon completion of grooming, Staff 10 removed gloves but did not perform hand hygiene. The need to ensure infection prevention and control practices were followed during personal care was discussed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 006/04/26 at 10:55 am. They acknowledged the findings.

1. Joshua Johnson, Infection Control Specialist, re-took the training and the Mosaic Infection Control Policies and Procedures Manual reviewed at all-staff Monday 03/08/2026 by Joshua Johnson, Infection Control Specialist for Lakeland Senior Living. Added more hand sanitizing stations. 2. Mosaic Infection Control Policies and Procedures Manual will be reviewed with every new hire as part of their onboarding and sections will be reviewed at least every other month at an all-staff meeting. Hand hygiene competencies reviewed and signed 06/25/2026.Rounding to be done by management will be implemented. Training and education will be done on proper ways to clean up bodily fluids, training and education on proper way to perform catheter care, training and education on infection control manual, proper use of biohazard bags. 3. Monthly and as needed 4. Executive Director / Licensed Nurse

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system. This Rule is not met as evidenced by: Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight of the medication and treatment administration system for 1 of 1 sampled resident (#4) whose oxygen use and narcotic medication was reviewed. The lack of adequate professional oversight and lack of a safe medication system, including the narcotic tracking system and failure to administer medications as prescribed, placed Resident 4 at unreasonable discomfort. Findings include, but are not limited to: Resident 4 was admitted to the facility in 09/2025 with diagnoses including chronic obstructive pulmonary disease. The resident’s 02/08/26 through 06/01/26 facility record was reviewed, and staff were interviewed. The following was identified: a. The resident had a signed physician order, dated 03/05/26, for morphine 10 mg/5 ml oral solution (for shortness of breath) to be administered once per day in the evening. Review of the 02/08/26 through 03/13/26 Controlled Substance Disposition log showed multiple discrepancies in recorded “remaining” quantities of the liquid morphine. The following discrepancies were identified: Staff documented removing 5 ml of morphine daily between 02/08/26 and 03/08/26 for the resident’s scheduled dose. On 03/08/26, the resident’s bottle was documented as having 30.5 ml remaining. On 03/09/26, after documenting removal of 5 ml for the resident’s scheduled dose, the resident’s bottle was documented as having only 5 ml remaining. In the margin of the log, a staff member had written “corrected count” and new “remaining” amounts from 02/14/26 and 03/08/26. The edit was not dated, and there was no additional documentation relating to either the incorrect documentation from staff or the missing morphine. On a separate page the resident was documented as having 2 ml of morphine remaining in a bottle last used on 02/13/26. On 03/09/26, an unidentified person wrote that at 3:00 pm s/he “waste[d]” 2 ml. A note in the margin, unsigned, stated “bottle empty, book says there is still 2 ml left.” There was no documented evidence showing where the medication went, how it was disposed of, or who disposed of it. The discrepancies above resulted in a failure to reorder the medication in a timely manner, which led to the resident missing two scheduled doses of the medication, on 03/11/26 and 03/12/26. Following the missed doses, the resident “requested to be sent out.” The resident was evaluated in the emergency room and treated with a morphine injection. The emergency room discharge instructions stated the physician had “sent a message to the administrator at [Resident 4’s] facility regarding our concerns about possible drug diversion.” In an interview on 06/04/26 at 3:20 pm, Staff 1 (ED) stated he was unaware of the 20 ml discrepancy noted on 03/09/26 or the edits documented in the Controlled Substance Disposition Log. He stated the facility had reported the missed morphine doses to Adult Protective Services but had not reviewed the medication system to ensure it was safe. In an interview on 06/04/26 at 11:45 am, Staff 2 (Resident Services Coordinator) stated she was unaware of any professional oversight of the narcotic tracking system. She stated a staff member should be reviewing the resident’s MARs quarterly at the same time service plans are updated. She acknowledged the reviews had not been occurring. The failure to ensure a safe medication system resulted in the resident experiencing unreasonable discomfort, including transport to the emergency room and immediate treatment for symptoms of shortness of breath via injection. There was no documented evidence that any changes were made to the medication system or narcotic tracking following the incident. Between 03/13/26 and 05/29/26, Resident 4’s Controlled Substance Disposition log, which included morphine, continued to contain errors, and there was a lack of professional oversight regarding the “remaining” amounts documented. b. The resident had a signed order, dated 03/05/26, for PRN oxygen to be administered at 4 liters per minute. The facility instructed staff, via the 03/05/26 service plan, that MTs would administer oxygen per the MAR; however, the 03/01/26 through 06/01/26 MARs were reviewed and did not include instructions for staff to administer oxygen. The service plan also instructed staff to ensure the resident’s oxygen concentrator was set to 2.5 liters per minute, not the 4 liters per minute as prescribed. On 03/27/26, the resident complained of shortness of breath and was transported to the emergency room. The emergency room physician documented on 03/28/26 a diagnosis “with hypoxemia [abnormally low level of oxygen in the blood], pulse oximetry reading down to 79 [normal range 98 to 100] on 3 [liters per minute of oxygen].” The resident was admitted to the hospital for 13 days. In an interview on 06/02/26 at 4:50 pm, Staff 3 (Regional RN) acknowledged discrepancies with Resident 4’s current signed order for oxygen and instructions to staff via his/her service plan. She acknowledged there was no indication of the use of PRN oxygen on the resident’s MAR and no indication in the resident’s evaluation of whether s/he could self-administer PRN oxygen or if MTs were responsible for administration. The facility failed to ensure adequate professional oversight related to oxygen use and the resident was admitted to the hospital and diagnosed with hypoxemia. The need to ensure a safe medication system, including adequate professional oversight of the medication and treatment administration system, was reviewed with Staff 1 and Staff 6 (Business Office Manager) on 06/04/26 at 3:20 pm. They acknowledged the findings.

1. This was a past medication issue with the morphine. The service plan updated with the correct oxygen information. 2. MT training on narcotic counting process, manager will audit a narcotic count weekly, education will be provided on policies for controlled substances. Orders will go through the 3rd check system with LN being the 3rd check. New 90 day orders will be sent to providers for signature to reconcile al medication lists 3. Weekly and as needed. 4. Executive Director / Licensed Nurse

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 observation, interview, and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments the facility was responsible for administering for 4 of 4 sampled residents (#s 1, 2, 3 and 4) who were administered medications and treatments. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility 09/2025 with diagnoses of restless leg syndrome and overactive bladder. There was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for the following medications and treatments the facility was responsible to administer: * Mirabegron ER (for overactive bladder); * Ocuvite adult 50+ softgel (supplement); * Ropinirole HCL 1 mg (for restless leg syndrome); * Ropinirole HCL 2 mg (for restless leg syndrome); * Solifenacine (for overactive bladder); * Ondansetron ODT (for nausea); and * Rizatriptan (for migraines). The need to ensure signed physician's orders were in place for all medications administered was discussed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:55 pm. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 04/2008 with diagnoses including Alzheimer’s disease and type 2 diabetes mellitus. The resident’s clinical record, dated 02/04/26 through 06/01/26, was reviewed, and the following was noted: a. There was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for the following treatments the facility was responsible to administer: * Calmoseptine (to protect skin); * Zinc cream (to protect irritated skin); and * Silicone barrier cream. b. Resident 3 had a physician's order, dated 05/07/26, to administer aluminum & magnesium hydroxide-simethicone 200-200-20 mg/5 ml every six hours as needed for indigestion. However, there was no evidence the order was transcribed to the MAR to carry out. c. Resident 3 had an order to administer morphine 5 mg every hour as needed for pain; however, conflicting information was identified on the resident’s MAR. One instruction indicated administration every hour, while another indicated every two hours. The need to ensure signed physician's orders were in place for all medications administered by the facility and were carried out as written was discussed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 10:55 am. They acknowledged the findings. 3. Resident 1 was admitted to the facility in 03/2026 with diagnoses including type 2 diabetes. The resident’s clinical record, dated 03/20/26 through 06/02/26, was reviewed, and the following was noted: * On 03/21/26, Resident 1 was identified as having three “sores on [his/her] bottom.” The facility faxed the physician on 03/21/26 and requested “something to help sores’s [sic] are bleeding,” noted as “Urgent.” On 03/23/26 the physician ordered “zinc oxide cream or ointment (cream preferable) daily.” Additional instructions included, “Avoiding moisture (scheduled checks and change) and pressure (up/down schedule) to avoid skin damage.” There was no documented evidence a cream or ointment was applied daily until Desitin cream was noted on the MAR on 04/10/26, 18 days after the physician order. During an interview on 06/04/26 at 10:52 am, Staff 2 (Resident Services Coordinator) acknowledged the Desitin cream was the treatment the facility used in response to the physician’s order. She also acknowledged there was no documented evidence the physician instructions regarding scheduled brief checks and changes, and a schedule for pressure relief, had been carried out. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:04 pm. They acknowledged the findings. No additional documentation was provided. 4. Resident 4 was admitted to the facility in 09/2025 with diagnoses including chronic obstructive pulmonary disease. The resident’s 03/01/26 through 06/01/26 clinical record was reviewed and staff were interviewed. The following was identified: a. The resident had a signed order, dated 03/05/26, for Mucinex 600 mg tablet extended release (for chronic obstructive pulmonary disease), to be administered one tablet four times per day. On 05/02/26, the facility changed the medication administration via the MAR so the medication was administered two times per day. In an interview at 1:30 pm on 06/02/26 Staff 3 (Regional RN) stated she was unable to find an order for the decreased frequency of administration. On 06/03/26 at 10:15 am, Staff 2 (Resident Services Coordinator) confirmed she was unable to find an order for the medication to be administered two times per day. b. The resident had a signed order dated 03/05/26 which stated the resident should use oxygen via nasal cannula as needed at 4 liters per minute. However, there was no evidence the order was transcribed to the MAR to carry out. The service plan instructed staff to ensure the resident’s oxygen concentrator was set to 2.5 liters per minute. The resident’s concentrator was observed to be set to 3 liters per minute on 06/02/26 at 2:26 pm. The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:04 pm. They acknowledged the findings.

1. Getting new 90 day orders to reconcile medication records 2. Training and education on what proper order processing of medications using the 3rd check system. 3. With every new order coming in the LN will verify that it is porperly input. 4. Executive Director / Licensed Nurse

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 supportive device with restraining qualities was assessed by an RN, PT, or OT prior to use, failed to document other less restrictive alternatives were evaluated prior to the use of the device, caregivers were instructed on the correct use of and precautions for the device, and use of the device was included in the resident’s service plan for 1 of 1 sampled resident (#1) who had side rails on their bed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 03/2026 with diagnoses including type 2 diabetes. Observations of the resident and the resident's room on 06/02/26 at 11:44 am identified Resident 1 had side rails in the up position on each side of the bed. A current assessment for the side rails was requested on 06/02/26, and a copy of the initial assessment, completed on 04/16/26, was provided. Review of the side rail assessment identified the following: * The assessment had been completed and signed by Staff 2 (Resident Services Coordinator). There was no documented evidence the assessment had been completed by an RN, PT, or OT for the use of side rails; and * There was no documented evidence other less restrictive alternatives were evaluated prior to the use of the side rails or that caregivers were instructed on the correct use of and precautions for the device. Additionally, review of the resident’s most recent service plan and temporary service plans did not include any instructions related to side rail use. During an interview on 06/03/26 at 11:45 am, Staff 2 confirmed she completed the assessment during a time they did not have a regularly scheduled RN. The need to ensure an assessment of assistive devices with restraining qualities was completed by an RN, PT, or OT and the documentation requirements for the use of such devices were discussed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 2:04 pm. They acknowledged the findings.

1. Every apartment audited for all supportive devices. Those with devices records were audited for accuracy including the RN initiating the first assessment. 2. This will be a physical visit to each apartment as part of the quarterly service plan update to ensure families or residents have not put something in place we are unaware of. Training and education to all staff on what assistive devices are and the need to notify clinical management if they find a new device in use. 3. Quarterly and with change of condition. 4. Executive Director / Licensed Nurse

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents. This Rule is not met as evidenced by: Based on interview and record review, it was determined the facility failed to ensure 4 of 4 direct care staff (#s 9, 16, 17, and 18) demonstrated knowledge and performance in all required areas. Findings include, but are not limited to: Employee training records were reviewed on 06/02/26 with Staff 2 (Business Office Manager). There was no documented evidence Staff 9 (MT), hired 04/12/26, Staff 16 (CG), hired 04/07/26, Staff 17 (MT), hired 03/23/26, and Staff 18 (CG), hired 03/15/26, had demonstrated knowledge and performance of the following areas: * The role of service plans in providing individualized resident care; * Providing assistance with the activities of daily living; * Changes associated with normal aging; * Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; and * Conditions that require assessment, treatment, observation and reporting. In an interview on 06/03/26 at 2:20 pm, Staff 2 (Resident Services Coordinator) confirmed the facility did not have evidence of staff demonstrating competency in all required areas within 30 days of hire. The need to ensure knowledge and performance in all required areas was demonstrated within 30 days of hire was reviewed with Staff 1 (ED) and Staff 6 (Business Office Manager) on 06/04/26 at 3:20 pm. They acknowledged the findings.

1. Frontline staff skills checklists reviewed at the all-staff meeting on 6/8/2026 to make sure everyone is current. 2. Skills checklist has been added to the training spreadsheet. The Businness Office Manager will put a reminder at day 29 of employment in her calendar and invite the direct supervisor and the Executive Direcctor so everyone has the reminder to collect the completed checklist. 3. At the 30 day point for every new hire. 4. Executive Director / Business Office Manager.