The findings of the Change of Ownership Survey, conducted 04/08/24 through 04/11/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the Change of Ownership Survey of 04/11/24, conducted 10/17/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:

During the re-licensure survey, conducted 04/08/24 through 04/11/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to the deficiencies identified in the report.

Pacific Living Centers of Roseburg at Ramp will implement the following:

1. The Executive Director is taking administrative training classes that are provided by the company that are put on by the owner of the company. She has all reviewed all the OARS and has them printed out and on her desk top for daily review.

2. The Executive Director Will complete the Administrative training classes by the owner and will have certificates from class

3. The area will be reviewed monthly with the Executive Director.  

4.The Regional Director will be responsible for monitoring to be sure the Executive Director finishes the Administrative classes and she reviews the OARS at least weekly.   

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 provided clear instructions to staff for 1 of 4 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2023 with diagnoses including dementia.

Observations, interviews, and review of the current service plan, dated 03/05/24, revealed the service plan was not reflective of the resident care needs and/or failed to provide clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services should be provided in the following areas:

* Side rails;
* Toileting; and
* Dressing;
 

On 04/11/24, the need to ensure service plans were reflective of resident care needs and included a written description of who should provide the services and what, when, how, and how often the services should be provided was discussed with Staff 1 (Executive Director), Staff 2 (Assistant Executive Director), and Staff 3 (RN). They acknowledged the findings.

Pacific Living Centers of Roseburg at Ramp will implement the following:

1.All Service Plans have been reviewed and updated to meet all the residents' needs.

oSide rails;

oToileting;

oDressing;

2.The Executive Director will be double checking all care plans after Nurse, Assistant and caregivers have done any changes or updates on care plans to be sure they meet the residents needs.

3.Service Plans will be reviewed by the whole team before completion and printed every update, Executive Director, Assistant,care staff and Nurse.

4.The Executive Director will be responsible for monitoring and be sure all service plans are completed and meet the needs of the residents.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services for 2 of 2 sampled residents (#s 1 and 2) whose service planning team was reviewed.  Findings include, but are not limited to:

Resident 1 and 2's most recent service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans.

In an interview on 04/09/24, Staff 1 (Executive Director) reported she was unaware of the regulation related to a Service Planning team and it's components.

On 04/11/24, the need to ensure service plans were developed by a Service Planning Team was as discussed with Staff 1, Staff 2 (Assistant Executive Director), and Staff 3 (RN). They acknowledged the findings.

Pacific Living Centers of Roseburg at Ramp will implement the following:

1.The Executive Director will email and call the residents' legal representative and let them know the date and time of the service planning meeting and document each time, and if no response she will email the completed care plan to them for verification.

All staff and nurse will sign completed care plan

2.The Executive Director will email and call the residents responsible parties to invite to care plan meetings  so she has verification that they were invited.

She will document all this in a service notification each time a care plan has been completed.

3. This will be evaluated each and every time a care plan is completed.  

4.The Executive Director will  be responsible to be sure this is completed and monitored.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled resident (#1) who had documented medication refusals. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2023 with diagnoses including dementia.

A review of the resident's physician orders and 03/01/24 through 04/08/24 MARs identified the resident had refused medications on 40 occasions.

There was no documented evidence the physician had been notified of the refusals, or a signed order stating how often the physician would like to be notified of refusals.

During an interview with Staff 1 (Executive director), she reported she was unaware of the regulation to notify the physician when a resident refused medications.

On 04/11/24, the need to ensure the facility notified physicians of medication refusals was discussed with Staff 1, Staff 2 (Assistant Executive Director), and Staff 3 (RN). They acknowledged the findings.

Pacific Living Centers of Roseburg at Ramp will implement the following:

1. The Executive Director has faxed all residents' PCP to clarify how often they want to be notified of medication refusals, this will then be put into the residents orders and mars.

2. All med techs will be trained to notify the PCP via fax of refusals per their preferences. Notifications will be documented on the EMAR.

3. Medication refusals will be monitored weekly.

4. The Executive Director and nurse will be responsible to be sure PCP is notified per orders.

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications at least quarterly and obtain a physician or other legally recognized practitioner's written order of approval for self-administration of medications for 1 of 1 sampled resident (#3) who administered their own medication. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 05/2023. Resident 3 was identified as administering his/her own insulin medications during the acuity interview on 04/08/24.

Review of Resident 3's record identified the following:

* There was no documented evidence of an evaluation to determine Resident 3's ability to safely self-administer medications; and

* There was no documented evidence the facility obtained a written physician order or other legally recognized practitioner's written order of approval authorizing the resident to self-administer their medications.

In an interview on 04/11/24, Staff 1 (Executive Director) reported she was unaware of the regulation needing a signed physician order and an evaluation for residents who self-administered their own medications.
 

On 04/11/24, the need to ensure the facility obtained a physician order for residents who chose to self-administer their own medications and residents were evaluated at least quarterly for their ability to safely self-administer medications was discussed with Staff 1, Staff 2 (Assistant Executive Director), and Staff 3 (RN). They acknowledged the findings.

Pacific Living Centers of Roseburg at Ramp will implement the following:

1.Facility Nurse will do an initial, 30 day, 90 day and Change of condition assessment on the residents' ability to safely self-administer medications and fax PCP to get a signed order and if a signed order is obtained this will be put into the residents mars/orders.

2.The Executive Director  will be sure Facility Nurse does a Full assessment on the residents' ability to safely self-administer medications each time a care plan is updated.

3.The Executive Director will check and verify this every time a service plan is done or updated.

4.The Executive Director  is responsible to be sure this is completed and monitored.

Based on interview and record review, it was determined the facility failed to provide documentation fire drills included all required components. Findings include, but are not limited to:

Fire drill records from October 2023 through March 2024 were reviewed. The facility failed to document the number of occupants evacuated during fire drills.

On 04/10/24, the need to ensure the facility had a written record of all required fire drill components was discussed with Staff 1 (Executive Director). She acknowledged the findings.

Pacific Living Centers of Roseburg at Ramp will implement the following:

1. An Evacuation List has been made with each resident's evacuation ability and status. Residents will be evacuated during drills and a copy of that list attached with any relevant notes of refusals, etc.

2. The new evacuation list will be utilized for all drills.

3.   This will be evaluated each and every time a fire drill is done.

4. The Executive Director will  be responsible to see that this is completed and monitored.  

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of admission and were re-instructed at least annually. Findings include, but are not limited to:

Fire and life safety records were reviewed with Staff 1 (Executive Director) on 04/10/24.

There was no documented evidence residents were instructed within 24 hours of admission and re-instructed at least annually in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places inside or outside of the building in the event of an actual fire.

In an interview on 04/10/24, Staff 1 reported she was unaware of the regulation of residents needing to be instructed on fire and life safety procedures within 24 hours of admission and annually.

On 04/10/24, the need to ensure residents received fire and life safety training within 24 hours of admission and were re-instructed at least annually was discussed with Staff 1. She acknowledged the findings.

Pacific Living Centers of Roseburg at Ramp will implement the following:

1.      Fire Safety/Evacuation form including review of safety/procedures will be done on all residents.

2. Staff will ensure that the evacuation evaluation is completed each admit and quarterly.

3. The Executive Director will be checking this with each move in and quarterly.

4. The Executive Director and nurse will be responsible to see that this is completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair. Findings include, but are not limited to:

The exterior of the facility was toured on 04/08/24. Exterior pathways in the Douglas courtyard contained multiple drop offs up to three inches, measured from the concrete to the ground. These drop-offs created potential fall hazards for residents.

On 04/08/24, the building's exterior was toured with Staff 1 (Executive Director) and Staff 4 (Maintenance). They acknowledged the findings.

Pacific Living Centers of Roseburg at Ramp will implement the following:

1.The Executive Director has made sure the Exterior pathways in the Douglas courtyard have all been fixed and no drop offs from the concrete to the ground.

2.   The Executive Director has added this to the maintenance checklist to check monthly.

3.  The Executive Director will do weekly walks around the building to double-check that there is not anything that needs to be repaired or filled in.

4. The Executive Director will be responsible  that corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:

On 04/08/24, the interiors of the Douglas and Ramp cottages were toured. The following areas were identified to be in need of cleaning and/or repair:

-Douglas cottage:

* The screen of the fireplace was covered in dust, and the screen had broken away from the frame;

* The floor heat vent in the dining room was dented and had scrapes; and
* A recliner in the living room was covered with stains.
 

-Ramp cottage:

* The screen of the fireplace was covered in dust and the screen had broken away from the frame;
* The floor heat vent in the dining room was dented and had scrapes;
* Dining room tables and chairs were worn down to bare wood;
* In the laundry room, there was an approximate six inch tear to the linoleum;
* A recliner in the living room was covered with stains;
* Living room couches with tears;
* The half wall separating the living/dining areas from the kitchen had splatters; and
* Room 6's wood flooring had scrapes and gouges.
 

On 04/08/24, an environment tour was conducted with Staff 1 (Executive Director) and Staff 4 (Maintenance). They acknowledged the findings.

Pacific Living Centers of Roseburg at Ramp will implement the following:

1.The Maintenance Employee has  completed all the below duties

* The screen of the fireplace was

covered in dust, and the screen had

broken away from the frame; This has been cleaned and screen repaired.

* The floor heat vent in the dining room

was dented and had scrapes; this has been replaced with new one

* A recliner in the living room was

covered with stains, this has been cleaned.

-Ramp cottage:

* The screen of the fireplace was

covered in dust and the screen had

broken away from the frame; this has been cleaned and fixed.

* The floor heat vent in the dining room

was dented and had scrapes; this has been replaced

* Dining room tables and chairs were

worn down to bare wood;  this has been sanded and restained.

* In the laundry room, there was an

approximate six inch tear to the linoleum; this has been fixed.

* A recliner in the living room was

covered with stains; this has been cleaned

* Living room couches with tears; another cover has been placed on them.

* The half wall separating the

living/dining areas from the kitchen had

splatters; this has been cleaned

* Room 6's wood flooring had scrapes

and gouges. This has been fixed.

2. The Maintenance Employee and Executive Director have put this on a check list so it can be monitored.

3.Executive Director  will   monitor maintenance checklist monthly  to be sure all completed,

4. The Executive Director will be responsible to be sure all corrections are completed and monitored.