Pacific Living Centers of Roseburg at Ramp.

“Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C231 and C242. Refer to C231 and C242.”

“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 C260 and C310. Refer to C260 and C310”

“Based on interview and record review, it was determined the facility failed to report possible neglect for 1 of 1 sampled resident (#1) whose record was reviewed for a fall. Findings include, but are not limited to: Resident 1 was admitted to the Memory Care Facility in 05/2025 and had diagnoses which included Alzheimer’s dementia and required staff assistance for transfers and mobility. In an interview with Witness 1 on 04/01/26 at 10:35 am, s/he said s/he installed a camera in the room that recorded interactions between Resident 1 and staff. During the interview, s/he reported that Resident 1 had a fall on 03/04/26 that was recorded on the video. S/he showed the video to the surveyor and explained how the CG did not engage the wheelchair brake on the left side. When the resident attempted to stand, the wheelchair on that side moved, the resident was unable to maintain his/her balance, and fell. Witness 1 said s/he felt the CG’s failure to engage the wheelchair brake contributed to the fall. The facility investigation of the fall indicated a CG was assisting the resident from his/her wheelchair to a recliner. During the transfer, “one of [the resident’s] brakes on [his/her] wheelchair was not clamped tight by mistake” and the wheelchair slid out from under the resident “causing [him/her] to fall…” The investigation indicated abuse and neglect was “ruled out as this was a witnessed fall and care plan was followed.” The incident was not reported to the local SPD office as suspected neglect. During a conversation with Staff 1 (ED), Staff 2 (VP of Operations), Staff 3 (Assistant ED - Ramp) and Staff 4 (Assistant ED – Douglas) on 04/02/26 at 11:20 am, Staff 1 stated the investigation was completed by staff that no longer worked at the facility. The circumstances surrounding the fall, failure to ensure the left brake was locked in place, and failure to follow the plan of care was discussed. Staff 1 and Staff 2 agreed the incident should have been reported to the local SPD office. The surveyor directed the facility to self-report the incident to the local SPD or AAA office. Confirmation the facility reported the incident was received on 04/02/26. Pacific Living Centers of Roseburg at Ramp will implement the following:”

“Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in the community at large. Findings include, but are not limited to: The facility was divided into two memory care houses, Douglas House and Ramp House. At the time of the survey the facility was home to 23 residents: 13 and 10, respectively. At the time of the survey, the facility did not have specific activity staff and had universal workers (direct care staff) who were expected to provide a daily program of social and recreational activities. The posted activity calendar showed the following activities were scheduled for 04/01/26: *Chair yoga; *Sing along; *Sensory game; *Reverse coloring; *Group puzzle; and *Music and dance. Observations during the survey on 04/01/26 at 9:15 am to approximately 5:00 pm identified the following activities were observed: * Group puzzle; and * Reverse coloring. In each unit during the survey, there were some residents who were in their rooms all day, a few residents would sit in the living room watching a television show that played continuously throughout the day and occasionally, when staff had time, a universal worker would sit and talk with some residents. On 04/02/26 at approximately 10:00 am, unsampled resident was overheard talking to Staff 2 (Vice President of Operations) saying “there isn’t much to do around here.” The facility lacked a daily program of social and recreational activities that was based on individual and group interests, physical, mental, and psychosocial needs, and created opportunities for active participation in their community. The need to develop and implement a daily program of social and recreational activities was discussed with Staff 1 (ED), Staff 2, Staff 3 (Assistant ED-Ramp) and Staff 5 (Regional Director of Operations) on 04/02/26 at 11:00 am. They acknowledged the findings. Pacific Living Centers of Roseburg at Ramp will implement the following:”

“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 provided clear direction for staff for 1 of 2 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the Memory Care Facility in 05/2025 and had diagnoses which included Alzheimer’s dementia. During the entrance conference on 04/01/26, staff reported the resident had a recent significant decline in health. Resident 1’s clinical record, interviews with care staff, an interview with Witness 1 (family), and observations during the survey revealed s/he was “high care”, needed staff assistance for ADLs, was on oxygen, had a foley catheter, and had skin breakdown to his/her bottom. Resident 1's current service plan, updated 02/13/26, was not reflective of the following areas: * Activity participation; * Bathing assistance; * Meal monitoring; * Meal location preferences; * Non-drug interventions for PRN psychoactive medications; and * Mobility and wheelchair use. The need to ensure the service plan was reflective of Resident 1's current needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (VP of Operations), Staff 3 (Assistant ED - Ramp) and Staff 4 (Assistant ED – Douglas) on 04/02/26 at 11:20 am. They acknowledged the service plan was not reflective in several areas and needed to be updated. No further information was provided. ? Pacific Living Centers of Roseburg at Ramp will implement the following: All Service Plans are reviewed and updated to meet all residents' needs. * Activity participation; * Bathing assistance; * Meal monitoring; * Meal location preferences; * Individualized Care plans PRN psychoactive medications; and * Mobility and wheelchair use to include locking the breaks Care plans are reflective of current care needs and provided with clear direction. 2.all level of care assessments including pre move in will address all Service plan items including but not limiting all ADLs and preferences. 3. ED and RN will review all level of care assessments completely before locking and putting out for staff. Service plan changes will be implemented in between level of care assessments to ensure service plan is up to date and accurate. 4. The Executive Director will be responsible for monitoring and be sure all service plans are completed”

“Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications for 1 of 2 sampled residents (#1) whose MARs were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the Memory Care Facility in 05/2025 and had diagnoses which included Alzheimer’s dementia. The resident's 02/01/26 through 03/31/26 physician orders and MARs were reviewed. The following was identified: * Resident 1 had an order for a Lidocaine patch twice a day for pain. The MAR instructed staff to document that the patches were applied and removed. According to the MARs, between 02/20/26 and 03/31/26, staff noted on several occasions the patch was removed when the documentation from the earlier administration times indicated the patch had not been applied because it was either refused or out of supply. * Resident 1 had orders for Albuterol two puffs every four hours for chronic obstructive pulmonary disease, and cranberry capsules 500 mg one daily for urinary tract infections. According to the MAR, staff documented on several occasions between 03/20/26 and 03/31/26 that the inhaler and/or cranberry capsules were not available. However, there were also multiple occasions when staff initialed the medications were administered during the same time frame. The MARs were reviewed with Staff 1 (ED) and Staff 3 (Assistant ED – Ramp) on 04/26/26 at 8:30 am. They viewed the MARs and stated staff had documented in error. They acknowledged the MARs were inaccurate. The need to ensure MARs were accurate was discussed with Staff 1 Staff 2 (VP of Operations), Staff 3 and Staff 4 (Assistant ED – Douglas) on 04/02/26 at 11:20 am. They acknowledged the findings. Pacific Living Centers of Roseburg at Ramp will implement the following: 1.Med techs will be retrained by Nurse and ED, on how to correctly communicate and document for any medications or treatments that are out of stock, so the next shift is aware too. 2. Retraining med techs on the 8 rights of med administration to ensure medications are being documented and administered appropriately. 3.ED/RN to do weekly audits on med administration weekly for 1 month and then monthly thereafter. 4. ED will be responsible to ensure these corrections are implemented and being followed.”

“Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000 or served residents with pureed textures palatable meals. Findings include, but are not limited to: Observation of the facility house kitchens (Douglas and Ramp) on 03/13/25, from 10:30 am through 1:30 pm, revealed the following: 1) Ramp House a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following: * Under the counter can opener; * Interior of oven; * Underneath range burners on cook top stove; * Interior of drawer under oven; * Interior of multiple drawers and cabinets storing food and/or cooking equipment; * Interior of lid of large chest freezer in garage; and * Interior of ice makers. b. The following areas needed repair: * Damaged caulking behind sink area; * Worn/exposed porous wood sections, yielding unsmooth surfaces, on interior of multiple drawers and cabinets; * Pipes under sink with active leaks and free-standing water in buckets/plastic containers; and * Multiple worn and uneven areas on countertop, leaving surfaces unsmooth and uncleanable. c. Multiple potentially hazardous food items were observed without open dates. d. A pan of raw chicken was observed stored directly on top of a bowl of ready-to-eat (RTE) pudding. Whole shell raw eggs were stored directly next to and touching multiple containers of RTE yogurts. Care staff were informed that the pudding would need to be discarded related to potential contamination. Staff 1 (Administrator/Person In Charge) was informed of the poor storage practices and the need to discard the food product. Staff 1 acknowledged the potential danger and contamination risk. e. Two large chest freezers were stored in the garage section. The freezers were stored directly next to personal care items, a recliner chair, and various other items that posed a potential cross contamination risk to the freezers and food items. Multiple garden/yard chemicals were found also stored in the garage, approximately 10-15 feet away from the freezers, and were not in closed/separate cabinets or containment units. An open half-full container of paint was found 10-15 feet from the freezers. The garage was not clean or kept in a sanitary condition and posed a potential contamination risk to food stored in the area. f. Multiple empty recyclable containers/pop cans and bottles were found stored on the countertop, directly above food prep spaces, rather than stored in a covered and approved container to minimize potential contamination and/or attracting pests. g. Staff drinks were stored in the kitchen area and were not of appropriate style, yielding potential of hand-to-lip contamination. h. Staff were not aware of the proper sanitizing solution parts per million needed for proper sanitizing of surfaces. The solution was checked and was at greater than 600 ppm of quaternary ammonia. Staff were not aware of the needed range for effective sanitation. 2) Douglas House a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following: * Reach-in refrigerators and freezers; * Interior of drawers and cupboards; * Interior of oven; * Interior and exterior of microwave; * Interior of ice makers; and * Drawer under oven where pan lids were stored. b. The following areas needed repair: * Worn/exposed porous wood sections on the interior of some drawers and cabinets, yielding unsmooth surfaces; and * The internal mechanism of the sanitizer dispenser for kitchen surfaces was damaged and not operating correctly. c. Multiple food items were observed stored in reach-in refrigerators with no date opened noted. A bag of salad was found without a prepared date noted. d. Packages of raw meats were observed stored directly next to gallons of ready-to-drink milk containers, causing the potential for cross contamination. e. House did not have any strips for testing sanitizer solution concentration to ensure appropriate PPM was utilized. Staff was not aware of the chemical used nor the proper PPM that was needed to sanitize. Surveyor used their strips to test the liquid in the sanitizer bucket and no PPM were detected. Staff indicated they must have forgotten to put in the tab. Staff then indicated that they use a spray from a dispenser from chemical room to sanitize. Surveyor reviewed the product, and it was labeled bathroom cleaner. Staff 2 (Assistant Administrator) was contacted and reported they had recently switched to a vendor that managed their chemicals. Surveyor reviewed the chemicals with Staff 2 who was not aware of the effective chemical for sanitation nor the proper PPM that was needed to sanitize surfaces in the kitchen. Surveyor reviewed provided label information and verified chemical to dispense was quaternary ammonia, and the system should dispense a diluted product at 200 PPM. Surveyor tested the chemical coming out of dispenser and it was not registering any PPM. After investigation, it was found that the mechanism in the dispenser was not holding the chemical in the tube so the sanitizer was not mixing correctly. Eventually the chemical did dispense correctly, after 30 seconds of continuous run, allowing time for the chemical to get from the bottle up to the dispenser. Staff were unaware of this malfunction. Multiple bottles of “dispensed” sanitizer were checked and did not have any PPM registering. Staff remade the bottles to ensure product was at the correct PPM for future sanitation. Staff 1 (Administrator) and Staff 2 verified the facility did not have a system to check to ensure product was dispensing correctly and was trusting the vendor and the dispenser. Staff 2 contacted the vendor, who indicated they would be out in a few days to fix the dispenser. Care staff were not aware of the needed contact time for the dispensed chemical to be effective nor the need to let it air dry. Staff interviewed indicated they were wiping off the sprayed chemical after spraying, which was not in line with directions for proper use. f. Staff was not observed to sanitize the thermometer prior to checking food temperatures. g. The house had one resident requiring puree textured foods. The resident was served one bowl of food for lunch that had all meal items pureed together in one blender and served as one dish. Staff was interviewed and stated this was a common practice, as they only had one blender. Surveyor reiterated the need for separate foods to be pureed separately so that all foods/menu items could be tasted and eaten separately for palatability. Care staff, Staff 1, and Staff 2 all acknowledged they would eat the menu items separately and agreed that residents with puree texture diets should be able to eat their food items the same as other residents were offered meals, despite texture modification. At approximately 1:00 pm, Staff 1 and Staff 2 reviewed all areas needing corrective action, and both acknowledged the findings. Pacific Living Centers of Roseburg at Ramp will implement the following: 1) *An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath, interior of the oven and drawer of oven as well as underneath range burners on cooktop stove were immediately cleaned. The interior lid of the large chest freezer in the garage has been cleaned. have been cleaned. Interior of ice makers: Ice makers removed and disposed of. Under the counter can opener has been removed and disposed of. * Interior of multiple drawers,cabinets, counter tops storing food and/or cooking equipment, Worn/exposed porous wood sections, yielding unsmooth surfaces, WE NEED to ask for extension please, we are getting quotes on the costs to fix , replace them. Requested ext”

“Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240. PLEASE REFER TO C 240”

“Based on observation, record review and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the house kitchens (Douglas and Ramp) on 03/13/25 from 10:40 am thru 2:00 pm revealed the following deficient practices. a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following: Douglas House: * Reach in refrigerators and freezers; * Drawers and cupboards; * Light fixtures above kitchen area; * Smoke detector and sprinklers above kitchen area; * Interior of oven; * Interior of microwave; and * Drawer under oven where pan lids were stored. Ramp House * Interior of oven; * Electric mounted can opener; * Interior of reach in refrigerators and freezers; * Thermometer used for temping food items; * Hot pads; * Interior of drawers; * Interior of cabinets/cupboards; * Cabinet under sink; * Baseboards near refrigerators; and * Left refrigerator seals with debris accumulation inside the cracks. b. The following areas needed repair: * Shelving in both dry storage areas with exposed wood; * Behind sink in Ramp house area with damaged caulking * Section under cabinets where mounted can opener with damage to backing coming off. * 3 of 4 reach in refrigerators not effectively holding temperatures. * Ceiling/attic space entry in dry good storage in Douglas house with hole allowing for potential pest entry. * Drawer directly under oven in Douglas not closing correctly. * Interior of some drawers and cabinets in both houses with worn/exposed porous wood sections yielding unsmooth surfaces. * Both refrigerators in the Ramp house had cracks or broken seals. * Right freezer in Douglas house with large section of unsmooth non cleanable area. * Left freezer in Ramp house with section of rusted area near the back of the freezer. c. Three of four reach in refrigerators were observed above 41 degrees Fahrenheit. The right fridge in Douglas was noted at 49 degrees at 11:12 am. The left fridge in Ramp house was noted at 49.1 degrees at 11:24am with yogurt stored in fridge noted at 46 degrees. The right fridge in Ramp house was noted at 44 degrees at 11:26am. All thermometers were located in the door of the reach in refrigerator where multiple food items were stored. The refrigerator temperature logs were reviewed for all refrigerators and documented majority of entries since January that were above 41 degrees. At 12:11pm the temperature of the fridge in Douglas house was rechecked and still read above 41 degrees. There was a pan of bbq chicken prepared on night shift for dinner that night. The temperature of that product was checked and read 54 degrees. At that time, Staff 2 (Person In Charge), was notified of the elevated temperatures and the need for intervention. Staff 2 verified the bbq chicken would be discarded as it had been out of acceptable refrigeration temperatures greater than 6 hours. Staff 2 also verified that all potentially hazardous food items would be discarded from that refrigerator. Staff 2 was not aware that the refrigerators were consistently not maintaining correct temperatures for cold food storage despite several staff entries into fridge temp logs of temperatures well above 41 degrees. d. Multiple food items were observed stored in both Ramp and Douglas house refrigerators that were not dated when opened as required. e. Multiple items were observed stored on the floor in Douglas house panty. Multiple canned good items were also noted in Douglas pantry that were damaged/Dented. Staff 2 was not aware canned goods that were dented could not be used in food service. f. Multiple pots/pans, cutting boards, dishes were noted in both houses that were heavily scratched, scored or damaged and in need of replacement. g. Staff in Douglas house were observed to reheat a resident’s alternative food choice in microwave for lunch. Staff did not check the temperature of the food product before going to serve to the resident. Surveyor intervened and asked them to check the temperature which was 160 degrees. Surveyor asked the staff what temperature reheated foods needed to be before serving to residents and they were not able to correctly identify the required 165 seconds. h. Food items for lunch were observed sitting on the counter or on the stove uncovered for both houses. Staff were not aware of the need to cover food items when not serving to ensure appropriate heat was retained. i. Staff in Douglas house did not sanitize the thermometer prior to checking food temperatures. j. Sanitation buckets in both Douglas and Ramp were observed higher than 600ppm for quaternary solutions. Staff did not have access to test strips and were using Bru tabs. Directions for bru tabs included 1-2 tabs per gallon of water. The bucket was ½ full (approx. ½ gallon) and staff used 2 tabs. Staff did not know the ppm (parts per million) required for effective sanitation. Staff 2 (PIC) did not know the correct ppm required for effective surface sanitation. k. Both Douglas and Ramp houses were utilizing residential style dishwashers for ware washing/sanitizing. Staff in both houses and PIC indicated use of “quick wash and heated dry” cycles for ware washing. Staff and PIC were not aware of internal wash or rinse temperatures of the machines. Facility did not have a system to test effectiveness of sanitizing for dishes. Surveyor asked for manufactures specifications which documented the ability to use a “sanitize cycle” for sanitation. Regular rinse water temperature of the machines were listed at 130 degrees. The sanitize cycle documented a final rinse temperatures of 155 degrees. Staff 2 verified no additional sanitize steps were done with dishes run thru the dishwasher. Staff 2 (PIC) was unaware of need for dishes to be sanitized. l. Whole shell eggs were noted to be stored above ready to eat foods in the refrigerator in Ramp house. m. Care staff were not wearing protective outer clothing or aprons during meal preparation, service or assistance potentially exposing food items to contaminants from person care tasks. n. At 1:00 pm, Staff 2 was interviewed. They were not able to demonstrate effective knowledge in final cook to temperatures for all meat/protein items. They were also not able to discus proper thawing practices, proper cooling time/temperature benchmarks and methods. The PIC did not demonstrate effective oversight for cold food storage with 3 of 4 refrigerators not storing food at appropriate temperatures. The facility did not have effective ware washing sanitation practices and oversight. Staff 2 (PIC) toured areas with surveyor and acknowledged areas in need of attention and correction. In an interview on at 1:45 pm, Staff 1 (Administrator) was informed of concerns found and acknowledged areas needing correction.”

“Based on observations, record review and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240. Please refer to C 240 OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57. This Rule is not met as evidenced by:”

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

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

“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. 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. o Side rails; o Toileting; o Dressing; 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. Pacific Living Centers of Roseburg at Ramp will implement the following:”

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

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

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

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

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

“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. 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. 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. There are no detail notes for this visit.”