Pacific Grove Senior Living Community

Last inspection

February 7, 2024

Inspections

4, 38 deficiencies cited

Substantiated abuse

3

Substantiated licensing violations

38

Regulatory actions

2

Fines assessed

$1,501.00 (3 violations)

Current owner since

February 1, 2021

License conditions and other regulatory actions

• February 29, 2024 to September 20, 2024: License Condition, Failed to provide safe environment ALFCD24-00081; 2 incidents: CALMS - 00052933, CALMS - 00043564
  The facility failed to comply with ODHS rules per Post Change of Owner Survey (#HFFP11) and Licensing Complaint Unit (LCU) visits. It was determined that substantial non-compliance with licensing requirements and renewed substantial non-compliance the residents of the facility are at risk of immediate jeopardy and the facilitys failure has caused or is likely to cause serious harm.
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services); 411-054-0050 (Infection Prevention and Control); 411-054-0055 (Medications and Treatments); 411-054-0070 (Staffing Requirements and Training); 411-054-0090 (Fire and Life Safety); 411-054-0105 (Inspections and Investigations); 411-054-0300 (Assisted Living Facility Building Requirements)
• July 27, 2023 to December 5, 2023: License Condition, Failed to use an ABST ALFCD23-00483; incident: CALMS - 00044932
  The facility failed to develop a staffing plan to meet the scheduled and unscheduled needs of the residents based on care minutes calculated by their ABST tool.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• February 7, 2024: Complaint Investig., 2 deficiencies cited report
  • C0270: Change of Condition and Monitoring severity level 4, scope L4 Isolated
  • C0325: Systems: Self-Administration of Meds severity level 4, scope L4 Isolated
• February 7, 2024: Complaint Investig., 17 deficiencies cited report
  • C0150: Facility Administration: Operation severity level 2, scope L2 Widespread
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Isolated
  • C0155: Facility Administration: Records severity level 3, scope L3 Isolated
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Widespread
  • C0231: Reporting & Investigating Abuse-Other Action severity level 4, scope L4 Pattern
  Show all 17

  • C0243: Resident Services: Adls severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 3, scope L3 Isolated
  • C0270: Change of Condition and Monitoring severity level 4, scope L4 Isolated
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 3, scope L3 Isolated
  • C0295: Infection Prevention & Control severity level 3, scope L3 Isolated
  • C0300: Systems: Medications and Treatments severity level 3, scope L3 Isolated
  • C0301: Systems: Medication Administration severity level 2, scope L2 Isolated
  • C0302: Systems: Tracking Control Substances severity level 3, scope L3 Isolated
  • C0303: Systems: Treatment Orders severity level 3, scope L3 Widespread
  • C0360: Staffing Requirements and Training: Staffing severity level 3, scope L3 Widespread
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
  • C0450: Inspections and Investigations severity level 2, scope L2 Isolated
• May 8, 2023: Validation, 19 deficiencies cited report
  • C0000: Comment severity level 0
  • C0150: Facility Administration: Operation severity level 3, scope L3 Isolated, corrected August 10, 2023
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Widespread, corrected August 10, 2023
  • C0200: Resident Rights and Protection - General severity level 3, scope L3 Isolated, corrected August 10, 2023
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected December 24, 2023
  Show all 21

  • C0243: Resident Services: Adls severity level 2, scope L2 Isolated, corrected August 10, 2023
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected January 27, 2024
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated, corrected August 10, 2023
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern, corrected August 10, 2023
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Widespread, corrected August 10, 2023
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Isolated, corrected August 10, 2023
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected December 24, 2023
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread, corrected August 10, 2023
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread, corrected December 24, 2023
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Isolated, corrected August 10, 2023
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Widespread, corrected August 10, 2023
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected August 10, 2023
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected January 27, 2024
  • C0610: General Building Exterior severity level 2, scope L2 Widespread, corrected August 10, 2023
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread, corrected August 10, 2023
  • C0655: Call System severity level 2, scope L2 Widespread, corrected August 10, 2023
• April 19, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0

Substantiated abuse or neglect

• December 15, 2024: Failed to provide a safe medication administration system Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) is a resident of the facility and the facility has a responsibility to provide a safe environment. AV care plan indicates, AV is to receive moderate care and support for medication and monitoring. AV has a seizure disorder that requires medication and monitoring from the facility. On or about December 12, 2024, AV's seizure medication ran out. Verbal reports were made by Witness 2 (W2) that AV’s provider’s office was notified of AV's medication being out on December 13, 2024, there is no documentation showing this occurred. AV’s provider’s office does not have record of communication from the facility regarding AV's medication being out of stock until December 16, 2024. AV was not placed on alert charting until December 15, 2024, regarding the missed medication. AV missed three days of h/h seizure medication starting December 13, 2024, to December 15, 2024, which resulted in AV having a seizure on December 15, 2024, that required hospitalization. The facility failed to provide a safe and homelike environment, failed to ensure a safe medication administration system, and failed to ensure AV's seizure medication was refilled prior to AV running out. The facility failed to administer AV's medication as prescribed, which resulted in AV missing h/h seizure medication for three days and resulted in AV having a seizure requiring emergency services and hospitalization.

• August 12, 2024: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) moved to into facility on or about August 5, 2024, from a sister facility. AV's service plan dated August 6, 2024, indicates AV self-administers medications, keeps all medications in h/h room, MT to order all medication through pharmacy as needed, self-medication evaluation will be done quarterly or as needed to make sure AV continues to safely self-administer h/h medications, and to see MAR. On or about August 7, 2024, AV requested help ordering medication that is almost out. AV was not sent with any backstock of medications from prior facility. On August 8 and 9, 2024, AV voiced concerns about h/h medications. On August 10, 2024, AV reported missing h/h blood pressure medication and reports experiencing headache and high blood pressure. AV continued to report missing blood pressure medication and experiencing headache and on August 12, 2024, AV reported pain in left shoulder and requested vitals be taken. AV blood pressure 203/97 EMTs were called, and AV was transported to the Emergency Department due to elevated blood pressure. AV returned to facility on August 13, 2024, with a new order for blood pressure medication. The facility failed to have a safe medication administration system in place, to evaluate AV upon move-in, to assure AVs ability to safely self-administer medications, and have all medications available for AV to take as ordered, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 15, 2023: Failed to follow care plan Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  Alleged Victim’s (AVs) service plan dated December 30, 2022, indicates AV has decreased mobility and requires staff to use a gait belt and provide standby assistance and a walker when ambulating. According to interviews and documentation AV fell on January 10, 2023, when in his/her bathroom alone and again on January 11, 2023, in the common area. On or about January 15, 2023, AV was discovered to have extreme difficulty ambulating, exhibiting signs of pain with every step while favoring their right leg and bruising on his/her left arm. AV was transported to the hospital and diagnosed with a left hip fracture. Camera review of night of January 14, 2023, shows AV sitting at dining room table, getting up, walking to bedroom without walker and without staff supervision or assistance. The facility repeatedly failed to follow the care plan and provide a safe environment, which is a violation of resident rights is neglect of care and constitutes abuse.

Substantiated licensing violations

• March 28, 2025: Failed to report potential or suspected abuse Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  Based on interview and record review, conducted during a site visit on 04/17/25, the facility’s failure to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse was substantiated for 1 of 1 sampled resident (# 2). Findings include, but are not limited to: In an interview, Resident 2 stated s/he had bruising on his/her left upper arm because the caregiver assisting him/her wasn’t patient enough to wait until s/he got into bed. Resident 2 stated, 'Staff 3(Caregiver) picked me up and put me in bed and hurt my arm. I had the bruising for a couple of days.” An interview on 04/17/25, Staff 1 (Administrator) stated that no instances occurred between 02/17/25 and 04/17/25 that required an internal investigation regarding whether or not abuse or neglect occurred. A record request for any incident of abuse or neglect for Resident 2 dated between 02/17/25 through 04/17/25 was made. The facility did not provide documentation, and no documentation was available. The facility’s failure to immediately notify the local Department office or the local AAA of any incident of abuse or suspected abuse was substantiated.

• March 28, 2025: Failed to follow care plan Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0036 (Service Plan – General)
  State’s findings

  Based on interview and record review, conducted during a site visit on 04/17/25, the facility’s failure to ensure the implementation of services was substantiated for 2 of 10 sampled residents (#2 and #6). Findings include, but are not limited to: In an interview on 04/17/25, Resident 2 stated, "I have waited up to one hour for a brief change." Review of Resident 2's service plan, dated 04/05/25, indicated Resident 2 required staff assistance with the following ADLs: Housekeeping Toileting, continence, bowel and bladder management Review of Resident 6's service plan, dated 01/29/25, indicated Resident 6 required assistance with the following ADLs: Housekeeping Toileting, continence, bowel and bladder management In an interview on 04/17/25, Resident 6 stated, "They have left a lot of BM (bowel movement) on me at times. I have let the administrator know," and "It has taken between 30 to 45 minutes for a brief change." The findings were reviewed with and acknowledged by Staff 1 (Administrator) and Staff 2 (LPN) on 04/17/25. The facility’s failure to ensure the implementation of services was substantiated.

• March 10, 2025: Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim's (AV's) Service Plan requires facility staff to administer, store and reorder all medication for AV according to physician's orders. On or about March 10, 2025, Alleged Perpetrator #2 (AP2) received a medication order for a new strength of Metoprolol. AV's medication order changed, AV was receiving two 25 mg Metoprolol, the order changed to one 50 mg Metoprolol instead. AP2 changed the medication record incorrectly by discontinuing the current order and not registering the new order. As a result, AV was not receiving their medication from March 10, 2025, until March 27, 2025. During that period AV complained of edema in their lower extremities, shortness of breath while ambulating and fatigue. AP2 received all required training to administer medications and to make entries into MAR and participated in follow up meetings monthly. AP2 acknowledged completing the Medication Technician Training and receiving a training manual on July 15, 2024. AP2 failed to update AV medication order, and administer AP2 medication as order, AP2's actions are a violation of resident rights, considered neglect of care and constitutes abuse. The facility failed to provide an oversight, and a safe medication administration system which violates Oregon Administrative Rules.

• December 15, 2024: Failed to administer medication as ordered Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility allegedly failed to administer medication as ordered for the Alleged Victim. An investigation determined this is a violation of Oregon Administrative Rules.

• June 19, 2024: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about June 19, 2024 Alleged Perpetrator (AP2) gave Alleged Victim (AV) another residents medications. AP2 notified the facility LPN who advised AP2 to call 911 and have AV taken to the hospital for evaluation. AV was not initially transported to the hospital but later felt dizzy and was then taken to the hospital. AP2 was trained by the facility on proper medication administration in April 2024. The facility failed to provide a safe medication administration system which is a violation of Oregon Administrative Rules.

Read the full record on the state’s site →

ODHS lists only substantiated violations: “either a substantiated instance of abuse or a licensing violation. Open investigations and complaints that are being appealed by the provider are not listed.” Oregon counts neglect as a form of abuse; see the state’s definitions of abuse. Each violation shows the level ODHS gives it, in the state’s words (for example “2 - Minor harm or potential for moderate harm”), and any fine ODHS assessed. Inspection citations show the state’s severity level and scope, and the date ODHS recorded the problem as corrected when it lists one. Rule names come from the Oregon Administrative Rules. ODHS: “Formal regulatory actions can range from a condition placed upon a license due to non-compliance or a notice to revoke a license.” This community is licensed for 78 residents; larger communities are inspected and reported on more often, so read counts with size in mind. Source: Oregon Department of Human Services, Long-Term Care Licensing, data as of October 15, 2026, showing the last five years. Always visit in person and ask the community about anything listed here.