Pacific Living Centers of Bend

Last inspection

October 11, 2024

Inspections

4, 10 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

0

Regulatory actions

1

Fines assessed

$1,126.00 (4 violations)

Current owner since

May 1, 2023

License conditions and other regulatory actions

• June 23, 2021 to December 21, 2021: License Condition, Failed to provide safe environment RCFCD21-02622; incident: CALMS - 00015405
  Re-licensure Survey #K8OQ11 completed June 17, 2021, determined that the facility is not in substantial compliance with Oregon Administrative Rules.
  Rules: 411-054-0020; 411-054-0025 (Facility Administration); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring); 411-054-0045 (Resident Health Services); 411-054-0055 (Medications and Treatments); 411-054-0070 (Staffing Requirements and Training); 411-054-0090 (Fire and Life Safety); 411-054-0200 (Residential Care Facility Building Requirements)

Inspections

• October 11, 2024: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• March 25, 2024: Validation, 7 deficiencies cited report
  • C0000: Comment severity level 0
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected May 25, 2024
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Pattern, corrected May 25, 2024
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected May 25, 2024
  • C0545: Plumbing Systems severity level 2, scope L2 Widespread, corrected May 25, 2024
  Show all 8

  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected May 25, 2024
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected May 25, 2024
  • Z0173: Secure Outdoor Recreation Area severity level 2, scope L2 Widespread, corrected May 25, 2024
• December 11, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• July 19, 2022: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 0, corrected September 18, 2022

Substantiated abuse or neglect

• February 7, 2025: Failed to provide service 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); 411-054-0030 (Resident Services)
  State’s findings

  The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and was admitted to the facility for care related to a knee infection. According to an investigation, on or about January 7, 2025, AV wound was observed by the facility medical professional and a request was made to have AV seen by a wound clinic. Between December 27, 2024, and February 7, 2025, AV missed eight appointments for wound care with outside providers. The facility failed to ensure transportation and coordination of care with outside providers and on-site providers for AV's wound care. The facilities failure ensure AV received needed services resulted in potential risk of serious harm for AV, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

• July 24, 2024: Failed to follow care plan Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; 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 (AV) relies on facility staff to meet his/her daily needs and requires assistance and supervision with meals. According to an investigation, on or about, July 24, 2024, the Alleged Perpetrator 2 (AP2) was assisting AV with eating a meal and walked away. Upon AP2's return, AV was found wheezing and was sent to the hospital for evaluation, where a piece of fruit was found lodged in AV's throat. AP2's actions are considered neglect and constitutes abuse. Based on the investigation, it was determined that AP2 did not follow the care plan for AV. The facility failed to follow the care plan, which is a violation of resident rights, is neglect of care which constitutes abuse.

• April 24, 2024: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; report
  Rules: 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)
  State’s findings

  The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her needs. The failure resulted in AV eloping the secured building, without staff knowledge, placing him/her at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• January 28, 2024: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 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)
  State’s findings

  The facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her needs. The failure resulted in AV eloping the secured building, without staff knowledge, placing him/her at risk of harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

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 15 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.