Pacific Living Centers of Klamath Falls

Last inspection

November 19, 2024

Inspections

4, 6 deficiencies cited

Substantiated abuse

8

Substantiated licensing violations

7

Regulatory actions

0

Fines assessed

$22,188.00 (10 violations)

Current owner since

May 1, 2023

Inspections

• November 19, 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
• January 29, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• March 27, 2023: Validation, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Isolated
• July 5, 2022: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0160: Reasonable Precautions severity level 2, scope L2 Widespread, corrected September 3, 2022
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected September 3, 2022

Substantiated abuse or neglect

• June 1, 2022: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $1,500.00; 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

  On or about May 18, 2022, the Alleged Victim (AV) was found on the floor of his/her room. AV was not using his/her walker, and has had prior falls as a result of not using his/her walker. AV suffered a skin tear to his/her head from the fall. The facility failed to properly care plan and add interventions addressing AV not using his/her walker to reduce the risk of falls. The facility failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• June 1, 2022: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; 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

  The Alleged Victim (AV) is a known fall risk and is known not to use his/her walker to ambulate. On or about June 1, 2022, AV fell while not using his/her walker and sustained a fractured hip. The facility failed to implement interventions and properly care plan regarding AV's falls. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• April 11, 2022: Failed to address resident's behavior Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0030 (Resident Services)
  State’s findings

  The facility failed to implement interventions and appropriately monitor Witness 1 according to his/her known aggressive behavior and prior attempted altercations. The failure resulted in a physical altercation and causing unreasonable discomfort to the Alleged Victim, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 24, 2022: Failed to provide oversight and monitoring of change of condition Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $750.00; 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); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  On or about March 24, 2022 the Alleged Victim (AV) had a discontinued medication and was showing signs of confusion and exhaustion. Medication was discontinued for 4 days, no interventions or monitoring was completed by the facility during AV's change of condition. The facility's failure to provide oversight and monitoring to AV's change of condition is a violation of resident rights, is considered neglect of care and constitutes abuse.

• March 2, 2022: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $750.00; 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); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The facility failed to appropriately care plan and properly train staff on interventions in place for the Alleged Victim (AV) regarding his/her risk of falls. AV suffered multiple falls and due to inadequate staffing, AV would not get checked on as frequently in the evenings. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• June 26, 2024: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
  State’s findings

  According to documentation, Alleged Perpetrator 2 (AP2) failed to follow the Alleged Victim’s (AV) care plan to use a gait belt during transfers to prevent falls. The failure resulted in AV being left alone and experiencing an injury fall, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure AV's care plan was followed, which is a violation of Oregon Administrative Rules.

• May 15, 2024: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide a safe medication administration system to ensure AV's medication was administered as ordered. The failure resulted in AV going approximately 21 days without his/her prescribed medication, which is a violation of Oregon Administrative Rules.

• June 1, 2022: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; fine $7,500.00; report
  Rules: 411-061-0010
  State’s findings

  On or about June 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from May 1, 2022 to May 31, 2022, for a total of 30 days.

• May 2, 2022: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; fine $7,500.00; report
  Rules: 411-061-0010
  State’s findings

  On or about May 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from April 1, 2022 to April 30, 2022, for a total of 30 days.

• March 1, 2022: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-061-0010
  State’s findings

  On or about March 1, 2022, the Oregon Health Authority reported to the Department that Respondent failed to comply with weekly reporting requirements of vaccinated individuals, residents and staff, to the proper authority as required by law. This failure has been ongoing from February 1, 2022 to February 28, 2022, for a total of 27 days.

• January 5, 2022: Failed to administer medication as ordered Licensing Violation; Level 1 - No harm or potential for minor harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to carry out medication orders as prescribed, which is a violation of Oregon Administrative Rules.

• October 27, 2021: Failed to administer medication as ordered Licensing Violation; Level 1 - No harm or potential for minor harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to carry out medication orders as prescribed, 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 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.