Pacific Living Centers of Madras

Last inspection

November 20, 2025

Inspections

4, 6 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

1

Regulatory actions

0

Fines assessed

$1,563.00 (4 violations)

Current owner since

May 1, 2023

Inspections

• November 20, 2025: 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
• June 26, 2024: Validation, 3 deficiencies cited report
  • C0000: Comment severity level 0
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Isolated, corrected August 27, 2024
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected August 27, 2024
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected August 27, 2024
• December 12, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• July 21, 2022: State Licensure, 1 deficiency cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected September 21, 2022

Substantiated abuse or neglect

• October 4, 2024: Failed to maintain a safe physical environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-057-0170 (Physical Design, Environment, and Safety)
  State’s findings

  The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of elopement from the secured unit. According to an investigation, on or about October 4, 2024, AV eloped from the back yard of the secured unit. The chain link fence of the backyard was less than six feet tall. The facility failed to ensure fences surrounding the perimeter of the outdoor recreation area are no less than six feet in height and constructed to reduce the risk of resident elopement, and provide a safe physical environment for AV, which is a violation of resident rights, is neglect of care and constitutes abuse.

• June 7, 2024: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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 on multiple occasions, without staff knowledge, placing him/her at risk of serious harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 12, 2021: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $500.00; 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, the facility failed to implement interventions to prevent further falls with injury. The failure resulted in the Alleged Victim (AV) falling and sustaining a fracture. The facility failed to create and implement interventions for the AV which is considered neglect of care and constitutes abuse.

• November 1, 2021: 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide a safe medication administration system to ensure alleged victim's (AV) physician orders were followed to discontinue a medication order effect October 28, 2021. This resulted in the AV getting the discontinued medication from November 1, 2021, through December 13, 2021, putting the AV at risk of harm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• January 21, 2025: Failed to use an ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  The facility allegedly failed to fully implement and update an acuity-based staffing tool. The facility’s failure 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.