Pacific Living Centers of Medford at Arrowhead

Last inspection

November 5, 2024

Inspections

3, 10 deficiencies cited

Substantiated abuse

5

Substantiated licensing violations

2

Regulatory actions

0

Fines assessed

$1,526.00 (5 violations)

Current owner since

May 1, 2023

Inspections

• November 5, 2024: Change of Owner, 3 deficiencies cited report
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  • Z0162: Compliance with Rules Health Care severity level 2, scope L2 Pattern
  • Z0173: Secure Outdoor Recreation Area severity level 2, scope L2 Widespread
• December 28, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• August 8, 2022: Validation, 7 deficiencies cited report
  • C0000: Comment severity level 0
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected October 8, 2022
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated, corrected October 8, 2022
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread, corrected October 8, 2022
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Isolated, corrected October 8, 2022
  Show all 8

  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected October 8, 2022
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Isolated, corrected October 8, 2022
  • C0510: General Building Exterior severity level 2, scope L2 Widespread, corrected October 8, 2022

Substantiated abuse or neglect

• July 31, 2025: Failed to provide safe environment Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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)
  State’s findings

  The Alleged Victim (AV) is dependent on the facility to meet his/her safety needs and has a history of wandering behavior within the secured unit. According to an investigation, on or about July 31, 2025, AV eloped from the secured unit by exiting through an unlocked and open gate. The AV was found on or about 25 minutes later by a neighbor and near a busy road, resulting in a risk of serious harm. The facility failed to prevent AV from eloping which is a violation of resident rights, is neglect of care which constitutes abuse.

• March 25, 2025: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; 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 dependent on the facility to meet his/her safety needs and has a history of falls. According to an investigation, on or about March 21, 2025, AV was found on the floor in AV's room. AV's service planned fall interventions were for staff to provide hourly safety checks and provide standby assistance with mobility and escorts to/from activities and dining room. Prior to the fall, AV was seen in the dining room. The frequency of safety checks provided was not clear to staff interviewed and AV had not been escorted to AV's room by staff, resulting in AV's fall with injury. The facility failed to properly care plan, which is a violation of resident rights, is considered neglect of care which constitutes abuse.

• February 29, 2024: Failed to provide safe environment 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 a known fall risk. On or about February 29, 2024, AV suffered a fall when he/she did not use his/her walker to stand while in the common area. Staff asked AV to stand and wait for staff to return with his/her walker, and AV suffered a fall, with bruising to his/her head. The facility's failure to provide a safe environment 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 $338.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to appropriately care plan for the alleged victim(AV) regarding his/her risk of falls. AV was found on the floor from a fall, was transported to the hospital for treatment and was diagnosed with a broken arm. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 4, 2021: Failed to protect resident from verbal abuse Abuse: Neglect; Level 3 - Moderate harm or potential for serious 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)
  State’s findings

  According to documentation, the Alleged Perpetrator 2 was verbally abusive to the Alleged Victim on multiple occasions and caused repeated emotional harm. AP2's actions are considered verbal/emotional abuse. The facility failed to protect the AV from abuse after concerns were voiced by staff, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• July 31, 2025: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  According to an investigation, on or about July 31, 2025, a resident eloped from the secured unit by exiting through an unlocked courtyard gate. The facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents and failed to prevent elopement. The facility’s failure is a violation of Oregon Administrative Rules.

• April 15, 2024: Failed to provide a safe medication administration system 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 provide a safe medication administration system to ensure the AV's medication was administered as ordered. The failure caused no negative outcome to the AV, but 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 11 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.