Pacific Living Centers of Medford at Brookhurst

Last inspection

November 7, 2024

Inspections

4, 19 deficiencies cited

Substantiated abuse

7

Substantiated licensing violations

2

Regulatory actions

0

Fines assessed

$2,189.00 (7 violations)

Current owner since

May 1, 2023

Inspections

• November 7, 2024: Change of Owner, 8 deficiencies cited report
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  • C0280: Resident Health Services severity level 2, scope L2 Isolated
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Widespread
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
  Show all 9

  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0162: Compliance with Rules Health Care severity level 2, scope L2 Pattern
  • Z0173: Secure Outdoor Recreation Area severity level 2, scope L2 Widespread
• October 23, 2024: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• December 28, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• February 16, 2022: Validation, 9 deficiencies cited report
  • C0000: Comment severity level 0
  • C0160: Reasonable Precautions severity level 2, scope L2 Widespread, corrected April 1, 2022
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected April 1, 2022
  • C0260: Service Plan: General severity level 2, scope L2 Isolated, corrected April 1, 2022
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected April 1, 2022
  Show all 10

  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected April 1, 2022
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected April 1, 2022
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected April 1, 2022
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected April 1, 2022
  • C0555: Call Sys, Exit Dr Alarm, Phones, Tv, Or Cable severity level 2, scope L2 Widespread, corrected April 1, 2022

Substantiated abuse or neglect

• November 27, 2024: 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

  Alleged Victim (AV) relies on facility staff to meet his/her daily needs and requires assistance with incontinence care. According to an investigation, on or about, November 27, 2024, the AV had been found soaked with urine by the incoming shift on multiple occasions over the previous four months. AP2 was assigned care of AV each time when AV was found soaked in urine. AV's service plan required staff to provide checks every two hours on night shift to check for incontinence care needs. AP2's actions are considered neglect and constitutes abuse. Based on the investigation, it was determined that AP2 did not provide timely incontinence care for AV. The facility failed to ensure incontinence care was provided, which is a violation of resident rights, is neglect of care which constitutes abuse.

• June 27, 2024: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to implement interventions and appropriately care plan related to the Alleged Victim’s (AV) change of condition and fall history. The failure resulted in AV experiencing another fall from his/her bed on June 13, 2024, causing unreasonable discomfort and risk of serious injury, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• June 21, 2023: Failed to follow care plan 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); 411-054-0036 (Service Plan – General); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The facility failed to follow the Alleged Victim’s care plan to provide two-person assistance for all transferring needs, including toileting every two hours, when only 1 caregiver was scheduled for NOC shift. The failure placed AV at risk of harm and injury, and s/he was discovered to have a large bruise that staff believe was likely due to transferring AV improperly, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• May 31, 2023: Failed to follow care plan 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); 411-054-0036 (Service Plan – General); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The facility failed to follow the Alleged Victim's (AV) care plan to have a functioning motion sensor to notify staff when AV is trying to get out of bed. The failure resulted in AV experiencing an unwitnessed fall out of bed, and due to only having one staff on shift, AV had to wait until next shift's caregiver to arrive to help him/her off the floor; AV was later transferred to the hospital with a fractured wrist, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 27, 2022: Failed to provide appropriate staffing Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $500.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0070 (Staffing Requirements and Training)
  State’s findings

  The facility failed to provide appropriate staffing levels to accommodate the Alleged Victim’s (AV) assistance with transferring and toileting needs. The failure resulted in AV experiencing repeated unreasonable discomfort and loss of personal dignity, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 27, 2022: 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 and AP2 failed to provide a safe medication administration system which resulted in the Alleged Victim (AV) running out of their long-lasting insulin prescription. The facility’s failure to re-order the medication timely, resulted in AP2 directing staff members to administer another resident’s insulin to AV, and substituting short acting insulin for their long-lasting insulin, from 12/22/2022 through 12/27/2022, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 22, 2022: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide a safe medication administration system to ensure all resident's medications are re-ordered timely, to prevent them from running out. The failure resulted in AV's medication being given to another resident, causing risk of serious harm and theft of medication, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The Alleged Perpetrator 2's actions to direct staff to give AV's medication to another resident is considered financial exploitation and constitutes abuse.

Substantiated licensing violations

• March 14, 2026: 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 failed to develop, maintain, and implement an Acuity Based Staffing Tool. The facility’s failure is a violation of Oregon Administrative Rules.

• March 14, 2026: 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

  The facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of residents. 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 14 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.