Pacific View Assisted Living Community

Last inspection

July 23, 2026

Inspections

3, 16 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

4

Regulatory actions

0

Fines assessed

$1,750.00 (4 violations)

Current owner since

September 1, 2023

Inspections

• July 23, 2026: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• March 4, 2024: Validation, 14 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected May 6, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected May 6, 2024
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected May 6, 2024
  • C0280: Resident Health Services severity level 2, scope L2 Isolated, corrected May 6, 2024
  Show all 15

  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Pattern, corrected May 6, 2024
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected May 6, 2024
  • C0310: Systems: Medication Administration severity level 2, scope L2 Pattern, corrected May 6, 2024
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern, corrected May 6, 2024
  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected May 6, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected May 6, 2024
  • C0610: General Building Exterior severity level 2, scope L2 Widespread, corrected May 6, 2024
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread, corrected May 6, 2024
  • C0630: House Keeping and Sanitation severity level 2, scope L2 Widespread, corrected May 6, 2024
  • C0655: Call System severity level 2, scope L2 Widespread, corrected May 6, 2024
• March 21, 2023: 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 May 20, 2023

Substantiated abuse or neglect

• December 11, 2023: Failed to provide oversight and monitoring of change of condition 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); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The facility failed to provide appropriate services according to the Alleged Victim’s (AV) needs and wound care. Based on facility documentation and interviews, AV's buttocks/thigh wound was first noted on October 12, 2023, which measured approximately 4" X 2". According to facility's progress notes, there was no indication AV's wound was treated until November 14, 2023. The facility failed to obtain orders and/or treatment for AV's wound in a timely manner resulting in AV's wound increasing in size and become sepsis. The facility's failure resulted in AV’s condition worsening causing further unreasonable discomfort, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• September 12, 2022: Failed to provide oversight and monitoring of change of condition 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); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The facility failed to sufficiently address known issues regarding the Alleged Victim (AV) change of condition with his/her bladder incontinence in an appropriate time frame. The facility's failure caused AV unreasonable discomfort which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• February 24, 2022: Failed to follow care plan 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 follow Alleged Victim’s (AV) care plan for his/her toileting needs. AV’s care plan stated that staff are to report personal hygiene concerns, AV's requests for additional assistance with toileting, and episodes of incontinence to appropriate facility staff. Facility documentation and interviews showed that AV’s change in toileting needs was not reported as care planned which caused AV unreasonable discomfort. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• October 17, 2021: 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) has a rash / skin condition on his/her side from frequently laying in a urine soaked bed. AV had a change of condition after he/she was diagnosed with COVID. AV was to be checked and changed every two hours. When AV was sick, staff admit AV may have went longer than two hours without being changed. AV was a heavy wetter and total assistance with toileting and mobility, AV does not have the ability to use the call light or let his/her needs be known. Based on interviews and facility documents, AV's needs were not being met in order to keep AV free of flare up of his/her skin condition. The facility's failure to properly care plan to meet AV's needs is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• May 9, 2025: Failed to provide a safe medication administration system Licensing Violation; Level 4 - Serious harm, death, imminent danger or chronic regulatory noncompliance; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about May 9, 2025, the Alleged Victim (AV) was administered medications that were not prescribed to AV, resulting in AV being admitted to the hospital due to a drug overdose. At the time of the incident, Alleged Perpetrator 2 (AP2) was working as the medication technician and was responsible for overseeing medication administration to AV. Based on facility documentation and interviews, it was determined that AP2 failed to provide the basic care and services necessary to maintain AV’s health and safety by instructing Witness 4 (W4) to administer the incorrect medications. As a result, AV experienced a major medical event, requiring admission to the hospital’s critical care unit for three days. Documentation further indicated that five days after the incident, AV remained unsteady, suggesting ongoing effects from the medication error. AP2, in a supervisory role over W4, bears responsibility for directing the improper medication distribution. AP2’s actions constitute serious neglect of care, which meets the definition of abuse. Furthermore, the facility failed to ensure a safe medication administration system for AV which resulted in AV being hospitalized due to drug overdose which a is a violation of Oregon Administrative Rules.

• December 13, 2023: 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

  On or about December 13, 2023, Alleged Victim (AV) went to the hospital for treatment for possible infection. While AV was in the hospital, Alleged Perpetrator 2 (AP2) contacted Witness 6 (W6) stating AV was relinquishing AV's ownership of his/her cat and AV's cat was removed from the facility while AV was away and without AV's permission. When AV learned that his/her cat was removed from the facility, AV could not eat, take medications, or allow staff to provide care to AV. AV also exhibited outbursts and behaviors with staff. AP2 failed to follow the facility's pet policy. Based on interviews and facility documentation, AP2 removed AV's cat while AV was out of AV's apartment by telling law enforcement that AV relinquished ownership of AV's cat resulting in severe mental cruelty to AV. AP2's actions is considered emotional abuse. The facility is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of his or her employment duties. The facility failed to provide a safe environment for AV which is a violation of Oregon Administrative Rules.

• June 27, 2022: 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 keep an accurate Medication Administration Record. The facility's failure is a violation of Oregon Administrative Rules.

• November 2, 2021: Failed to provide or assist with hygiene 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); 411-054-0030 (Resident Services)
  State’s findings

  The Alleged Victim (AV) needs some assistance with toileting. AV is to be checked to ensure that his/her bedding and pajamas are dry. Alleged Perpetrator #2 (AP2) failed to ensure that AV's bed and clothing were kept dry during night shift. AV was found to have his/her chux completely wet, however his/her brief was dry. AP2's failure to ensure AV's comfort is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility 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 85 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.