Pacific View Memory Care Community

Last inspection

July 23, 2026

Inspections

5, 24 deficiencies cited

Substantiated abuse

7

Substantiated licensing violations

14

Regulatory actions

0

Fines assessed

$4,938.00 (7 violations)

Current owner since

September 1, 2023

Inspections

• July 23, 2026: 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
• March 4, 2024: Validation, 18 deficiencies cited report
  • C0000: Comment severity level 0
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Pattern, corrected October 12, 2024
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected May 6, 2024
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected May 6, 2024
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected May 6, 2024
  Show all 20

  • C0280: Resident Health Services severity level 2, scope L2 Isolated, corrected May 6, 2024
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated, corrected May 6, 2024
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread, corrected May 6, 2024
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern, corrected May 6, 2024
  • C0340: Restraints and Supportive Devices severity level 2, scope L2 Isolated, corrected May 6, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected May 6, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Isolated, corrected October 12, 2024
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread, corrected May 6, 2024
  • C0530: Housekeeping and Laundry severity level 2, scope L2 Widespread, corrected May 6, 2024
  • C0540: Heating and Ventilation severity level 2, scope L2 Widespread, corrected May 6, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected October 12, 2024
  • Z0155: Staff Training Requirements severity level 2, scope L2 Pattern, corrected May 6, 2024
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected May 6, 2024
  • Z0173: Secure Outdoor Recreation Area severity level 2, scope L2 Widespread, corrected May 6, 2024
  • Z0176: Resident Rooms severity level 2, scope L2 Widespread, corrected May 6, 2024
• December 21, 2023: Complaint Investig., 1 deficiency cited report
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
• March 21, 2023: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected May 20, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected May 20, 2023
• September 29, 2022: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0300: Systems: Medications and Treatments severity level 2, scope L2 Isolated

Substantiated abuse or neglect

• February 8, 2026: Failed to provide safe environment 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about February 8, 2026, the facility failed to appropriately monitor and supervise Witness 1 (W1) according to his/her known behaviors resulting in a physical altercation with Alleged Victim (AV), causing unreasonable discomfort to the AV. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 3, 2024: 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is a known fall risk and has suffered multiple falls from May 2024 through August 2024, these falls were with and without injury. Prior to May 2024, staff were working to get AV physical therapy and working on medication believed to cause dizziness for AV, however, these items were not followed up on timely, and AV did not get physical therapy until August 1, 2024. The facility interventions for prevent AV from falling were not consistent or able to be followed by facility staff, resulting in AV continuing to suffer falls. AV had multiple hospitalization from falls and continued to suffer from falls, averaging two falls per week. The facility's failure to properly care plan to reduce AV's risk of falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

• May 16, 2024: Failed to provide safe environment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $1,000.00; 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

  On or about May 16, 2024, the Alleged Victim (AV) was in his/her room with a visitor. Witness #1(W1) entered AV's room and began rubbing AV's feet, making AV uncomfortable. The visitor in AV's room tried to redirect W1 three times before W1 stopped. AV typically has a mesh stop sign across his/her door to the room, however, there is no mention in the service plan of how to utilize this when AV has visitors, and AV has stated that the stop doesn't work, as W1 will just duck under the stop to get into his/her room. The facility's failure to ensure the safety of AV is a violation of resident rights, is considered neglect of care and constitutes abuse.

• May 16, 2024: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $1,000.00; 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 due to vision impairment and has suffered multiple falls from March 2024 until May 2024. On or about May 16, 2024, AV was returning from the bathroom and suffered a fall, causing a skin tear to his/her knee. Interventions in place were not effective to keep AV from falling. The facility's failure to properly care plan to reduce the risk of falls is a violation of resident rights, is considered neglect of care and constitutes abuse.

• December 7, 2023: Failed to properly plan care 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)
  State’s findings

  The facility failed to provide appropriate services according to the Alleged Victim’s (AV) care needs and wound care. AV was admitted to the hospital on December 7, 2023, and during AV's initial assessment at the hospital AV was found to be in an adult brief that was completely saturated in foul smelling urine. AV's brief was fully soaked through and was leaking out the sides, the urine was dark in color and there was blood on the edge of AV's brief. During AV's assessment at the hospital, skin break down and open wounds were observed all over AV's genitals and buttock area. The hospital stated that AV's skin break down was due to prolonged contact with a soiled diaper. The facility's failure to provide appropriate services 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.

• November 29, 2023: Failed to provide a safe medication administration system 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); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0055 (Medications and Treatments)
  State’s findings

  Alleged Victim (AV) is a resident and under the care of this facility. On or about November 28, 2023, AV was prescribed a pain patch by AV's medical community partner to determine if AV's behaviors were caused by pain. The facility dispensed one pain patch which fell off and another patch was not dispensed or applied to AV. Based on facility documentation and interviews, facility staff requested clarification as to why the pain patch was ordered when AV had not indicated AV was in pain at any time. Facility staff were directed to not apply a second pain patch after the initial one fell off of AV. The facility contacted AV's primary care physician (PCP) for clarification of the order knowing AV was under the care of AV's medical community partner and all medication questions were to go through the medical community partner and not through the PCP that facility staff contacted. The facility has a responsibility to dispense medications as ordered by medical community partner. The facility's failure to dispense AV's pain patch as ordered as well as not following the order resulted in unreasonable discomfort, which is considered a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 2 (AP2) is an employee of this facility and assists indirectly with AV's care. AV's service plan requires interventions/assistance with medication management resulting in the facility dispensing medications. AP2 refused to have staff follow AV's doctor's order for the pain patch to be dispensed and attempted to contact PCP via email, fax, and phone call without success to attempt to discuss the pain patch order. All medical contact should go through community partner as per community partner documentation. AV's community partner did not receive a request to review AV's medications from AP2. AP2 contacted AV's family, and a meeting was arranged. After the meeting, it was decided to dismiss AV's current primary care physician and bring in a new primary care physician who discontinued AV's pain patch. Based on facility documentation and interviews, AP2 stated the order for AV's pain patch was too extreme as AV had no prior use of pain medication. AP2 requested overdose medication due to concerns of AV receiving the pain patch. AV did not show signs/symptoms of oversedation due to the pain patch being applied/dispensed. AP2 instructed staff to not dispense AV's pain patch as order. AP2's actions of not following the order resulted in unreasonable discomfort to AV which is considered neglect of care and constitutes abuse. Based on facility documentation and interviews, Alleged Perpetrator 3 (AP3) put a hold on AV's pain patch indicating the pain patch was not to be dispensed as ordered. AP3 requested clarification on the order for the pain as AP3 did not agree with the order or dosage. AV's medical community partner was providing oversight of AV's care, and all medication orders/questions were to be completed through the medical community partner. AP3 instructed staff to not dispense AV's pain patch as ordered. AP3's lack of following the order resulted in unreasonable discomfort for AV which is considered neglect of care and constitutes abuse. An unknown Alleged Perpetrator 4 (AP4) allegedly financially exploited AV. An investigation inconclusively determined no abuse occurred by AP4.

• October 19, 2021: Failed to follow care plan 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is care planned to have his/her compression stockings removed each night prior to bed time. On or about October 19, 2021, AV was complaining that his/her legs hurt. It was discovered that AV's compression stockings were not removed at night as care planned. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• July 11, 2026: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about July 11, 2026, the facility failed to provide a safe medication administration system to ensure the Alleged Victim’s (AV) medications were administered as ordered. The facility's failure is a violation of Oregon Administrative Rules.

• June 2, 2026: Failed to staff as indicated by ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  On or about June 2, 2026, the facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffed to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

• May 19, 2026: Failed to staff as indicated by ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  On or about May 19, 2026, the facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffed to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this is a violation of Oregon Administrative Rules.

• May 16, 2026: Failed to cooperate with an investigation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  Based on interview and record review, conducted during an investigation on July 30, 2026, the facility’s failed to provide records to the Department upon request. Findings include but are not limited to: A review of electronic communication, dated 05/26/26, indicated the Department requested documents related to the facility’s Acuity-Based Staffing Tool (ABST) alleged event date 05/16/26. The facility had not provided all requested documentation by the due date of 05/27/26. The facility’s failure to provide records to the Department upon request is a violation of Oregon Administrative Rules.

• May 13, 2026: Failed to staff as indicated by ABST Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)
  State’s findings

  On or about May 13, 2026, the facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffed to the levels as indicated by the ABST to meet the scheduled and unscheduled needs of residents. An investigation determined this 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 30 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.