Pricing ranges from
    $4,900 – 6,370/month

    Pacific Grove Senior Living

    2112 Oak St, Forest Grove, OR 97116
    • Assisted Living
    • Memory Care

    Compassionate, responsive memory care community

    I'm very pleased with my wife's stay - the community is clean, well-staffed, and the caregivers are compassionate, attentive, and skilled in memory care. Staff give detailed updates, respond quickly, and provide high-quality meals, lots of activities, hospice support when needed, and reliable services that have eased our stress. Management improvements have made it a warm, social, supportive place I'd recommend.

    Loved one of resident
    Jul 2026

    Pricing

    Prices shown are estimates and subject to change. Contact your senior living advisor for current pricing.

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Memory care community services

    • Mild cognitive impairment
    • Specialized memory care programming

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    3.84·(55)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      3.2
    • Staff

      3.7
    • Meals

      3.9
    • Amenities

      4.0
    • Value

      3.8

    Pros

    • Compassionate caregiving staff
    • Attentive licensed nurses
    • Personalized care plans
    • Engaging social and recreational programs (when active)
    • Clean, home-like interior in many areas
    • Private rooms with en-suite bathroom and kitchenette
    • Professional medication-management processes (when followed)
    • Regular housekeeping services
    • Frequent family updates and progress reporting
    • Skilled hospice and end-of-life support
    • Convenient location near shops and services
    • Warm, community-oriented atmosphere

    Cons

    • Inconsistent staffing levels and coverage
    • High employee turnover and low staff morale
    • Management instability and leadership gaps
    • Gaps in clinical training and onboarding practices
    • Medication-administration and medication-safety gaps
    • Weak emergency-response and resident-monitoring practices
    • Inconsistent dining quality and food-service continuity
    • Irregular housekeeping and laundry reliability
    • Limited and inconsistent memory-care programming
    • Sanitation and odor concerns in some common areas
    • Disorganized admissions and move-in processes
    • Restricted family communication hours and access policies
    • Regulatory and code-compliance lapses affecting admissions
    • Opaque ownership and redevelopment priorities

    Summary of reviews

    Care quality at this community appears polarized: several families describe compassionate, skilled caregivers and attentive licensed nurses who provide individualized care plans, hospice support, and steady communication. Those positive accounts highlight staff who notice small behavior changes, regular progress reporting to families, and instances where caregiving reduced family stress. Conversely, other accounts describe inconsistent clinical oversight, gaps in memory-care training, and situations where medication handling and emergency response were unreliable. These contrasting descriptions suggest care quality is highly dependent on staffing level and local supervision.

    Staff and workforce issues are a central theme. Multiple accounts indicate chronic understaffing, high turnover, and variable punctuality and presence on shifts; those operational factors are linked to delayed responses to call lights, inconsistent assistance with bathing and grooming, and intermittent laundry and housekeeping reliability. When teams are intact, reviewers note a clean, warm environment and staff who treat residents like family; when gaps occur, families report missed services and slower attention to clinical needs. Training and onboarding practices were also raised as concerns, including unpaid training expectations and occasions where staff without full clinical preparation were involved in medication passing.

    Dining and activities are similarly mixed. Several families praised the meals, salad bar, and engaged dining staff; others noted food-quality inconsistencies, cold meals, and limited reheating. Activity programming has historically included group trips and robust social calendars that supported friendships and engagement, but multiple reports indicate a recent reduction in organized activities and stimulation, especially in memory-care neighborhoods. Facilities themselves are described as home-like by many — clean common areas, private rooms with en-suite bathrooms and kitchenettes, and a convenient neighborhood location — though sanitation and odor concerns in some common spaces were mentioned by others.

    Management, ownership, and regulatory patterns are notable. Reviews document episodes of leadership turnover and perceptions of management apathy or poor communication during admissions and move-ins. There are references to sustained code-compliance issues that affected the community’s ability to accept new residents, and some families raised concerns about ownership priorities and potential redevelopment. At the same time, several reviewers describe a turnaround under new management with improved training, enhanced programming, and better resident engagement. Overall, the pattern across reviews is one of variability: the presence of stable leadership and adequate staffing correlates with positive experiences, while gaps in staffing, training, and oversight correlate with negative experiences. Prospective residents and families should prioritize current staffing ratios, recent regulatory history, memory-care training practices, and direct observation of mealtime and activity programming during visits.

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    Location

    Map showing location of Pacific Grove Senior Living

    Pacific Grove Senior Living is located at 2112 Oak St, Forest Grove, OR, 97116.

    About Pacific Grove Senior Living

    Pacific Grove Senior Living sits in Forest Grove, Oregon, offering a variety of care for seniors who want some support or for those living with Alzheimer's or other kinds of dementia, and you'll find both assisted living and memory care services here, which includes help with daily needs like bathing, dressing, and medicine management, and there are options for short-term respite care if someone needs a temporary stay. This place has 64 beds, with several floor plans to pick from, and there's an on-site 24-hour staff always ready if someone needs help, and a pretty friendly and caring crew that tries to make everyone feel safe and comfortable while paying attention to personal needs.

    Pacific Grove Senior Living serves meals made from good ingredients meant to support nutrition, and you'll find snacks as well as planned dining, and folks can get personal laundry help if needed. Residents go to social events and activities that encourage hobbies and keep everyone busy, and for those who might forget things or wander, there's a special memory care program with sensory gardens and bright gathering areas meant to support memory skills and encourage safe socializing, and all these services are offered in a place designed to feel like home with both private and shared spaces.

    There's a focus on fairness here, with policies protecting people from being turned away from housing or services, or fired from a job, based on things like race, gender, disability, or who they love, and LGBTQ+ protections are part of how they do things, following federal law including source of income protections too. Rent covers utilities, though there aren't specifics on which ones, and parking is available but again, details aren't spelled out, and you'll find some outdoor amenities and access to local transportation even though those details are pretty basic.

    Pets are close, Wi-Fi and high-speed internet are available, and there are planned activities meant to keep the mind and body active, plus recreation areas outside for enjoying the natural surroundings of Forest Grove, and if someone wants a place that tries to honor individual needs with a person-centered approach-whether someone's staying a little while or living there full-time-the staff aim to make it a welcoming spot, and you'll often see the stylized compass star logo that marks the Pacific Grove Senior Living Community.

    People often ask...

    Pacific Grove Senior Living offers competitive pricing, with rates starting at a cost of $4,900 per month.

    Pacific Grove Senior Living offers assisted living and memory care.

    There are 36 photos of Pacific Grove Senior Living on Mirador.

    The full address for this community is 2112 Oak St, Forest Grove, OR 97116.

    No, Pacific Grove Senior Living does not offer respite care. Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.

    Safety & Compliance

    In Oregon, the Department of Human Services' Aging & People with Disabilities program licenses assisted living and residential care facilities, conducting inspections, complaint investigations, and renewals.

    License number5MA242
    StatusActive
    Facility typeResidential Care Facility
    Capacity56 residents
    LicenseeForest Grove Senior Living LLC
    EffectiveApril 7th, 2000
    Special certificationMemory Care
    View the official license record

    Inspection Reports

    163

    Reports

    0

    Type A Citations

    0

    Type B Citations

    6

    Complaints

    13

    Years

    29 Dec 2025Inspection
    Investigated the allegation and determined there was a violation for failing to administer medication as ordered.
    • LicensingFailed to administer medication as ordered
    10 Oct 2025Inspection
    Investigated the allegation and found a violation for failing to protect, report, and investigate abuse, including injury falls not reported to local Adult Protective Services.
    • LicensingFailed to report potential or suspected abuse
    09 Oct 2025Inspection
    Determined that a medication was not administered as ordered, violating state rules.
    • LicensingFailed to administer medication as ordered
    11 Sept 2025Abuse: Neglect
    Found a failure to provide a safe medication administration system, resulting in a resident not receiving prescribed medication between September 11 and September 17, 2025.
    • AbuseFailed to provide a safe medication administration system
    02 Jul 2025Inspection
    Found failure to update the acuity-based staffing tool to reflect resident needs and care time, causing gaps between service plans and documented staff activities.
    • LicensingFailed to update staffing plan based on ABST
    02 Jul 2025Inspection
    Found deficiencies in oversight of a change in condition, including failure to evaluate, refer to the nurse, document the change, and update the service plan.
    • LicensingFailed to provide oversight and monitoring of change of condition
    08 Jun 2025Inspection
    Investigated the allegation and found a failure to evaluate behavioral symptoms and include them in the care plan for the resident.
    • LicensingFailed to address resident's behavior
    17 Apr 2025Inspection
    Found deficiencies in operating and providing quality services, including gaps in abuse reporting, staffing, acuity-based staffing tools, and service plans. The violations were ongoing for over a year.
    • LicensingFailed to provide safe environment
    01 Apr 2025Inspection
    Identified deficiencies where residents' service plans did not reflect their needs and the implementation of required services was inconsistent.
    • LicensingFailed to provide service
    01 Apr 2025Inspection
    Determined that there was a failure to immediately report potential or suspected abuse to the appropriate authorities. Found that an unwitnessed fall occurred while the service plan required a walker, which was not followed.
    • LicensingFailed to report potential or suspected abuse
    01 Apr 2025Inspection
    Investigated and identified deficiencies in the acuity-based staffing system, with ABST data not accurately reflecting resident needs and ADLs. Inconsistencies between the roster, care plans, and ABST data led to staffing not aligning with scheduled and unscheduled resident needs.
    • LicensingFailed to use an ABST
    01 Apr 2025Inspection
    Found staffing levels insufficient to meet residents' scheduled and unscheduled needs, causing care to be delayed or unmet.
    • LicensingFailed to meet the scheduled and unscheduled needs of residents
    28 Mar 2025Inspection
    Determined that staff failed to immediately notify the local Department office or local AAA of abuse or suspected abuse.
    • LicensingFailed to report potential or suspected abuse
    28 Mar 2025Inspection
    Found deficiencies in implementing services per care plans for two residents, including delays in toileting assistance and other ADLs.
    • LicensingFailed to follow care plan
    10 Mar 2025Inspection
    Identified violations in medication administration and resident rights, showing neglect and abuse. The finding noted a lapse in providing prescribed medications for a period due to improper order handling.
    • Licensing
    18 Jan 2025Inspection
    Investigated the allegation of failing to report potential abuse and suspected abuse; determined there was a failure to immediately notify the local Department office or local AAA and to promptly investigate such reports.
    • LicensingFailed to report potential or suspected abuse
    15 Dec 2024Abuse: Neglect
    Investigated a case of neglect related to seizure medication management that left a resident without seizure medication for three days, resulting in hospitalization.
    • AbuseFailed to provide a safe medication administration system
    15 Dec 2024Inspection
    Found that medication was not administered as ordered. The finding constitutes a violation of Oregon Administrative Rules.
    • LicensingFailed to administer medication as ordered
    15 Nov 2024Abuse: Neglect
    Found abuse by neglect due to failure to provide a safe environment and monitor an individual with elopement risk; a $375 fine was assessed.
    • AbuseFailed to provide safe environment
    21 Oct 2024Inspection
    Found failure to carry out prescribed medication and diet orders for a resident, leading to a mechanical soft diet and lack of Safestrraw assistance.
    • LicensingFailed to administer medication as ordered
    21 Oct 2024Inspection
    Investigated the allegation of failing to maintain a safe physical environment and determined a deficiency existed.
    • LicensingFailed to maintain a safe physical environment
    21 Oct 2024Inspection
    Investigated the allegation of failing to provide a therapeutic diet and determined a violation.
    • LicensingFailed to provide a therapeutic diet
    21 Oct 2024Complaint
    Investigated and identified deficiencies in following prescribed medication orders. Also found failures to develop and maintain an acuity-based staffing tool.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencySystems: Treatment Orders
    • DeficiencyAcuity-Based Staffing Tool
    08 Oct 2024Abuse: Neglect
    Investigated a neglect allegation and found that nail care was not performed, leaving the resident with injuries and risk of harm; a fine was assessed.
    • AbuseFailed to provide service
    27 Sept 2024Inspection
    Found violations of medication administration rules after a resident received 40mg of a narcotic instead of 10mg, with delayed reporting and no adverse outcome.
    • LicensingFailed to administer medication as ordered
    14 Sept 2024Inspection
    Investigated the allegation of failing to provide service and determined there was a rule violation.
    • LicensingFailed to provide service
    28 Aug 2024Inspection
    Found missed medications ordered by the ER and delays in dispensing due to unsigned orders, indicating deficiencies in medication administration processes.
    • LicensingFailed to have medication available
    27 Aug 2024Inspection
    Investigated and found that an updated ABST reflecting resident needs was not maintained, with inconsistencies between the resident roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    26 Aug 2024Inspection
    Identified that the ABST was not updated to reflect residents' care needs, with inconsistencies between the roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    26 Aug 2024Inspection
    Investigated the allegation that medication was not administered as ordered and found a deficiency in medication administration.
    • LicensingFailed to administer medication as ordered
    21 Aug 2024Inspection
    Found a violation for failing to administer ordered medication as prescribed.
    • LicensingFailed to administer ordered medication
    12 Aug 2024Abuse: Neglect
    Investigated a medication-safety complaint and found a missing system for safe medication administration and insufficient evaluation of a move-in resident's ability to self-administer, leading to unsafe conditions and risk.
    • AbuseFailed to provide a safe medication administration system
    11 Aug 2024Inspection
    Found violations for incorrect anxiety dose administration and a missed pain medication dose.
    • LicensingFailed to administer medication as ordered
    19 Jun 2024Inspection
    Investigated and found a deficient safe medication administration system. The incident involved giving another resident's medications and required hospital evaluation.
    • LicensingFailed to provide a safe medication administration system
    28 Apr 2024Inspection
    Investigated the allegation and found a violation for failing to administer ordered medication.
    • LicensingFailed to administer ordered medication
    17 Apr 2024Inspection
    Identified failure to maintain an up-to-date Acuity-Based Staffing Tool with inconsistencies between roster, care plans, and ABST data.
    • LicensingFailed to use an ABST
    16 Apr 2024Complaint
    Identified multiple deficiencies, including failure to notify residents about move-out rights, failure to report abuse promptly, delayed nurse assessment of significant changes in condition, and inaccurate medication records.
    • DeficiencyResident Rights and Protection - General
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyResident Health Services
    • DeficiencySystems: Treatment Orders
    • DeficiencySystems: Medication Administration
    • DeficiencyBehavior
    12 Apr 2024Inspection
    Found a deficiency in oversight and monitoring of residents' significant changes in condition due to untimely RN assessments.
    • LicensingFailed to provide oversight and monitoring of change of condition
    12 Apr 2024Inspection
    Investigated a resident-rights notification issue and determined a violation occurred when proper notification for move-out was not provided.
    • LicensingFailed to assure resident rights
    01 Apr 2024Inspection
    Investigated the allegation and found that medication orders were not carried out as prescribed, resulting in a resident receiving the wrong dose.
    • LicensingFailed to administer medication as ordered
    14 Mar 2024License Condition
    Found that the facility failed to provide a safe environment, placing residents at risk of serious harm.
    • Regulatory ActionFailed to provide safe environment
    06 Mar 2024Inspection
    Identified deficiencies in keeping accurate medication administration records for 15 residents, with multiple missing signatures on MAR entries.
    • LicensingFailed to keep medication record current or accurate
    06 Mar 2024Inspection
    Found that medication orders were not administered as prescribed for 15 of 15 sampled residents, with multiple missed doses across numerous medications.
    • LicensingFailed to administer medication as ordered
    04 Mar 2024Abuse: Neglect
    Investigated an incident involving an extra insulin dose and unsafe medication practices. Found neglect of care and abuse, with a $375 fine assessed.
    • AbuseFailed to provide a safe medication administration system
    29 Feb 2024License Condition
    Investigated an allegation of failing to provide a safe environment and identified deficiencies in providing needed/necessary services.
    • Regulatory ActionFailed to provide safe environment
    29 Feb 2024License Condition
    Determined substantial non-compliance with licensing requirements and immediate jeopardy risk from failure to provide needed services.
    • Regulatory ActionFailed to provide safe environment
    22 Feb 2024Inspection
    Found a violation of resident rights in connection with a resident-to-resident altercation that caused injuries; the incident was self-reported six days later.
    • LicensingFailed to assure resident rights
    14 Feb 2024Inspection
    Identified violations for failure to monitor residents' changes in condition and provide meals and monitoring, risking harm to residents.
    • LicensingFailed to provide oversight and monitoring of change of condition
    14 Feb 2024Inspection
    Identified a deficient safe medication administration system that left a resident unable to self-administer insulin and led to hospitalization.
    • LicensingFailed to provide a safe medication administration system
    13 Feb 2024Inspection
    Investigated an allegation that a safe environment was not provided and found a safety deficiency.
    • LicensingFailed to provide safe environment
    07 Feb 2024Inspection
    Investigated the allegation of failing to report abuse and found a failure to immediately notify the local Department office or local AAA of abuse.
    • LicensingFailed to report potential or suspected abuse
    07 Feb 2024Inspection
    Found that a fire drill record was falsified and no written policy prohibited falsification of records.
    • LicensingFailed to assure resident rights
    07 Feb 2024Complaint
    Investigated abuse reporting and care deficiencies; Found multiple rule violations across policy and procedure, records, infection control, medication handling, staffing, and acuity-based planning.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyFacility Administration: Policy & Procedure
    • DeficiencyFacility Administration: Records
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyService Plan: General
    • DeficiencyInfection Prevention & Control
    • DeficiencySystems: Tracking Control Substances
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyAcuity-Based Staffing Tool
    07 Feb 2024Inspection
    Investigated an allegation of medication safety and found a system for tracking controlled substances and disposing of unused medications was not implemented.
    • LicensingFailed to provide a safe medication administration system
    07 Feb 2024Inspection
    Found failures to maintain infection prevention and control protocols. Signs about active COVID were posted, staff were observed not wearing masks, used PPE overflowed, and notification to the Safety, Oversight and Quality unit was delayed.
    • LicensingFailed to provide infection control
    07 Feb 2024Inspection
    Found that a resident's records were not properly prepared, complete, accurate, or preserved, and that an incident report and interim service plan related to an alleged incident were deleted.
    • LicensingFailed to assure resident rights
    07 Feb 2024Inspection
    Found that a resident's records were not properly prepared, complete, accurate, or preserved, including an incident report and interim service plan that were deleted.
    • LicensingFailed to assure resident rights
    07 Feb 2024Inspection
    Determined that a policy to refer residents who may be victims of acute sexual assault to a trained examiner within 86 hours was not implemented, and no referral was documented for a sampled resident.
    • LicensingFailed to assure resident rights
    07 Feb 2024Inspection
    Determined that there was a failure to immediately notify the local Department office or the local AAA of an incident of abuse or suspected abuse.
    • LicensingFailed to report potential or suspected abuse
    07 Feb 2024Inspection
    Found that the facility failed to have effective methods for responding to and resolving resident complaints.
    • LicensingFailed to assure resident rights
    07 Feb 2024Inspection
    Determined there was a deficiency in infection prevention and control that failed to provide a safe environment.
    • LicensingFailed to provide safe environment
    07 Feb 2024Inspection
    Investigated and found insufficient qualified awake direct care staff to meet residents' 24-hour needs.
    • LicensingFailed to meet the scheduled and unscheduled needs of residents
    07 Feb 2024Inspection
    Investigated and found that essential housekeeping services based on residents' needs and preferences were not provided.
    • LicensingFailed to provide appropriate housekeeping services
    07 Feb 2024Inspection
    Found failure to implement a written policy prohibiting falsification of narcotic log records.
    • LicensingFalsified records
    07 Feb 2024Inspection
    Identified insufficient qualified awake direct care staff to meet the 24-hour needs of residents.
    • LicensingFailed to meet the scheduled and unscheduled needs of residents
    07 Feb 2024Inspection
    Investigated an allegation that a safe medication administration system was not provided and identified a violation of Oregon Administrative Rules.
    • LicensingFailed to provide a safe medication administration system
    07 Feb 2024Inspection
    Investigated an allegation that medication was not administered as ordered and identified a violation of Oregon Administrative Rules.
    • LicensingFailed to administer medication as ordered
    07 Feb 2024Complaint
    Investigated and found a failure to ensure a safe medication system for a resident unable to self-administer insulin, leading to hospitalization for high blood sugars.
    • DeficiencyChange of Condition and Monitoring
    • DeficiencySystems: Self-Administration of Meds
    07 Feb 2024Inspection
    Investigated the allegation and found deficiencies in providing a safe environment, quality of services, and in staff supervision and conduct.
    • LicensingFailed to provide safe environment
    07 Feb 2024Inspection
    Found a deficiency for failing to immediately notify the local Department office or local AAA of any incident of abuse or suspected abuse.
    • LicensingFailed to report potential or suspected abuse
    07 Feb 2024Inspection
    Found a deficiency: no written policy prohibiting the falsification of meal tracking logs.
    • LicensingFalsified records
    07 Feb 2024Inspection
    Found that the care plan was not followed, resulting in a resident not receiving a shower for three weeks.
    • LicensingFailed to follow care plan
    07 Feb 2024Inspection
    Found that the care plan was not followed. This constitutes a violation of Oregon Administrative Rules.
    • LicensingFailed to follow care plan
    07 Feb 2024Inspection
    Found a failure to observe residents taking medications, with doses left on nightstands and not verified, creating a safety risk.
    • LicensingFailed to provide a safe medication administration system
    07 Feb 2024Inspection
    Investigated abuse-reporting failure and determined that a violation occurred.
    • LicensingFailed to report potential or suspected abuse
    07 Feb 2024Inspection
    Investigated and determined that a deficiency related to resident rights existed due to ineffective methods for responding to and resolving resident complaints.
    • LicensingFailed to assure resident rights
    07 Feb 2024Complaint
    Investigated a complaint and found multiple deficiencies across administration, records, resident rights, services, health care, medications, infection control, and staffing.
    • DeficiencyFacility Administration: Operation
    • DeficiencyFacility Administration: Policy & Procedure
    • DeficiencyFacility Administration: Records
    • DeficiencyResident Rights and Protection - General
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyResident Services: Adls
    • DeficiencyService Plan: General
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyRes Hlth Srvc: On- and Off-Site Health Srvc
    • DeficiencyInfection Prevention & Control
    • DeficiencySystems: Medications and Treatments
    • DeficiencySystems: Medication Administration
    • DeficiencySystems: Tracking Control Substances
    • DeficiencySystems: Treatment Orders
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyAcuity-Based Staffing Tool
    • DeficiencyInspections and Investigations
    07 Feb 2024Inspection
    Investigated the abuse reporting allegation and found a failure to immediately notify the local Department office, or the local AAA, of any incident of abuse or suspected abuse.
    • LicensingFailed to report potential or suspected abuse
    07 Feb 2024Inspection
    Investigated an allegation of falsified records and found a lack of a written policy prohibiting falsification related to MAR. Concluded this violated Oregon Administrative Rules.
    • LicensingFalsified records
    07 Feb 2024Inspection
    Determined that residents were not treated with dignity and respect.
    • LicensingFailed to assure resident rights
    29 Jan 2024Abuse: Neglect
    Identified failures to protect a resident from possible sexual abuse, including deleting an incident report and failing to intervene, which created risk of serious harm and resulted in a $500 fine.
    • AbuseFailed to provide safe environment
    12 Jan 2024Inspection
    Found that the provider failed to implement services as outlined in the resident's care plan for one resident.
    • LicensingFailed to follow care plan
    08 Jan 2024Inspection
    Investigated an allegation of an unsafe medication administration system and determined a violation of Oregon Administrative Rules.
    • LicensingFailed to provide a safe medication administration system
    27 Dec 2023Inspection
    Found failure to implement services per the care plan, including not providing twice-weekly showers for one resident.
    • LicensingFailed to follow care plan
    26 Dec 2023Inspection
    Investigated and found failures to immediately notify authorities about multiple instances of abuse and unwitnessed injury falls.
    • LicensingFailed to report potential or suspected abuse
    25 Dec 2023Inspection
    Investigated a failure to provide relevant information to an outside provider and found that only a face sheet was printed for responders while MARs could not be printed for a resident.
    • LicensingFailed to provide social services
    25 Dec 2023Inspection
    Investigated and found deficiencies in medication administration for two residents, including failures to give prescribed doses and falsified records.
    • LicensingFailed to administer medication as ordered
    22 Dec 2023Inspection
    Confirmed the failure to immediately notify local SPD or AAA about suspected abuse involving a resident. This involved one sampled resident.
    • LicensingFailed to report potential or suspected abuse
    01 Dec 2023Inspection
    Found insufficient awake direct care staff to meet 24-hour needs, leaving units unstaffed and creating poor visibility between wings at night.
    • LicensingFailed to meet the scheduled and unscheduled needs of residents
    11 Sept 2023Inspection
    Investigated a staffing-related allegation and found the acuity-based staffing tool was not updated to reflect resident acuity.
    • LicensingFailed to update staffing plan based on ABST
    11 Sept 2023Inspection
    Found insufficient awake direct care staff to meet 24-hour needs, leaving units unattended.
    • LicensingFailed to meet the scheduled and unscheduled needs of residents
    08 Aug 2023Inspection
    Found a failure to provide a safe medication administration system and adequate administrator oversight.
    • LicensingFailed to provide a safe medication administration system
    27 Jul 2023Inspection
    Investigated and found failures to immediately notify local SPD/AAA about abuse and to investigate and notify the local department office about an unwitnessed fall for a sampled resident.
    • LicensingFailed to report potential or suspected abuse
    27 Jul 2023License Condition
    Identified failure to use an ABST to develop a staffing plan based on care minutes. The finding cites noncompliance with ABST-related staffing requirements.
    • Regulatory ActionFailed to use an ABST
    27 Jul 2023License Condition
    Found that the staffing plan was not updated to reflect ABST requirements.
    • Regulatory ActionFailed to update staffing plan based on ABST
    25 Jul 2023Complaint
    Identified deficiencies in several areas with potential for moderate harm. Deficiencies affected resident rights, abuse reporting, laundry, service planning, treatment orders, psychotropic medications, and staffing.
    • DeficiencyLicensing Complaint Investigation
    • DeficiencyResident Rights and Protection: Personal Rela
    • DeficiencyReporting & Investigating Abuse-Other Action
    • DeficiencyResident Services: Laundry
    • DeficiencyService Plan: General
    • DeficiencySystems: Treatment Orders
    • DeficiencySystems: Psychotropic Medication
    • DeficiencyStaffing Requirements and Training: Staffing
    25 Jul 2023Abuse: Neglect
    Found that a safe environment was not provided, resulting in abuse and neglect with minor harm.
    • AbuseFailed to provide safe environment
    19 Jul 2023Inspection
    Found that records were not provided to the Department upon request in relation to an allegation of failing to cooperate with an investigation.
    • LicensingFailed to cooperate with an investigation
    15 May 2023Validation
    Found deficiencies in resident activities, move-in evaluations, and service plans. Also found lapses in infection control, medication management, and safety procedures.
    • DeficiencyComment
    • DeficiencyResident Services: Activities
    • DeficiencyResident Move-In and Eval: Res Evaluation
    • DeficiencyService Plan: General
    • DeficiencyInfection Prevention & Control
    • DeficiencySystems: Treatment Orders
    • DeficiencyAcuity-Based Staffing Tool
    • DeficiencyFire and Life Safety: Safety
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyGeneral Building Exterior
    • DeficiencyDoors, Walls, Elevators, Odors
    • DeficiencyHousekeeping and Laundry
    • DeficiencyHeating and Ventilation
    • DeficiencyCall Sys, Exit Dr Alarm, Phones, Tv, Or Cable
    • DeficiencyAdministration Compliance
    • DeficiencyStaff Training Requirements
    • DeficiencyCompliance With Rules Health Care
    • DeficiencyActivities
    • DeficiencyBehavior
    • DeficiencyOutside Area
    • DeficiencySecure Outdoor Recreation Area
    12 May 2023Inspection
    Determined that there was a deficiency in responding to and resolving resident complaints. The deficiency affected resident rights.
    • LicensingFailed to assure resident rights
    08 May 2023Validation
    Investigated deficiencies across multiple operations, resident rights, care planning, medication management, staffing, and safety during relicensure; numerous citations issued for notable lapses.
    • DeficiencyComment
    • DeficiencyFacility Administration: Operation
    • DeficiencyFacility Administration: Policy & Procedure
    • DeficiencyResident Rights and Protection - General
    • DeficiencyResident Services Meals, Food Sanitation Rule
    • DeficiencyResident Services: Adls
    • DeficiencyService Plan: General
    • DeficiencyChange of Condition and Monitoring
    • DeficiencyRes Hlth Srvc: On- and Off-Site Health Srvc
    • DeficiencySystems: Medications and Treatments
    • DeficiencySystems: Tracking Control Substances
    • DeficiencySystems: Treatment Orders
    • DeficiencyStaffing Requirements and Training: Staffing
    • DeficiencyAcuity-Based Staffing Tool
    • DeficiencyStaffing Requirements and Training – Pre-Serv
    • DeficiencyAnnual and Biennial Inservice For All Staff
    • DeficiencyFire and Life Safety: Training For Residents
    • DeficiencyInspections and Investigation: Insp Interval
    • DeficiencyGeneral Building Exterior
    • DeficiencyGeneral Building: Doors-Walls, Cleanable
    • DeficiencyCall System
    21 Apr 2023Inspection
    Investigated an allegation that staff acted as a resident's guardian or attorney-in-fact and obtained power of attorney from memory care residents. Found a rights violation.
    • LicensingFailed to assure resident rights
    21 Apr 2023Inspection
    Found a medication administration deficiency that resulted in missed doses of quetiapine fumarate between 1/16/2023 and 1/26/2023.
    • LicensingFailed to administer medication as ordered
    19 Apr 2023Licensure
    Determined substantial compliance with applicable meal service and sanitation requirements after a kitchen review.
    • DeficiencyComment
    19 Apr 2023Licensure
    Determined substantial compliance with applicable meal service and sanitation requirements.
    • DeficiencyComment
    13 Apr 2023Inspection
    Found that residents' medical and other records were not kept confidential as required by law. The finding identified a licensing rule violation related to resident rights.
    • LicensingFailed to assure resident rights
    07 Apr 2023Inspection
    Investigated and found failure to fully implement and update an Acuity Based Staffing Tool.
    • LicensingFailed to use an ABST
    25 Mar 2023Inspection
    Determined that resident complaints were not effectively responded to or resolved, and outsiders approached residents at the smoking area.
    • LicensingFailed to assure resident rights
    22 Mar 2023Inspection
    Found a deficiency in storage and handling of soiled linens and clothing due to the absence of a separate closed-container area and one-way flow from soiled to clean areas.
    • LicensingFailed to provide service
    20 Jan 2023Inspection
    Investigated and found a failure to report potential or suspected abuse, resulting in unexplainable injuries and an ER visit.
    • LicensingFailed to report potential or suspected abuse
    15 Jan 2023Abuse: Neglect
    Investigated a care plan violation and found that staff did not follow the plan, resulting in neglect and abuse with potential for moderate harm; a fine was assessed.
    • AbuseFailed to follow care plan
    25 Dec 2022Inspection
    Identified a violation for not using ABST; an ABST condition was imposed and later closed.
    • LicensingFailed to use an ABST
    12 Sept 2022Inspection
    Investigated the abuse reporting process and found a failure to promptly investigate all reports of abuse and suspected abuse and to take measures to protect residents from re-occurrence.
    • LicensingFailed to report potential or suspected abuse
    12 Sept 2022Inspection
    Investigated the allegation of failing to report potential or suspected abuse and determined that no licensing violation or abuse occurred.
    • LicensingFailed to report potential or suspected abuse
    02 Sept 2022Abuse: Neglect
    Found a failure to provide a safe environment that resulted in injury and constitutes abuse. The incident involved an altercation and harm to a resident.
    • AbuseFailed to provide safe environment
    29 Aug 2022Abuse: Neglect
    Found a failure to provide a safe environment when a courtyard door was propped open on a hot day, resulting in a resident being found outside and unable to stand.
    • AbuseFailed to provide safe environment
    14 Aug 2022Abuse: Neglect
    Investigated and found neglect and abuse stemming from failure to locate a resident's belt buckles, which led to theft. A $250 fine was assessed.
    • AbuseFailed to protect resident from financial exploitation
    19 May 2022Inspection
    Found a violation for failing to provide a safe and homelike environment.
    • LicensingFailed to provide a homelike environment
    18 May 2022Inspection
    Investigated the medication administration oversight allegation and verified inadequate professional oversight of the medication and treatment administration system.
    • LicensingFailed to administer medication as ordered
    18 May 2022Inspection
    Investigated the allegation that medications were not kept secure between setup and administration and found a deficiency.
    • LicensingFailed to properly secure or store medication
    18 May 2022Inspection
    Investigated and found a safety deficiency due to a door that did not latch and open areas that allowed memory care residents to access cabinets.
    • LicensingFailed to provide safe environment
    18 May 2022Inspection
    Investigated an allegation of failing to administer medication as ordered and identified a deficiency for not carrying out medication and treatment orders.
    • LicensingFailed to administer medication as ordered
    18 May 2022Inspection
    Investigated and verified a failure to keep medical and other records confidential as required by law.
    • LicensingFailed to assure resident rights
    10 Mar 2022Abuse: Neglect
    Found that a resident was not provided a safe environment, resulting in abuse and neglect findings and a $250 fine assessed.
    • AbuseFailed to provide safe environment
    26 Jan 2022Inspection
    Investigated a complaint and found a deficiency in providing a safe environment, including inadequate PPE usage during the COVID outbreak.
    • LicensingFailed to provide safe environment
    18 Jan 2022Abuse: Neglect
    Investigated and found neglect and abuse due to failure to provide proper care, with a resident found in urine-soaked clothing and a room smelling of urine and rotten food.
    • Abuse
    02 Nov 2021Inspection
    Investigated a staffing allegation and verified that staffing levels were not adequate.
    • LicensingFailed to provide appropriate staffing
    08 Jun 2021Inspection
    Found inadequate staffing. The staffing allegation was verified.
    • LicensingFailed to provide appropriate staffing
    08 Jun 2021Inspection
    Investigated the allegation and found housekeeping services were not provided as required.
    • LicensingFailed to provide appropriate housekeeping services
    08 Jun 2021Inspection
    Found a deficiency in providing or assisting with hygiene. The allegation was verified.
    • LicensingFailed to provide or assist with hygiene
    08 Jun 2021Inspection
    Investigated a falsified records allegation and found the alleged victim's record was not current or accurate.
    • LicensingFalsified records
    18 May 2021Inspection
    Investigated and determined equipment was not kept in good repair.
    • LicensingFailed to provide service
    18 May 2021Inspection
    Found a deficiency in providing a safe environment for residents.
    • LicensingFailed to provide safe environment
    31 Mar 2021Inspection
    Investigated and verified a failure to provide three daily nutritious, palatable meals.
    • LicensingFailed to provide proper food/nutrition
    31 Mar 2021Inspection
    Investigated the infection control allegation and verified that reasonable precautions to protect residents' health, safety, or welfare were not provided.
    • LicensingFailed to provide infection control
    10 Mar 2021Inspection
    Identified a violation for failing to administer medication as ordered.
    • LicensingFailed to administer medication as ordered
    12 Aug 2020Inspection
    Found insufficient staff to meet residents' scheduled and unscheduled needs; the related call-light response allegation was confirmed.
    • LicensingFailed to answer call light in a timely manner
    12 Aug 2020Inspection
    Investigated the allegation that resident rights were not assured and found a deficiency in responding to and resolving resident complaints.
    • LicensingFailed to assure resident rights
    23 Jun 2020Abuse: Neglect
    Investigated a complaint and found neglect of care and abuse for failing to respond to a resident's significant change in condition.
    • AbuseFailed to intervene when resident's condition changed
    22 Oct 2019Inspection
    Investigated an allegation of failing to provide proper food and nutrition and found a deficiency.
    • LicensingFailed to provide proper food/nutrition
    20 Aug 2019Abuse: Neglect
    Found a violation for failing to provide a safe environment, risking serious harm to a resident during an exit-seeking incident in a secured memory care unit.
    • AbuseFailed to provide safe environment
    29 Jul 2019Abuse: Neglect
    Identified neglect of care and assessed a $375 fine.
    • AbuseFailed to follow care plan
    10 Jul 2019Abuse: Financial abuse
    Investigated an allegation of financial exploitation and identified a failure to protect a resident from financial exploitation.
    • AbuseFailed to protect resident from financial exploitation
    07 Jul 2019Abuse: Neglect
    Identified neglect involving a resident found with a head injury.
    • AbuseFailed to follow care plan
    16 Apr 2019Abuse: Financial abuse
    Investigated a report of missing funds and identified theft/financial exploitation; an allegation of unsafe environment was noted.
    • AbuseFailed to provide safe environment
    09 Apr 2019Inspection
    Found that a resident did not receive medication as prescribed.
    • LicensingFailed to administer medication as ordered
    09 Apr 2019Inspection
    Found a deficiency in the safe medication administration system.
    • LicensingFailed to provide a safe medication administration system
    04 Apr 2019Inspection
    Found failure to report suspected abuse and assessed a $750 fine.
    • LicensingFailed to report potential or suspected abuse
    04 Apr 2019Abuse: Neglect
    Found neglect related to medication administration that prevented proper delivery of prescribed medications. A $500 fine was assessed.
    • AbuseFailed to provide a safe medication administration system
    05 Dec 2018Abuse: Neglect
    Found neglect due to failure to provide a safe environment, creating risk of serious harm.
    • AbuseFailed to provide safe environment
    01 Dec 2018Abuse: Neglect
    Found neglect of care due to failing to provide a safe environment and safe medication administration, creating risk of serious harm.
    • AbuseFailed to provide a safe medication administration system
    25 Nov 2018Abuse: Neglect
    Investigated and found neglect due to failure to assure resident safety after a fall during care; the resident sustained a leg injury.
    • AbuseFailed to assure resident was safe
    22 Oct 2018Inspection
    Investigated the allegation and substantiated a licensing violation.
    • LicensingFailed to provide service
    11 Aug 2018Inspection
    Found that a safe environment was not provided to residents.
    • LicensingFailed to provide safe environment
    02 Aug 2018Abuse: Neglect
    Investigated an abuse/neglect allegation and found a failure to maintain a safe environment, with a $375 fine assessed.
    • AbuseFailed to follow care plan
    26 Mar 2018Abuse: Financial abuse
    Investigated an allegation of financial exploitation and found a failure to protect a resident from theft.
    • AbuseFailed to protect resident from financial exploitation
    22 Sept 2016Inspection
    Found a safety deficiency due to failure to provide a safe environment.
    • LicensingFailed to follow care plan
    19 Sept 2016Inspection
    Investigated and found a failure to provide a safe environment.
    • LicensingFailed to provide safe environment
    11 Dec 2015Inspection
    Identified a failure to carry out medication orders as prescribed, a Level 1 licensing violation with no harm or potential for minor harm.
    • LicensingFailed to administer medication as ordered
    08 Jul 2014Abuse: Financial abuse
    Investigated an allegation of financial abuse and found a deficiency in protecting a resident from theft.
    • AbuseFailed to provide safe environment
    16 Dec 2013Abuse: Restraints
    Found a failure to provide a safe environment related to a restraint allegation.
    • AbuseFailed to provide safe environment
    26 Jul 2013Abuse: Physical Abuse
    Investigated a report of abuse and found a safe environment was not provided.
    • AbuseFailed to provide safe environment
    02 Jul 2013Abuse: Financial abuse
    Identified a deficiency for failing to provide a safe environment, resulting in property theft.
    • AbuseFailed to provide safe environment

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    Mirador Living is not affiliated with the owner or operator(s) of Pacific Grove Senior Living. The information above has not been verified or approved by the owner or operator. For exact information, please contact Pacific Grove Senior Living directly. There is no cost for this service. We are compensated by the community you select.

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