Prestige Senior Living Arbor Place

Last inspection

March 20, 2024

Inspections

4, 14 deficiencies cited

Substantiated abuse

6

Substantiated licensing violations

8

Regulatory actions

0

Fines assessed

$2,000.00 (6 violations)

Current owner since

December 1, 2013

• No deficiencies cited at the last inspection (March 2024)
• Every deficiency from the November 6, 2023 inspection was corrected by July 27, 2024

Inspections

• March 20, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• November 6, 2023: Validation, 10 deficiencies cited report
  • C0000: Comment severity level 0
  • C0231: Reporting & Investigating Abuse-Other Action severity level 2, scope L2 Isolated, corrected January 7, 2024
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected July 27, 2024
  • C0260: Service Plan: General severity level 2, scope L2 Pattern, corrected January 7, 2024
  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern, corrected January 7, 2024
  Show all 12

  • C0370: Staffing Requirements and Training – Pre-Serv severity level 2, scope L2 Pattern, corrected January 7, 2024
  • C0372: Training Within 30 Days: Direct Care Staff severity level 2, scope L2 Pattern, corrected January 7, 2024
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Isolated, corrected January 7, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected January 7, 2024
  • C0422: Fire and Life Safety: Training For Residents severity level 2, scope L2 Widespread, corrected January 7, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Isolated, corrected July 27, 2024
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread, corrected January 7, 2024
• January 17, 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 March 18, 2023
• September 19, 2022: Complaint Investig., 3 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0160: Reasonable Precautions severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Isolated
  • C0611: General Building Interior severity level 2, scope L2 Isolated

Substantiated abuse or neglect

• May 14, 2024: Failed to protect resident from financial exploitation 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)
  State’s findings

  The Alleged Victim (AV) relies on facility staff to ensure resident’s rights. On or about, May 14, 2024, it was discovered that an unknown Alleged Perpetrator 2 (AP2) had taken $200 from AV's purse. AP2's actions are considered financial exploitation and constitutes abuse. It was also determined that AV did have access to a key for his/her locking drawer. The facility did not keep AV free from financial exploitation, which is a violation of resident rights, is neglect of care which constitutes abuse.

• April 27, 2023: Failed to administer medication as ordered 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide a safe medication administration system to ensure AV's medications were administered as ordered. According to an investigation, the order was entered incorrectly on the Medication Administration Record (MAR), and AV did not receive his/her blood thinning medications according to the doctor’s orders for approximately five days, placing AV at risk for serious harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• February 8, 2023: Failed to protect resident from financial exploitation 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)
  State’s findings

  According to an investigation, on or about February 8, 2023, the Alleged Victim (AV) went to the hospital and when AV returned on or about March 6, 2023, AV discovered a ring and money were missing. Based on interviews and facility documentation it was determined an unknown Alleged Perpetrator 2 (AP2) financially exploited AV. AP2’s (unknown) actions are considered financial exploitation and constitutes abuse. The facility failed to protect AV’s property from theft. This failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• November 12, 2022: Failed to provide service 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs relating to his/her medication (portable oxygen containers). On or about November 12, 2022, AV was unable to attend an event/outing as AV did not have enough portable oxygen available, resulting in AV experiencing emotional distress. The failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• April 4, 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

  On or about April 4, 2022, the Alleged Victim (AV) was upset that he/she did not receive his/her insulin as ordered. Alleged Perpetrator #2 (AP2) was asked by other staff if he/she had administered AV his/her insulin and replied that he/she had given it. The next morning, AV's evening insulin was found in a drawer of the medication cart. AP2's actions are a violation of resident rights, are considered neglect of care and constitute abuse. The facility's failure to provide a safe medication administration system is a violation of resident rights, is considered neglect of care and constitutes abuse.

• April 4, 2022: Failed to intervene when resident's condition changed 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); 411-054-0040 (Change of Condition and Monitoring); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about April 4, 2022, the Alleged Victim (AV) was not feeling well and it was recorded that his/her blood sugar reading was high. AV's Primary Care Physician (PCP) has instructed the facility to contact him/her if AV's blood sugar is over 350 for three consecutive readings. On April 4, 2022, AV's blood sugar was over 350 five (5) consecutive readings. Neither Alleged Perpetrator #2 (AP2) or any other facility staff contacted AV's PCP to advise of the increased blood sugar reading, placing AV at risk for harm. AP2's actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failed to intervene at AV's change of condition, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• December 12, 2025: 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

  The facility failed to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. The facility’s failure is a violation of Oregon Administrative Rules.

• July 16, 2025: 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’s failure to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required. The facility’s failure is a violation of Oregon Administrative Rules.

• February 18, 2025: Failed to administer medication as ordered Licensing Violation; Level 3 - Moderate harm or potential for serious harm; 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 Alleged Victim (AV) relies on the facility to manage their medications. According to an investigation, on or about February 18, 2025, the Alleged Perpetrator 2 (AP2) gave AV the wrong medication. The AV experienced side effects due to the medication error and was sent the hospital. AP2’s actions are a violation of resident rights, considered neglect, and constitutes abuse. The facility failed to ensure a safe medication administration system which violates Oregon Administrative Rules.

• January 22, 2024: Failed to protect resident from verbal abuse 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)
  State’s findings

  The Alleged Victim (AV) resides at the facility and relies on the facility to deliver meals to his/her room as needed. According to an investigation, on or about January 22, 2024, Alleged Perpetrator 2 (AP2) yelled at AV when AV came to the kitchen asking about his/her dinner not being delivered, causing AV to feel threated and scared. AP2's actions are a violation of resident's rights, are considered neglect of care and constitutes verbal/emotional abuse. The facility failed to protect AV from verbal/emotional abuse, which is a violation of Oregon Administrative Rules.

• September 30, 2022: Failed to protect resident from verbal abuse 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); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  According to an investigation, Alleged Perpetrator 2 (AP2) was verbally aggressive towards Alleged Victim (AV) when AV was asking AP2 questions. AP2 also made an inappropriate verbal comment to another staff member about the Alleged Victim (AV) in his/her presence. AV experienced emotional distress and loss of personal dignity. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute verbal abuse. The facility failed to protect AV from verbal abuse, which 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 64 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.