Prestige Senior Living Five Rivers

Last inspection

July 2, 2025

Inspections

4, 13 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

11

Regulatory actions

0

Fines assessed

$1,875.00 (5 violations)

Current owner since

December 1, 2013

Inspections

• July 2, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• January 22, 2024: 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 24, 2024
• August 16, 2023: Licensure Complaint, 3 deficiencies cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0154: Facility Administration: Policy & Procedure severity level 2, scope L2 Widespread
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Isolated
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Isolated
• April 3, 2023: Validation, 8 deficiencies cited report
  • C0000: Comment severity level 0
  • C0200: Resident Rights and Protection - General severity level 2, scope L2 Pattern, corrected March 9, 2024
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated, corrected June 6, 2024
  • C0280: Resident Health Services severity level 3, scope L3 Isolated, corrected March 9, 2024
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated, corrected June 6, 2024
  Show all 11

  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated, corrected June 6, 2023
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Isolated, corrected June 6, 2024
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread, corrected March 9, 2024
  • C0455: Inspections and Investigation: Insp Interval severity level 2, scope L2 Widespread, corrected March 9, 2024
  • C0610: General Building Exterior severity level 2, scope L2 Widespread, corrected June 6, 2024
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread, corrected June 6, 2024

Substantiated abuse or neglect

• August 29, 2024: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The Alleged Victim (AV) relies on the facility for his/her care. The facility failed to appropriately care plan and provide services according to the AV's needs, relating to AV's change of condition. According to an investigation, AV had a wound and became bed ridden. AV's care plan was not updated to include frequent rotations, resulting in unreasonable discomfort from AV's wound being irritated and bleeding. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 29, 2024: Failed to follow care plan Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is care planned for two-hour checks of incontinence. According to an investigation, on or about August 29th, 2024, AV was found soiled in urine. AV’s care plan was not followed, resulting in unreasonable discomfort and a loss of personal dignity. The facility’s failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 29, 2024: Failed to provide service Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $375.00; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0027 (Resident Rights and Protections); 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 (AV)'s needs, relating to change of condition when AV experienced a physical decline. Due to AV's decline, AV's food needed to be cut up into bite size pieces and placed directly in front of AV. AV's care plan and/or temporary service plan was not updated to ensure all staff knew AV's dietary and nutrition needs, placing AV 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.

• September 3, 2023: Failed to provide a safe medication administration system 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The Alleged Victim (AV) relies on the facility to manage his/her medications. According to an investigation, AV ran out of his/her narcotic pain medication and did not receive the medication for approximately six days, resulting in AV being sent to the hospital where he/she experienced withdrawal symptoms. The facility failed to provide a safe medication administration system to ensure AV’s pain medication was available to be administered as ordered, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• November 3, 2025: Failed to make facility or resident records accessible Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  State’s findings

  The facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.

• November 2, 2025: Failed to provide inservice Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0105 (Inspections and Investigations)
  State’s findings

  The facility failed to provide records upon request. The facility’s failure is a violation of Oregon Administrative Rules.

• March 1, 2024: Failed to submit timely or adequate staffing documentation Licensing Violation; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-061-0010
  State’s findings

  On or about March 1, 2024, the Oregon Health Authority (OHA) reported to the Department that Respondent failed to comply with monthly reporting requirements of vaccinated individuals, residents, and staff, to the proper authority as required by law. This failure has been ongoing from December 1, 2024, to February 1, 2024, for a total of three months. The facility’s failure is a violation of Oregon Administrative Rules.

• July 19, 2023: Failed to provide proper food/nutrition Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0030 (Resident Services)
  State’s findings

  The facility failed to provide three daily nutritious, palatable meals seven days a week. The facility’s failure is a violation of Oregon Administrative Rules.

• January 5, 2023: Failed to assure resident rights Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration)
  State’s findings

  The facility failed to implement effective methods of responding to and resolving resident complaints. 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 82 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.