Arbors at Oregon

In the surveyor’s words

From the most serious findings on record at Arbors at Oregon, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 27, 2025

  Based on review of a social media post, medical record review, staff interview, Police Detective (PD) interview, review of the facility video surveillance, review of the Local Police Department (LPD) report, review of the local weather report and review of the facility policy, the facility failed to ensure Resident #23, who had a diagnosis of alcohol dependence with induced persisting dementia, had a history of an elopement from a previous facility, was assessed to be at risk for elopement, and had a Wanderguard (wearable bracelet that triggers alarms at the doors to alert staff when a resident attempts to exit) applied to his left ankle, did not elope from the facility without staff knowledge. […]

• Actual harm, isolatedF695Jun 25, 2026

  Based on medical record review, review of hospital documentation, resident interview, staff interview, and review of a facility policy, the facility failed to ensure residents ordered supplemental oxygen were provided timely care and services to maintain adequate oxygen levels and prevent a change in condition. Actual harm occurred to Resident #59 on 12/09/25 when the resident was removed from her bedroom to accommodate the need for maintenance staff to make repairs in the resident's room, and the resident was placed on an oxygen tank and taken to the dining room with no means to alert staff for clinical needs and no monitoring put into place to check the resident's condition. […]

• Actual harm, isolatedF686Aug 5, 2024

  AMENDED 08/27/24 Based on observation, medical record review, family and staff interview, and review of the facility's Pressure Ulcer/Skin Breakdown Clinical Protocol, and review of the guidelines from the National Pressure Ulcer Advisory Panel (NPUAP), the facility failed to accurately assess wounds, provide timely interventions to prevent the development of pressure ulcers or healing of existing pressure ulcers, failed to obtain timely treatments of existing wounds, and failed to timely identify the resident's pressure ulcers until it reached an advanced stage. […]

• Actual harm, isolatedF689Nov 11, 2023

  Based on closed record review, staff interviews, review of hospital documentation, review of witness statements, review of a fall policy, and review of the facility's fall investigation, the facility failed to ensure care was provided per Resident #71's plan of care, failed to prevent an avoidable fall with injuries and failed to conduct a thorough post-fall investigation including a root cause analysis to identify potential hazards and resident-specific interventions to reduce and/or eliminate falls. […]

• No harm, potential for more than minimal, widespreadF921Apr 14, 2022

  Based on observation, staff interview, and review of facility policy, the facility failed to maintain a clean and sanitary environment. This had the potential to affect all residents of the facility. The facility census was 56. Findings include: Observation on 04/11/22 at 5:03 A.M. of the C Hall revealed straws, wrappers, and papers on the floor throughout the hall. Interview of State tested Nursing Assistant (STNA) # 184 at the time of the observation verified the debris in the hallway. STNA #184 stated housekeeping staff took care of those things during the day. Observation on 04/11/22 at 5:09 A.M. of the D Hall revealed broken, orange crackers on the floor outside of room 404 and a puddle of liquid on the floor between rooms 401 and 403. Continued observation on 04/11/22 at 6:07 A.M. […]