4
Inspections
2
Deficiencies
17
Abuse Violations
20
Licensing Violations
0
Regulatory Actions
In plain language
- The most recent inspection was on June 23, 2025 (complaint investig. visit) and found 2 deficiencies.
- Across 4 inspections since 2023, inspectors cited 2 deficiencies in total. The state lists no correction dates for them.
- There are 17 substantiated abuse violations on record.
- The provider also has 20 substantiated licensing violations — rule breaches that did not involve abuse.
Deficiencies are rule violations noted by a state inspector. Most are minor and get corrected quickly; the sections below show exactly what was found and how the provider responded.
Provider Information
Status
Open
Type
Assisted Living Facility
County
Multnomah
Licensed Since
August 21, 2000
Classification
Not listed
Phone
503-465-1404
Email
huntingtonterraceed@prestigecare.com
Administrator
TERRY BRAUN
Accepts Medicaid
Yes
Memory Care
No
Inspections
4 records6/23/2025 Complaint Investig. · Event I0QV Complaint Investig.2 deficiencies ▼
Deficiencies cited (2)
C0360 Staffing Requirements and Training: Staffing Severity 2 ▼
Visit 1 · 6/23/2025 · Scope: Widespread/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on interview and record review, conducted during a site visit on 06/23/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of community staffing pattern, dated 03/10/25, indicated five staff and one-half shift on day shift, four staff and one-half shift on swing shift, and three staff on night shift. A review of the facility's ABST dated 06/23/25 indicated the staff the facility would have needed to meet the scheduled needs of the residents was six staff for day shift, five staff for swing shift, and two staff for night shift. A review of the facility's staff schedule from 06/17/25 - 06/23/25 indicated the facility was not staffed to their ABST time; each swing shift reviewed was short by one-half staff member. In an interview on 06/23/25, Staff 2 (Health Services Director) stated s/he picked the day with the highest required care time for each shift from the ABST, rounded up and then divided by seven and a half to determine how many staff should be working. The facility failed to use the results of an ABST to develop and update the facility's posted staffing plan; and the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 06/23/25.
C0363 Acuity Based Staffing Tool - Updates & Plan Severity 2 ▼
Visit 1 · 6/23/2025 · Scope: Widespread/Minimal harm or potential for moderate harm
No correction date recorded
Findings
Based on interview and record review, conducted during a site visit on 06/23/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to: A review of community staffing pattern, dated 03/10/25, indicated five staff and one-half shift on day shift, four staff and one-half shift on swing shift, and three staff on night shift. A review of the facility's ABST dated 06/23/25 indicated the staff the facility would have needed to meet the scheduled needs of the residents was six staff for day shift, five staff for swing shift, and two staff for night shift. A review of the facility's staff schedule from 06/17/25 - 06/23/25 indicated the facility was not staffed to their ABST time; each swing shift reviewed was short by one-half staff member. In an interview on 06/23/25, Staff 2 (Health Services Director) stated s/he picked the day with the highest required care time for each shift from the ABST, rounded up and then divided by seven and a half to determine how many staff should be working. The facility failed to use the results of an ABST to develop and update the facility's posted staffing plan; and the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 2 on 06/23/25.
3/15/2024 State Licensure · Event M6SH State LicensureNo deficiencies ▼
No deficiencies cited
This inspection closed without citations.
8/29/2023 Validation · Event 5SLB ValidationNo deficiencies ▼
No deficiencies cited
This inspection closed without citations.
4/18/2023 State Licensure · Event PEEF State LicensureNo deficiencies ▼
No deficiencies cited
This inspection closed without citations.
Abuse Violations
17 records10/28/2022 Failed to follow care plan · 00229603-AP-187688 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) has a history of falls due to impaired gait and poor balance and is care planned for assistance with undressing in the evening. According to an investigation, on or about October 28. 2022, AV was getting ready for bed on his/her own and fell against a clothes hamper, resulting in a skin tear on his/her left forearm. The facility failed to follow AV’s care plan, which is a violation of resident rights, is neglect of care which constitutes abuse.
Sanction
ALFCP23-00429 $188.00 fine assessed
10/20/2022 Failed to follow care plan · 00227672-AP-185938 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
Findings
The Alleged Victim (AV) is care planned for staff to accompany AV within community property and to redirect if he/she attempts to leave property. According to an investigation, on or about October 20, 2022, the facility was notified that AV was walking in a nearby parking lot alone, posing a serious risk of harm. The facility failed to follow the care plan, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP24-00657 $188.00 fine assessed
12/15/2021 Failed to administer medication as ordered · 00176045-AP-139932 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(f)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) relies on the facility to manage his/her medications. On or about December 15, 2021, Alleged Perpetrator 2 (AP2) administered AV an incorrect dosage of medication. AV experienced side effects due to the medication error. The facility and AP2 failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
ALFCP22-00329 $188.00 fine assessed
10/30/2021 Failed to provide a safe medication administration system · 00199192-AP-160254 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(f)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
The facility failed to provide a safe medication administration system to ensure the Alleged Victim's (AV) medications were administered as ordered. According to an investigation, AV did not receive his/her medications according to the doctor’s orders from approximately October 30, 2021, to December 31, 2021, leaving AV at risk for serious harm. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction
ALFCP23-00196 $250.00 fine assessed
5/6/2020 Failed to provide a safe medication administration system · 00084527-AP-063181 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0028(2)
411-054-0055(1)(a)
Findings
Alleged Victim (AV) requires the facility to administer his/her medication and is care planned for a complex medication management. On or about May 6th, May 7th, May 12th and May 13, 2020, it was discovered AV did not receive his/her 6am medications due to the medications still being in the bubble packs. Through the investigative process it was determined that several different staff had a different understanding as to how the bubble packs correlate with the date of administration. The facility did not have a process in place to review the medication administration system to determine if medications were being administered appropriately putting AV at risk for serious harm. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
ALFCP20-00657 $375.00 fine assessed
5/6/2020 Failed to provide a safe medication administration system · 00084647-AP-063183 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0028(2)
411-054-0055(1)(a)
Findings
Alleged Victim (AV) requires the facility to administer his/her medication and is care planned for a complex medication management. On or about May 5th, May 6th, May 7th, May 12th and May 13, 2020, it was discovered AV did not receive his/her 5am and 8am medications due to the medications still being in the bubble packs. Through the investigative process it was determined that several different staff had a different understanding as to how the bubble packs correlate with the date of administration. The facility did not have a process in place to review the medication administration system to determine if medications were being administered appropriately putting AV at risk for serious harm. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
ALFCP20-00660 $375.00 fine assessed
5/6/2020 Failed to provide a safe medication administration system · 00084649-AP-063185 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0028(2)
411-054-0055(1)(a)
Findings
Alleged Victim (AV) requires the facility to administer his/her medication and is care planned for a complex medication management. On or about May 6th, May 7th, May 12th and May 13, 2020, it was discovered AV did not receive his/her 5am medications due to the medications still being in the bubble packs. Through the investigative process it was determined that several different staff had a different understanding as to how the bubble packs correlate with the date of administration. The facility did not have a process in place to review the medication administration system to determine if medications were being administered appropriately putting AV at risk for serious harm. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
ALFCP20-00656 $375.00 fine assessed
5/6/2020 Failed to provide a safe medication administration system · 00084651-AP-063186 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0028(2)
411-054-0055(1)(a)
Findings
Alleged Victim (AV) requires the facility to administer his/her medication and is care planned for a complex medication management. On or about May 6th, May 7th, May 12th and May 13, 2020, it was discovered AV did not receive his/her 5am medications due to the medications still being in the bubble packs. Through the investigative process it was determined that several different staff had a different understanding as to how the bubble packs correlate with the date of administration. The facility did not have a process in place to review the medication administration system to determine if medications were being administered appropriately putting AV at risk for serious hard. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
ALFCP20-00659 $375.00 fine assessed
5/6/2020 Failed to provide a safe medication administration system · 00084657-AP-063192 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0028(2)
411-054-0055(1)(a)
Findings
Alleged Victim (AV) requires the facility to administer his/her medication and is care planned for a complex medication management. On or about May 6th, May 7th, May 12th and May 13, 2020, it was discovered AV did not receive his/her 6am medications due to the medications still being in the bubble packs. Through the investigative process it was determined that several different staff had a different understanding as to how the bubble packs correlate with the date of administration. The facility did not have a process in place to review the medication administration system to determine if medications were being administered appropriately putting AV at risk for serious hard. The facility failed to provide a safe medication administration system, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
ALFCP20-00658 $375.00 fine assessed
12/13/2019 Failed to administer medication as ordered · 00062149-AP-044842 Level 3Substantiated ▼
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0027(1)(f)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) receives an injection of medication every three weeks to treat his/her mental disorder. On December 9, 2019, AV was scheduled to receive his/her injection however medication aides did not alert the person that gives the injection. On or about December 13, 2019, AV was hospitalized due to increased behaviors and given his/her injection. The facility failed to administer AV's medication as ordered, which is a violation of resident rights, is neglect of care and constitutes abuse.
Sanction
ALFCP20-00269 $500.00 fine assessed
2/27/2019 Failed to provide safe environment · 00020924AP-014963 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(f) and (r)
411-054-0028(2)
411-054-0036(2)(g)
411-054-0300(11)
Findings
The facility neglected the alleged victim (AV) as defined in OAR 4110200002(1)(b)(A(i)&(ii) by failing to provide basic care and service to maintain AV's safety, resulting in minor injury and creating a risk of serious harm.
Sanction
ALFCP19-272 $250.00 fine assessed
4/29/2016 Failed to administer medication as ordered · BC165699 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(f) and (r)
411-054-0055(1)(a) and (f)
Findings
The facility failed to administer the reported victims (RV) medication as ordered.
10/18/2015 Failed to administer ordered medication · BC153290 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(b)
411-054-0055(1)(a) and (f)
Findings
The Facility failed tomaintain an adequate medication system.
12/4/2014 Failed to provide safe environment · BC149495 Level 2Substantiated ▼
Type
Abuse: Financial abuse
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(b)
411-054-0027(1)(r)
411-054-0300(5)(b)(D)
Findings
Facility failed to prevent RV from loss of property.
9/27/2014 Failed to provide oversight and monitoring of change of condition · BC148913 Level 3Substantiated ▼
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0027(1)(f) and (r)
411-054-0036(1)(e) and (g)
411-054-0040(1)(b) and (c)
411-054-0045(1)(f)(A)
Findings
The facility failed to provide appropriate care for RV.
Sanction
ALFCP15-038 $300.00 fine assessed
1/29/2014 Failure to provide a system that prevents theft or misuse of medication · BC146122 Level 2Substantiated ▼
Type
Abuse: Neglect
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0027(1)(f)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
The facility failed to maintain a safe medication system.
1/11/2014 Failed to provide safe environment · BC145704 Level 3Substantiated ▼
Type
Abuse: Neglect
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-020-0002(1)(b)(A)
411-054-0025(1)(b)
411-054-0027(r)
Findings
The Facility failed to provide a safe environment.
Licensing Violations
20 records1/14/2026 Failed to administer medication as ordered · 00451274-AP-403586 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) relies on their care, including medication management. According to an investigation, on or about January 14, 2026, Alleged Perpetrator 2 (AP2) administered two doses of AV's anxiety medication, instead of one dose of anxiety medication, and a one dose of pain medication. AV went to the ER due to low oxygen saturation and blood pressure. AP2’s actions are a violation of resident rights, are considered neglect of care and constitute physical abuse. The facility failed to administer medication as ordered, which is a violation of Oregon Administrative Rules.
3/10/2025 Failed to make facility or resident records accessible · CALMS - 00104797 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0105(1)(a)
Findings
Based on interview and record review, the facility failed to provide records to the Department upon request. The facility’s failure is a violation of Oregon Administrative Rules.
2/13/2025 Failed to use an ABST · CALMS - 00085420 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0037(4), (5)(a)(B) and (C)
Findings
The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing 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.
2/10/2025 Failed to use an ABST · CALMS - 00085421 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0037(4), (5)(a)(B) and (C)
Findings
The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing 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.
7/13/2024 Failed to administer medication as ordered · 00345076-AP-295597 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0027(1)(g) and (s)
411-054-0028(2)
411-054-0055(1)(a) and (f)
Findings
The Alleged Victim (AV) relies on the facility to manage his/her medications. According to an investigation, on or about July 13, 2024, when AV requested his/her PRN pain medication, Alleged Perpetrator 2 (AP2) administered AV’s PRN behavior medication in a higher dosage than prescribed in error and as a result, AV experienced increased lethargy. AP2’s actions are a violation of resident rights, are considered neglect of care and constitutes abuse. The facility failed to administer medication as ordered, which is a violation of Oregon Administrative Rules. The allegation that the medication resulted in AV’s rapid decline to death, was investigated and determined to be not substantiated.
10/20/2023 Failed to use an ABST · OR0004578100 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0037(4), (5)(a)(B) and (C)
Findings
The facility failed to have an Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population, their needs, and all required Activities of Daily Living (ADL). Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. Facility was not staffing 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.
12/23/2021 Failed to administer medication as ordered · OR0003364100 Level 0Substantiated ▼
Type
Licensing Violation
Level
0 - Not substantiated or inconclusive
Rules violated (OAR)
411-054-0055(1)(f)
Findings
The facility failed to carry out medication orders as prescribed. An investigation determined this is a violation of Oregon Administrative Rules.
6/18/2021 Failed to administer medication as ordered · 00146264-AP-115724 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0055(1)(a) and (f)
Findings
Alleged Victim (AV) relies on the facility to manage his/her medications. On or about June 18, 2021, Alleged Perpetrator 2 (AP2) did not follow proper procedure for medications and gave AV an incorrect dosage of medication. AV experienced side effects due to the incorrect dosage. AP2's actions are considered neglect and constitutes abuse. The facility failed to provide a safe medication administration system which violates Oregon Administrative Rules.
9/11/2020 Failed to provide a safe medication administration system · 00102800-AP-078945 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a) and (b)
411-054-0055(1)(a) and (f)
Findings
The Alleged Perpetrator 2 failed to provide a safe medication administration system to ensure the AV's medications were administered as ordered. The failure resulted in the AV experiencing unreasonable discomfort due to not receiving his/her evening medications, which is a violation of resident rights, is considered neglect of care and constitutes abuse. The facility failed to ensure AV's medication was administered as ordered which is a violation of Oregon Administrative Rules.
9/11/2020 Failed to administer medication as ordered · OR0002655600 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0055 (1)(f)
Findings
The allegation that the facility failed to given medications as prescribed was verified.
9/1/2020 Failed to assure resident rights · OR0003587800 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0025(4)
Findings
The allegation that the facility allegedly failed to assure the Alleged Victim rights was verified.
9/1/2020 Failed to maintain a safe physical environment · OR0003587801 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0300(4)(i)
Findings
The allegation that the facility allegedly failed to maintain a safe physical environment was verified.
9/1/2020 Failed to properly secure or store medication · OR0003587802 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0055(1)(d)
Findings
The allegation that the facility allegedly failed to provide a safe medication administration system for the Alleged Victim was verified.
5/6/2020 Failed to provide a safe medication administration system · OR0002497900 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0055(1)(a)
Findings
The allegation that the facility allegedly failed to provide a safe medication administration system for the Alleged Victim was verified.
5/6/2020 Failed to administer ordered medication · OR0002497901 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0055(1)(f)
Findings
The allegation that the facility allegedly failed to administer ordered medication was verified.
5/6/2020 Failed to administer ordered medication · OR0002497902 Level 1Substantiated ▼
Type
Licensing Violation
Level
1 - No harm or potential for minor harm
Rules violated (OAR)
411-054-0055(2)
Findings
The allegation that the facility allegedly failed to administer ordered medication was verified.
2/27/2019 Failed to report potential or suspected abuse · SR19216 Level 3Substantiated ▼
Type
Licensing Violation
Level
3 - Moderate harm or potential for serious harm
Rules violated (OAR)
411-054-0028(2)
411-054-0120(4)(a)(E)
Findings
Facility failed to report suspected abuse
Sanction
ALFCP19-274 $750.00 fine assessed
11/20/2018 Failed to provide medical treatment as ordered · 00010227AP-007371 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0025(1)(a)
411-054-0055(1)(a) and (f)
Findings
The facility negelcted the alleged victim (AV) as defined in OAR 4110200002(1)(b) by failing to provide basic care, creating a risk of serious harm
10/27/2014 Failed to administer medication as ordered · BC149134 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0055(1)(a) and (f)
Findings
The Facility failed to administer the Reported Victim's medications as physician ordered.
6/9/2012 Failed to administer medication as ordered · BC120592 Level 2Substantiated ▼
Type
Licensing Violation
Level
2 - Minor harm or potential for moderate harm
Rules violated (OAR)
411-054-0055(1)(f)
Findings
The facility failed to maintain a safe medication system.
Regulatory Actions
No regulatory actions
The state portal lists no regulatory actions for this provider.