Terwilliger Plaza MetcALF Unit

Last inspection

November 19, 2025

Inspections

6, 13 deficiencies cited

Substantiated abuse

1

Substantiated licensing violations

9

Regulatory actions

0

Fines assessed

$188.00 (1 violation)

Current owner since

May 25, 2000

Inspections

• November 19, 2025: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• November 12, 2024: Kitchen, 1 deficiency cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
• October 9, 2024: Re-Licensure, 8 deficiencies cited report
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Isolated
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
  Show all 8

  • C0510: General Building Exterior severity level 2, scope L2 Widespread
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • C0555: Call Sys, Exit Dr Alarm, Phones, TV, or Cable severity level 2, scope L2 Widespread
• November 13, 2023: Complaint Investig., 3 deficiencies cited report
  • C0260: Service Plan: General severity level 2, scope L2 Isolated
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Widespread
  • C0374: Annual and Biennial Inservice For All Staff severity level 2, scope L2 Isolated
• November 7, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• October 19, 2022: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0

Substantiated abuse or neglect

• August 6, 2025: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $188.00; 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); 411-054-0030 (Resident Services); 411-054-0036 (Service Plan – General)
  State’s findings

  The Alleged Victim (AV) is a high risk for falls and had approximately seven (7) falls unwitnessed and One (1) witnessed fall during the period from August 6, 2025 through September 3, 2025. AV's service plan was followed but did not prevent AV from experiencing a fall, AV's existing service plan interventions were not preventing recurring falls. No additional interventions were added. The facility failed to appropriately care plan and implement reasonable interventions to address AV’s increasing and ongoing falls, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• October 15, 2025: Failed to investigate injury of unknown origin to rule out abuse Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare)
  State’s findings

  On 08/15/25, Resident 1 had been found on the floor lethargic, confused, his/her eyes were non-reactive, and s/he could not keep her eyes open. The facility’s investigation was dated 08/24/25, with administrator review dated 08/27/25; On 08/16/25, Resident 1 was noted as having a bruise on his/her left thigh, with notes that s/he had received from the fall the day prior. The facility’s investigation was dated 08/24/25, with administrator review dated 08/27/25; On 08/17/25, Resident 1 had suffered a fall with injury. The facility’s investigation was dated 08/24/25, with administrator review dated 08/27/25; An incident report, dated 08/19/25, indicated Resident 1 had not received medication from 08/06/25 through 08/14/25. The facility’s investigation was dated 08/24/25, with administrator review dated 08/27/25; On 09/03/25, Resident 1 was found on the floor of his/her room unresponsive, with the electrical cord from his/her oxygen concentrator wrapped around his/her neck. There was no documented evidence the facility had investigated the incident, nor was their administrator review of the incident as of the site visit on 09/08/25. The facility failed to promptly investigate all reports of abuse and suspected abuse with administrator review was substantiated, an investigation determined this is a violation of Oregon Administrative Rules.

• October 9, 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 resident returned to the facility with increased care needs, including mobility and transfer assistance. The resident's ABST profile indicated zero minutes for transfer assistance or ambulation. It was observed the resident was being offered assistance with ambulation during the investigation. The facility failed to update to include all ADLs in Acuity-Based Staffing Tool (ABST) was substantiated. An investigation determined this is a violation of Oregon Administrative Rules.

• September 15, 2025: Failed to provide oversight and monitoring of change of condition Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  Resident returned to the facility, and missed h/h medication as staff left the medication on hold. There is no documentation resident was monitored for adverse effect regarding the missed medications. The facility’s failure to monitor a resident was substantiated, an investigation determined this is a violation of Oregon Administrative Rules.

• September 8, 2025: Failed to administer medication as ordered Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  The resident had medication orders dated August 6, 2025, as well as additional orders dated August 12, 2025. A review of the resident’s Medication Administration Record (MAR) for the period of August 1 through August 31, 2025, indicates that scheduled medications were not administered, as they had been placed on hold. Furthermore, the resident had other medications that were not on hold, yet were also not administered. The facility’s failure to administer medications in accordance with the prescribed orders was substantiated. An investigation concluded that this constitutes a violation of the Oregon Administrative Rules.

• September 8, 2025: Failed to provide a safe medication administration system Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0055 (Medications and Treatments)
  State’s findings

  Resident 1’s MAR, dated 08/01/25 through 09/03/25, indicate s/he had been administered behavioral mental health medication11 times. There is no documented evidence non-pharmacological interventions had been attempted prior to administering the medications. The facility failed to ensure medications that are administered PRN to treat a resident's behavior were used only after documented; non-pharmacological interventions had been tried with ineffective results was substantiated, 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 29 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.