Evergreen Memory Care Community

Last inspection

January 14, 2026

Inspections

6, 33 deficiencies cited

Substantiated abuse

4

Substantiated licensing violations

8

Regulatory actions

2

Fines assessed

$2,375.00 (4 violations)

Current owner since

January 1, 2025

License conditions and other regulatory actions

• February 5, 2026 to April 7, 2026: License Condition, Failed to staff as indicated by ABST RCFCD26-00098; incident: CALMS - 00098431
  Violation 1: The facility failed to fully implement an Acuity-Based Staffing Tool (ABST). 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.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool); 411-054-0070 (Staffing Requirements and Training)
• August 28, 2023 to December 5, 2023: License Condition, Failed to use an ABST RCFCD23-00967; incident: CALMS - 00045569
  The facility failed to ensure the ABST (Acuity Based Staffing Tool) was updated at least quarterly and following changes of condition, to determine appropriate staffing levels to address activities of daily living.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• January 14, 2026: Change of Owner, 16 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
  • C0270: Change of Condition and Monitoring severity level 3, scope L3 Isolated
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Isolated
  Show all 16

  • C0310: Systems: Medication Administration severity level 2, scope L2 Isolated
  • C0330: Systems: Psychotropic Medication severity level 2, scope L2 Isolated
  • C0360: Staffing Requirements and Training: Staffing severity level 2, scope L2 Widespread
  • C0362: Acuity Based Staffing Tool - ABST Time severity level 2, scope L2 Isolated
  • C0513: Doors, Walls, Elevators, Odors severity level 2, scope L2 Widespread
  • C0545: Plumbing Systems severity level 2, scope L2 Widespread
  • H1517: Individual Privacy: Own Unit severity level 2, scope L2 Pattern
  • L0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Isolated
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
  • Z0162: Compliance with Rules Health Care severity level 3, scope L3 Isolated
  • Z0164: Activities severity level 2, scope L2 Pattern
• August 7, 2025: Kitchen, 2 deficiencies cited report
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread
• August 5, 2024: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected October 4, 2024
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected October 4, 2024
• October 3, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• July 10, 2023: Validation, 11 deficiencies cited report
  • C0000: Comment severity level 0
  • C0252: Resident Move-In and Eval: Res Evaluation severity level 2, scope L2 Isolated, corrected September 10, 2023
  • C0260: Service Plan: General severity level 2, scope L2 Isolated, corrected September 10, 2023
  • C0262: Service Plan: Service Planning Team severity level 2, scope L2 Pattern, corrected September 10, 2023
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern, corrected September 10, 2023
  Show all 12

  • C0280: Resident Health Services severity level 2, scope L2 Pattern, corrected September 10, 2023
  • C0290: Res Hlth Srvc: On- and Off-Site Health Srvc severity level 2, scope L2 Isolated, corrected September 10, 2023
  • C0301: Systems: Medication Administration severity level 2, scope L2 Isolated, corrected September 10, 2023
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern, corrected September 10, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Pattern, corrected September 10, 2023
  • Z0162: Compliance With Rules Health Care severity level 2, scope L2 Pattern, corrected September 10, 2023
  • Z0163: Nutrition and Hydration severity level 2, scope L2 Pattern, corrected September 10, 2023
• November 15, 2022: State Licensure, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0240: Resident Services Meals, Food Sanitation Rule severity level 2, scope L2 Widespread, corrected March 5, 2023
  • Z0142: Administration Compliance severity level 2, scope L2 Widespread, corrected March 5, 2023

Substantiated abuse or neglect

• May 19, 2024: Failed to properly plan care Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0036 (Service Plan – General); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The Alleged Victim (AV) is dependent on facility staff to meet his/her care needs, has a history of falls and is care planned for stand-by assistance for transfers and frequent safety checks. AV had five falls in in one month. According to an investigation, on or about May 21, 2024, AV was found on the floor, was experiencing pain and bleeding, and was transported to the hospital. AV's service plan did not have effective interventions to address the frequent falls. The facility failed to ensure fall interventions were service planned and communicated to staff, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• February 17, 2023: Failed to assure timely medical treatment Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $250.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  The Alleged Victim (AV) has a known history of UTI’s. According to an investigation, on or about February 16, 2023, the facility contacted AV’s doctor to request a UA for a possible UTI. There was no follow-up with the doctor's office until approximately February 27, 2023, based on no documentation and the doctor’s office having no record of calls. AV was prescribed an antibiotic on or about February 27, 2023, and on or about March 2, 2023, was diagnosed with a UTI. The facility failed to assure timely medical treatment, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• September 20, 2022: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to implement interventions and appropriately care plan related to AV’s history of falls. AV experienced approximately nine falls, from approximately July 23, 2022, and September 20, 2022. AV experienced repeated unreasonable discomfort, including shoulder pain and right hip fracture. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 23, 2022: Failed to provide service Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $375.00; report
  Rules: 411-054-0027 (Resident Rights and Protections); 411-054-0028 (Reporting and Investigating Abuse and Other Actions Affecting Resident Welfare); 411-054-0036 (Service Plan – General)
  State’s findings

  The facility failed to provide appropriate services according to the Alleged Victim (AV)'s needs, relating to number of falls with lack of appropriate interventions, AV's known history of self-transfer and not using assistive device. On or about August 23, 2022, AV experienced a fall that resulted in AV being sent to the hospital where he/she was diagnosed with a fractured scapula and pubis. The facility's failure is a violation of resident rights, is considered neglect of care and constitutes abuse.

Substantiated licensing violations

• July 19, 2026: 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

  Based on interview and record review, conducted during an investigation on 08/18/26, the facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and use the results of an Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility's posted staffing plan was substantiated. Findings include, but are not limited to: The facility’s posted staffing plan indicated: For Day shift, 8 direct care staff; For Swing shift, 7.5 direct care staff; and For Night shift, 4 direct care staff. A review of the facility’s ABST care times as of 07/19/26 indicated: For Day shift, 7.83, or a minimum of 8 direct care staff; For Swing shift, 7.73, or a minimum of 8 direct care staff; and For Night shift, 2.92, or a minimum of 3 direct care staff. The facility’s staffing schedule indicated: For Day shift, 8 direct care staff; For Swing shift, 6.5 direct care staff; and For Night shift, 4 direct care staff. The facility’s staffing schedule, dated 07/19/26, indicated the facility was not staffing to its posted staffing plan and to its ABST care times for 1 of 6 shifts reviewed. The posted staffing plan did not exceed the ABST care times for swing shift. The facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident and use the results of an ABST to develop and routinely update the facility's posted staffing plan is a violation of Oregon Administrative Rules.

• April 23, 2026: 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

  Based on interview and record review, conducted during an investigation on 08/18/26, the facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was substantiated. Findings include, but are not limited to: The facility’s posted staffing plan indicated: For Day shift, 10 direct care staff; For Swing shift, 9 direct care staff; and For Night shift, 4.5 direct care staff. The facility’s staffing schedule, dated 04/23/26, indicated the facility was not staffing to its posted staffing plan for 2 of 6 shifts reviewed. The facility’s failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident is a violation of Oregon Administrative Rules.

• February 16, 2026: Failed to provide safe environment 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); 411-054-0030 (Resident Services)
  State’s findings

  On or about February 18, 2026, the facility failed to provide appropriate supervision to the Alleged Victim (AV) according to his/her needs. The failure resulted in AV eloping the secured building, without staff knowledge. AV unsafely left the facility without assistance and was exposed to potential harm but did not suffer any injury while out of the facility, The facility's failure is a violation of Oregon Administrative Rules.

• October 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

  Based on interview and record review, conducted during a site visit on October 10, 2025, the facility’s failure to ensure adequate professional oversight of the medication and treatment administration system was substantiated for 1 of 1 sampled resident (#1). Findings include, but are not limited to: Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas: 411-054-0055(1)(f-h): Systems: Medication and Treatment Orders; and 411-054-0055(2): Systems: Medication Administration **Refer to allegations LCU00094743 and LCU00094748. The facility failed to follow their own medication administration systems and did not document follow-though efforts to determine why the medication was unavailable nor was there oversight of the MAR by Staff 2 or Staff 3. Additionally, Staff 2 scheduled an emergency MT training on 09/04/25, however, Staff 5 and Staff 6, did not attend training and they continued to administer medications to the residents. Staff 5 and Staff 6 did not receive the emergency MT training until after the site visit on October 8, 2025. The facility's failure to provide a safe medication administration system is a violation of Oregon Administrative Rules.

• October 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

  Based on interview and record review, conducted during a site visit on October 8, 2025, the facility’s failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#1). Resident 1 was not administered his/her mood stabilization medication for approximately one month. Resident 1 experienced increased agitation. Findings include, but are not limited to: Service plan dated July 10, 2025, indicated: - Diagnosis of post-traumatic stress disorder, psychotic disturbance, mood disturbance and anxiety; and - Required staff assistance with all medication orders and administration Physician orders dated April 15, 2025, indicated: - Olanzapine, 5mg tablet every day at bedtime for steady mood Interview Staff 2: - Med tech staff discovered the medication was gone but did not reorder the medication nor did they document a conversation with the pharmacy regarding the refill request. - Medication Administration Record (MAR) dated August 2025, indicated s/he had not been administered his/her Olanzapine 25 times, with notes that said the medication was unavailable. Progress notes indicated: - On August 31, 2025, Resident 1’s irritation with staff had increased over the last week with “today being the worst”; - On September 1, 2025, Staff 2 was informed that Resident 1 had not received Olanzapine for two weeks. Staff 3(RCC) stated a priority refill of Olanzapine was requested and it will be administered to Resident 1 in the evening on 09/01/25; and - On September 3, 2025, staff reported Resident 1's Olanzapine was not reordered because the prescription bottle was thrown away and staff did not have the prescription number to order a refill. There was no documented evidence the facility had attempted to contact Resident 1's pharmacy to request a refill for Olanzapine in 08/2025. The facility's failure to carry out medication and treatment orders 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.