Evergreen Senior Living Community

Last inspection

July 10, 2025

Inspections

7, 18 deficiencies cited

Substantiated abuse

11

Substantiated licensing violations

13

Regulatory actions

2

Fines assessed

$6,502.00 (10 violations)

Current owner since

January 1, 2025

License conditions and other regulatory actions

• May 2, 2025 to June 11, 2025: License Condition, Failed to provide safe environment ALFCD25-00192; incident: CALMS - 00078069
  Rules: 411-054-0045 (Resident Health Services); 411-054-0055 (Medications and Treatments)
• August 28, 2023 to September 19, 2023: License Condition, Failed to use an ABST ALFCD23-00557; incident: CALMS - 00045874
  The facility failed to ensure the Acuity-Based Staffing Tool (ABST) was updated no less than quarterly and accurately reflected resident care needs of residents.
  Rules: 411-054-0037 (Acuity-Based Staffing Tool)

Inspections

• July 10, 2025: Change of Owner, 13 deficiencies cited report
  • C0252: Resident Move-in & Evaluation: Res Evaluation severity level 2, scope L2 Pattern
  • C0260: Service Plan: General severity level 2, scope L2 Pattern
  • C0270: Change of Condition and Monitoring severity level 2, scope L2 Pattern
  • C0295: Infection Prevention & Control severity level 2, scope L2 Widespread
  • C0302: Systems: Tracking Control Substances severity level 2, scope L2 Isolated
  Show all 13

  • C0303: Systems: Treatment Orders severity level 2, scope L2 Pattern
  • C0305: Systems: Resident Right to Refuse severity level 2, scope L2 Pattern
  • C0370: Staffing Requirements and Training ? Pre-service severity level 2, scope L2 Isolated
  • C0372: Training Within 30 Days of Hire ? Direct Care Staff severity level 2, scope L2 Pattern
  • C0374: Annual and Biennial Inservice for All Staff severity level 2, scope L2 Pattern
  • C0420: Fire and Life Safety: Safety severity level 2, scope L2 Widespread
  • C0422: Fire and Life Safety: Training for Residents severity level 2, scope L2 Widespread
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Widespread
• April 2, 2025: Complaint Investig., 1 deficiency cited report
  • C0303: Systems: Treatment Orders severity level 2, scope L2 Isolated
• July 23, 2024: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• September 20, 2023: State Licensure, 0 deficiencies cited report
  • C0000: Comment severity level 0
• July 10, 2023: Validation, 2 deficiencies cited report
  • C0000: Comment severity level 0
  • C0361: Acuity-Based Staffing Tool severity level 2, scope L2 Pattern, corrected August 2, 2023
  • C0613: General Building: Doors-Walls, Cleanable severity level 2, scope L2 Pattern, corrected August 10, 2023
• December 7, 2022: Complaint Investig., 1 deficiency cited report
  • C0010: Licensing Complaint Investigation severity level 2, scope L2 Isolated
  • C0640: Heating and Ventilation severity level 2, scope L2 Isolated
• November 15, 2022: 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 January 20, 2023

Substantiated abuse or neglect

• November 28, 2025: Failed to properly plan care Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,500.00; 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); 411-054-0036 (Service Plan – General)
  State’s findings

  The investigation determined that the facility failed to implement necessary fall-prevention interventions and did not ensure the Alleged Victim (AV) had an accurate, complete care plan related to AV’s known fall risk. AV is a resident whose care needs are managed by the facility. Although AV experiences some cognitive decline, AV remains alert, oriented, and able to participate in direct care. AV is identified as a fall risk due to a diagnosis affecting memory and cognition. On or about November 28, 2025, AV was found on the floor next to AV’s bed. The investigation established that AV had been moved to a new room at the facility on November 24, 2025. During this move, the bed’s side rails, previously used by AV, were removed and were not reapplied after AV was settled into his/her new room. AV’s care plan did not document the use of any assistive devices, including bed rails, despite their prior use. The facility did not ensure that previously utilized safety measures were reassessed or reinstated following the room change. The facility’s failure to maintain appropriate fall-prevention measures and to update and implement an accurate care plan resulted in AV experiencing an unwitnessed fall and sustaining a serious injury which is a violation of resident rights, is considered neglect of care which constitutes abuse.

• November 14, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,013.00; 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  On or about November 14, 2025, Alleged Perpetrator 2 (AP2) discontinued Alleged Victim's (AV) routine calcium channel blocker, and AV did not receive this daily medication from November 14, 2025, to December 15, 2025. Based on facility documentation and interviews, AP2 discontinued AV's medication in error due to reading AV's electronic medication administration record (EMAR) incorrectly. AP2 did not communicate in AV's communication log that AP2 discontinued this medication. AV experiences lower kidney functioning and not taking this medication as ordered put AV at elevated risk for cardiac event and/or increased risk of kidney damage or failure. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide adequate oversight of the facility's Medication Administration System which placed AV at risk of moderate harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.

• August 26, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $500.00; 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  On August 26, 2025, ODHS Adult Protective Services (APS) initiated investigation #00422483 and issued a written investigation report, which is incorporated here by reference. Alleged Victim (AV) lived at Respondent’s facility. The APS investigation determined that on or about August 22, 2025, the facility failed to provide a safe medication administration system to ensure AV’s medications were administered as ordered. Facility documentation, staff interviews, and APS Investigator observations confirm that the facility did not provide adequate oversight of medication administration by Alleged Perpetrator 2 (AP2), Alleged Perpetrator 3 (AP3), and Alleged Perpetrator 4 (AP4), which resulted in multiple medication errors and caused AV unreasonable discomfort, including increased pain, heightened anxiety, and sleep difficulties. The facility's failure is a violation of resident rights, is considered neglect of care, and constitutes abuse. AP2 had a professional duty to administer medications to AV as ordered. On August 22, 2025, AP2 provided an incorrect opioid dosage to AV, which resulted in unreasonable discomfort to AV in the form of increased pain. AP2's actions is considered neglect of care which constitutes abuse. AP3 had a professional duty to administer medications to AV as ordered. On August 22, 2025, AP3 provided an incorrect opioid dosage to AV, which resulted in unreasonable discomfort to AV in the form of increased pain. AP3's actions is considered neglect of care which constitutes abuse. AP4 had a professional duty to administer medications to AV as ordered. On August 22, 2025, AP4 failed to administer medications to AV as ordered by giving the incorrect dose of opioid to AV, which resulted in unreasonable discomfort to AV in the form of increased pain. AP4's actions is considered neglect of care which constitutes abuse.

• May 19, 2025: Failed to provide a safe medication administration system Abuse: Neglect; Level 2 - Minor harm or potential for moderate harm; fine $225.00; 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); 411-054-0055 (Medications and Treatments)
  State’s findings

  The facility failed to provide a safe medication administration system to ensure The Alleged Victim’s (AV) medications were administered as ordered. Based on facility documentation and interviews, AV missed several doses of his/her prescribed medication due to the facility failing to reorder more before running out. The facility failed to have a supply of AV's medication in stock sufficient to allow for the administration of AV's medication according to medical orders, which caused AV unreasonable discomfort, which is a minor violation of resident rights, is considered neglect of care and constitutes abuse.

• April 27, 2025: Failed to follow care plan Abuse: Neglect; Level 3 - Moderate harm or potential for serious harm; fine $1,125.00; 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); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about April 27, 2025, the facility failed to provide appropriate services according to the Alleged Victim’s (AV) care needs and wound care. The facility's failure resulted in AV experiencing unreasonable discomfort and tissue damage due to an improperly wrapped bandage, which is a violation of resident rights, is considered neglect of care and constitutes abuse. Alleged Perpetrator 3 (AP3), Alleged Perpetrator 4 (AP4), Alleged Perpetrator 5 (AP5) allegedly neglected AV. An investigation determined no abuse occurred by AP3, AP4, and AP5. Alleged Perpetrator 2 (AP2) allegedly neglected AV. An investigation inconclusively determined no abuse occurred by AP2.

Substantiated licensing violations

• May 27, 2026: 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

  Based on interview and record review, conducted during an investigation on 07/23/26, the facility’s failure to complete or update and review the Acuity-Based Staffing Tool (ABST) evaluation for each resident quarterly as required was substantiated. Findings include but are not limited to: The facility’s census was 60. A review of the facility’s last ABST evaluation update per resident indicated 7 of 60 residents had not been updated quarterly as required as of 05/27/26. The facility failed to have an updated Acuity-Based Staffing Tool (ABST) that accurately reflected the resident population and their care needs. Inconsistencies were identified between the resident roster, care plans, and the data entered into the ABST. An investigation determined this is a violation of Oregon Administrative Rules.

• April 5, 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

  On or about April 5, 2026, the facility failed to consistently staff to the levels, intensity and qualifications indicated by the Acuity-Based Staffing Tool (ABST). Inconsistencies were identified between the staffing schedule and the data produced by the ABST. Facility was not staffed 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.

• December 1, 2025: Failed to provide safe environment Licensing Violation; Level 2 - Minor harm or potential for moderate harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0036 (Service Plan – General)
  State’s findings

  On or about December 1, 2025, the Alleged Victim (AV) exited the facility without staff knowledge. According to facility documentation and staff interviews, the AV was admitted on November 12, 2025, for respite care, with an anticipated discharge date of December 11, 2025. The AV has a diagnosed cognitive impairment and a progressive neurodegenerative disease. The care plan identifies the AV as unsafe to leave the facility independently. The AV returned to the facility the following day without signs of injury. The facility failed to provide adequate supervision consistent with the AV’s assessed needs, constituting a violation of Oregon Administrative Rules.

• August 19, 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 observations, interviews, and record review conducted during a site visit on October 23, 2025, it was determined that the facility failed to implement a safe and effective medication administration system for 1 of 1 sampled resident (Resident #1). Specifically, the facility did not ensure that prescribed medication and treatment orders were carried out as directed by the healthcare provider. This failure resulted in unreasonable discomfort to the resident and constitutes a violation of resident rights. The substantiated findings meet the definitions of neglect of care and abuse under applicable regulatory standards. Although the resident did not experience a negative outcome, the facility’s failure to carry out prescribed medication and treatment orders constitutes noncompliance with Oregon Administrative Rule.

• April 29, 2025: Failed to provide oversight and monitoring of change of condition Licensing Violation; Level 3 - Moderate harm or potential for serious harm; report
  Rules: 411-054-0025 (Facility Administration); 411-054-0040 (Change of Condition and Monitoring)
  State’s findings

  Based on interview and record review, conducted during a site visit on 05/07/25, the facility's failure to document the change, and update the service plan when a resident experiences a change of condition; and ensure a resident monitoring and reporting system is implemented 24-hours a day was substantiated for 1 of 1 sampled residents (#1). Resident 1 experienced sepsis (life-threatening bodily response to an infection) associated with the worsening of a toenail wound. Findings include but are not limited to: During a Compliance Specialist's (CS) onsite visit on 05/07/25, Resident 1 was out of the facility at the local hospital. The CS was unable to interview Resident 1 or make observations during the site visit. During the entrance conference with Staff 1, Staff 2, and Staff 3, they stated Resident 1 was at the local hospital for a right toe amputation. Resident 1’s progress notes revealed the following: - On 11/29/24, the resident had part of his/her toenail, and some infection removed. - On 12/26/24, Resident 1's toe appeared to have worsened since the last visualization. Slough to wound bed, antibiotics completed. Resident continues to verbalize pain at the site; wound care provided. The resident started Home Health for wound care. - On 01/02/25, “The resident’s toe does not appear worse since the last visualization.” The LPN had not used descriptive words to indicate if the toe had gotten better or worsened in the observation note. - The LPN noted, 02/05/25, in the residents’ quarterly evaluation, “Wound to toe was reported. [S/He] was followed by home health (HH), was seen by providers, and eventually an angioplasty was done to promote circulation, wound healing. That showed a marked improvement to the toe wound. Report any of the following to the RN, RCC, and administrator immediately. Any changes, including new rashes, skin tears, cuts, abrasions, bruises, or discomfort. Report any safety concerns, any new pain or increase in pain, please include the type of pain and location." - On 03/06/25, the resident's toe continues to improve since the last visualization and appears resolved at that time. Appears to be a small area near and under the toenail, scabbed area resolved, just appears to be thickened, dry, and slightly darker in appearance, no signs of infection. On 01/06/24 resident had angioplasty, which was due to try and improve circulation and promote wound healing. S/He reported a recent f/u about that, and the provider had told him/her the toe was healed. No longer needs License Nurse following. Discussed notifying staff if painful, worsening or any infection. Will continue to monitor as needed. - On 03/18/25, indicated the Resident Care Coordinator sent two pictures via text as requested by Resident 1’s family member regarding the right toe. - On 03/27/25, the resident was seen for “left [actually right] great toenail" removal. - On 04/24/25, Resident recently had the “left [right] great toenail” removed. Staff soaking and bandage per orders, see EMAR. No signs of infection, no reports of worsening or increased pain. “Less than 1 cm area remains, appears fragile, and is likely still open. Appears to be healing appropriately, is followed by a podiatrist for wound healing. Likely to be resolved within the next week or two.” Will continue to monitor and support as needed. - On 04/29/25 at 11:58 am, the LPN noted, after speaking with the med tech, it had come to our attention that the treatment was not done, and s/he had not known how to correct the incorrect documentation. S/he ran out of time and was unable to do the treatment on 04/26/25. - On 04/29/25, the resident was sent to the hospital to be evaluated, running a 102 Fahrenheit fever. - On 04/30/25, Resident 1 was placed on alert for a wound to her right big toe. The wound had increasingly gotten worse over the last five days; and the resident was admitted to the hospital for sepsis. A review of Resident 1’s current service plan, dated 02/05/25, revealed the following: - Soak the right foot in Epsom Salt for 10 minutes. after soaking, cover the wound with Betadine ointment and dress with a loose band-aid twice daily at 9:00 am and 8:00 pm; and change the toe dressing, clean with saline, alcohol wipes, or wound spray, pat dry, apply a small amount of antibiotic ointment, cover and wrap the toe twice daily at 8:00 am and 8:00 pm. - A temporary service plan (TSP) dated 03/28/25, noted the removal of the right toenail. Instructions stated to monitor “Bleeding, pain, signs of infection, change in gait, and discoloration.” - A treatment order, dated 03/27/25, to soak the toe in warm water with very diluted Epsom salt for 10 minutes twice daily for one week, then switch to once-a-day soaks until drainage stops. Massage the toe after soaks to help decrease scab formation. Apply betadine ointment to the area and cover with a loose band-aid. The treatment order had not been correctly transcribed into the Treatment Administration Records (TARs). Resident 1’s TARs for April 2025 instructed staff to draw hot water into a basin, lightly dilute with Epsom salt, and soak the right foot uncovered for 10 minutes. After soaking, cover the wound with betadine ointment and dress with a loose band-aid or non-stick adhesive with medical tape. Keep dressing on for the first minute of soak, twice daily. - The treatment was not completed for 11 out of 18 occurrences between 04/11/25 until hospitalization on 4/29/25. - A treatment order, dated 04/16/25, directed the facility to soak the right foot in an Epsom salt bath, apply betadine ointment, and band-aid once daily. The treatment order had not been added to the TARs. During an interview on 05/07/25, Staff 4 and Staff 8 stated Staff 9 marked the TARs as having completed treatment for soaking Resident 1’s toe on 04/26/25; however, indicated Staff 9 had not completed the treatment. The facility's failed to ensure a resident monitoring and reporting system was implemented 24-hours a day was substantiated. The facility failed to monitor that treatments were provided as ordered and failed to accurately document on the status of Resident 1's toe. As a result, the toenail area worsened, and Resident 1 was hospitalized with sepsis. The facility failed to document Resident 1's change of condition and failed to update the service plan when a Resident 1 experienced a change of condition; and failed to ensure a resident monitoring and reporting system is implemented 24-hours a day is 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 80 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.