Evan Terrace Post Acute
421 Se Evans Street, McMinnville, OR 97128 · Yamhill County · (503) 472-3141
96 certified beds, about 89 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1991
Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
3 of 5
Quality measures
3 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 385225 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on June 9, 2025, inspectors cited 15 health deficiencies (the Oregon average is 9.2, the national average 9.2).
Of 60 health citations since February 2023, 2 were rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $25,116 in the last three years; the largest was $25,116, and the latest is dated June 9, 2025.
Nurses and nurse aides worked 4.69 hours per resident per day, against 5.03 across Oregon and 3.86 nationally. Registered nurses accounted for 0.34 of those hours.
51.1% of nursing staff left within the year CMS measured (Oregon average 47.4%).
CMS links it to PACS Group, an affiliated group of 275 nursing homes.
Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
802/23
510/23
512/23
904/24
811/24
203/25
1606/25
306/25
111/25
103/26
207/26
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 60 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
43D
12E
1F
Potential for minimal harm
0A
0B
2C
July 17, 2026Complaint inspection · 2 citations
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and record review it was determined the facility failed to report an injury of unknown origin to the State Agency for 1 of 7 sampled residents (#1) reviewed for safety. This placed residents at risk for a delay in the investigation and continued injuries.
- D Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, interviews and record review it was determined the facility failed to provide ADL assistance for 1 of 5 sampled residents (# 7) reviewed for ADLs. This placed residents at risk for not receiving ADL assistance for hygiene care. Resident 7 was admitted to the facility in 6/2026 with diagnoses including a stroke with right sided hemi-paralysis and aphasia (the inability to speak). Resident 7's 6/29/26 Care Plan indicated Resident 7 was dependent on staff for all ADLs. Resident 7's 6/2026 MDS Assessment indicated the resident was severely impaired. Resident 7's 6/2026 and 7/2026 Point of Care record indicated the resident was dependent for brushing teeth, washing face, combing hair, and shaving. On 7/15/26 at 10:07 AM, Staff 6 (CNA) charted in the Point of Care document she had provided oral care and a warm washcloth to Resident 7 on 7/15/26. [...]
March 16, 2026Complaint inspection · 1 citation
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident's indwelling urinary catheter had a clinical indication for use for 1 of 3 sampled residents (#8) reviewed for indwelling catheter use. This placed residents at risk for infection.
November 18, 2025Complaint inspection · 1 citation
- D Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents received appropriate care and services for a feeding tube for 1 of 3 sampled residents (#2) reviewed for feeding tubes. This placed residents at risk for complications related to the use of a feeding tube.
June 16, 2025Complaint inspection · 3 citations
- G Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide pressure ulcer care consistent with professional standards of practice for 1 of 5 sampled residents (#6) reviewed for pressure ulcers. As a result, Resident 6 developed multiple facility-acquired pressure ulcers and placed residents at risk for new and worsening pressure ulcers.
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 2 of 5 sampled residents (#s 25 and 26) reviewed for medications. This placed residents at risk for missed medications.
- D Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Inspectors wroteBased on interview and record review it was determined the facility failed to implement and maintain an effective tracheostomy training program for 1 of 1 sampled resident (#19) reviewed for respiratory care. This placed residents at risk for inappropriate tracheostomy care and the potential for a decline in respiratory status.
June 9, 2025Standard inspection, Complaint inspection · 16 citations
- E Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wrote3. Resident 66 admitted to the facility in 10/2024 with diagnoses including Huntington's Disease (a genetic disorder which causes a progressive breakdown of nerve cells in the brain). An 10/18/24 admission MDS revealed Resident 66 had a BIMS of 10, which indicated her/his cognition was moderately impaired. On 6/2/25 at 12:30 PM Witness 4 (Complainant) stated in 11/2024 Resident 66 reported to her a staff member at the facility fondled her/him. Witness 4 did not indicate if this was reported to the facility and did not have additional information related to the allegation. Resident 66 was unable to be interviewed due to being discharged from the facility and poor cognition. No evidence was found to indicate the incident was reported to the state agency. [...]
- E Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review it was determined the facility failed to investigate allegations of sexual, physical, and verbal abuse for 4 of 6 sampled residents (#s 11, 43, 61, and 66) reviewed for abuse. This placed residents at risk for further abuse.
- E Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure pharmacist recommendations were considered for 4 of 5 sampled residents (#s 20, 31, 44 and 56) reviewed for medications. This placed residents at risk for unnecessary medication.
- E Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to follow proper infection control protocols related to transmission based and enhanced barrier precautions for 2 of 4 sampled residents (#s 48 and 60) reviewed for feeding tube and infection control. This placed residents at risk for cross-contamination and infection.
- D Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide the risk and benefits for the use of an antipsychotic medication to a resident/responsible party prior to administration for 1 of 5 sampled residents (#20) reviewed for medications. This placed residents at risk for lack of informed consent.
- D Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to promote self determination for 1 of 1 sampled resident (#44) reviewed for choices. This placed residents at risk for lack of honoring choices and room preferences.
- D Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from unnecessary psychotropic medications for 1 of 5 sampled residents (#56) reviewed for medications. This placed residents at risk for adverse side effects of medication.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review it was determined the facility failed to develop a comprehensive care plan for 1 of 1 sampled resident (#43) reviewed for choices. This placed residents at risk for unmet needs.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to obtain treatment orders and provided treatment for diabetic ulcers for 1 of 1 sampled resident (#8) reviewed for pressure ulcers. This placed residents at risk for lack of timely treatment.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete a timely assessment after a fall and conduct a thorough investigation for 2 of 6 sampled residents (#s 20 and 66) reviewed for accidents.
- D Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents received appropriate care and services for a feeding tube for 1 of 1 sampled resident (#60) reviewed for feeding tubes. This placed residents at risk for complications related to the use of a feeding tube including bacterial growth.
- D Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to comprehensively assess and revise a resident's care plan related to dementia for 1 of 1 sampled resident (#20) reviewed for dementia. This placed residents at risk for unaddressed dementia and behavioral needs.
- D Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure physician orders were followed for 1 of 3 sampled residents (#59) reviewed for rehabilitative and restorative services. This placed residents at risk for not receiving physical therapy services.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to accurately document feeding tube treatments for 1 of 1 sampled resident (#60) reviewed for feeding tube. This placed the residents at risk for inaccurate records.
- C Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Inspectors wroteBased on observations and interviews the facility failed to ensure the state survey inspection results were readily accessible for 1 of 1 facility reviewed for resident council. This placed residents and the public at risk of not being informed of the facility's survey history.
- C Post nurse staffing information every day.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure accurate staffing information was posted for 10 of 31 days reviewed for staffing reports. This placed residents and the public at risk for lack of staffing information.
March 4, 2025Complaint inspection · 2 citations
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure physician orders related to diabetic management were followed for 1 of 3 sampled residents (#9) reviewed for physician orders. This placed residents at risk for diabetic complications.
- D Provide or get specialized rehabilitative services as required for a resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to provide rehabilitation services for 1 of 3 sampled residents (#3) reviewed for rehabilitation services. This placed residents at risk for declined mobility and lack of quality of life.
November 26, 2024Complaint inspection · 8 citations
- F Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on interview and record review it was determined the facility failed to update the Facility Assessment and failed to show resources needed to care for residents with tube feeding requirements for 1 of 1 Facility Assessment reviewed. This failure placed residents at risk for being uninformed of facility ownership, unmet care needs due to lack of staff training on services rendered and an insufficient supply of equipment needed to provide care for the residents.
- E Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure staff were trained on appropriate skills and competencies necessary to care for residents with feeding tubes and NG tubes (nasogastric tube inserted through the nose to the stomach, used for nutritional supplementation) for 3 of 3 staff (#s 9, 26 and 45) reviewed for nurse competencies. This placed residents at risk for lack of care by competent staff.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to thoroughly and timely investigate an allegation of abuse and neglect for 3 of 3 sampled residents (#s 1, 5 and 13) reviewed for abuse. This placed residents at risk for abuse.
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and record review it was determined the facility failed to complete a baseline care plan within the required timeframe for 2 of 4 sampled residents (#s 1 and 3) reviewed for care plans. This placed residents at risk for unmet care needs.
- D Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure discharge needs were in place for 2 of 3 sampled residents (#s 4 and 5) reviewed for discharge. This placed residents at risk for a decline in abilities and unmet care needs after discharge.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders and notify the physician of omitted medications for 3 of 10 sampled residents (#s 2, 3 and 13) reviewed for medications and pressure ulcers. This placed residents at risk for unmet medication and treatment needs.
- D Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure residents received appropriate care and services for a feeding tube for 1 of 3 sampled residents (#3) reviewed for feeding tubes. This placed residents at risk for complications related to the use of a feeding tube.
- D Ensure that residents are free from significant medication errors.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from significant medication errors for 2 of 10 sampled residents (#s 3 and 13) reviewed for medications.
April 19, 2024Standard inspection, Complaint inspection · 9 citations
- E Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure physician orders were followed for 12 of 15 sampled residents (#s 1, 4, 10, 11, 14, 28, 30, 32, 33, 94, 144 and 145) reviewed for medications. This placed residents at risk for reduced medication efficacy and adverse medication side effects.
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure sufficient staffing to meet resident care needs for 2 of 2 halls reviewed for staffing. This placed residents at risk for delayed and unmet care needs.
- E Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents were free from unnecessary medications for 2 of 6 sampled residents (#s 4 and 6) reviewed for medication. This placed residents at risk for adverse side effects of medication and hypoglycemia.
- E Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure proper labeling of biologicals, proper storage temperatures were logged and maintained, and medication carts were properly secured for 2 of 2 treatment carts and 1 of 1 medication room reviewed for medication storage and observed during random observations. This placed residents at risk for reduced efficacy of medication and unauthorized access to medications.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review it was determined the facility failed to accurately code MDS assessments for 1 of 1 sampled resident (#295) reviewed for oxygen. This placed residents at risk for unidentified treatment needs.
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a written summary of a baseline care plan was reviewed and provided to residents within 48 hours of admission for 1 of 1 sampled resident (#245) reviewed for care planning. This placed residents at risk for being uninformed about their plan of care.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure care plans were revised to accurately reflect the needs of residents for 1 of 1 sampled resident (#246) reviewed for staffing. This placed residents at risk for unmet needs.
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to ensure pressure ulcers were assessed, treated and care planned appropriately for 1 of 2 sampled residents (#145) reviewed for pressure ulcers. This placed residents at risk for worsening pressure ulcers.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure records were accurate for 1 of 18 sampled residents (#246) reviewed for staffing. This placed residents at risk for inaccurate treatment.
December 20, 2023Complaint inspection · 5 citations
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review it was determined the facility failed to prevent abuse for 1 of 4 sampled residents (#22) reviewed for abuse. This placed residents at risk for abuse.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review it was determined the facility failed to report timely to the state agency an incident of misappropriation of medications for 1 of 3 sampled residents (#8) reviewed for misappropriation. This placed residents at risk for misappropriation of property.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete an incident investigation within five working days for 1 of 3 sampled residents (#8) reviewed for misappropriation. This placed residents at risk for misappropriation of property.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (#24) reviewed for medications. This placed residents at risk for unmet medication needs.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review it was determined the facility failed to accurately document medication administration for 1 of 1 sampled resident (#24) reviewed for medications. This placed residents at risk for inaccurate medical records.
October 2, 2023Complaint inspection · 5 citations
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and record review it was determined the facility failed to notify the physician of a significant change of condition for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. This placed residents at risk for a decline in health status.
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and record review it was determine the facility failed to complete and implement a person-centered baseline care plan for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. This placed residents at risk for a decline in status.
- D Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a safe discharge for 1 of 3 sampled residents (#4) reviewed for safe discharges. This placed residents at risk for unmet care needs.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to follow physician orders for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. This placed residents at risk for a decline in health status.
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review it was determined the facility failed to assess, treat and prevent pressure ulcers for 1 of 3 sampled residents (#1) reviewed for pressure ulcers. This placed residents at risk for new and worsening wounds.
February 16, 2023Standard inspection · 8 citations
- G Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure a resident had interventions in place to prevent pressure ulcers and update the plan of care to prevent worsening of pressure ulcers for 1 of 3 sampled residents (#12) reviewed for pressure ulcers. Resident 12 developed two stage 2 pressure ulcers (shallow partial thickness skin loss) to the coccyx and a deep tissue injury (Persistent non-blanchable deep red, maroon or purple discoloration of intact skin due to damage of underlying soft tissue) to the heel which deteriorated to an unstageable ulcer (depth unable to be determined due to slough/nonviable tissue covering the base of the ulcer).
- E Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete an admission or Annual MDS for 4 of 6 sampled residents (#s 2, 3, 19 and 27) reviewed for nutrition, unnecessary medications and behavioral health. This placed residents at risk for unmet needs.
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to provide sufficient staffing to ensure residents were showered and care plans were followed for 1 of 1 evening shift (2/14/23) observed for staffing. This placed residents at risk for lack of hygiene and unmet psychosocial needs.
- D Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, interview and record review it was determined the facility failed to honor resident choices for 1 of 1 sampled resident (#10) reviewed for ADL care. This placed residents at risk for choices not being honored.
- D Assure that each resident’s assessment is updated at least once every 3 months.
Inspectors wroteBased on interview and record review it was determined the facility failed to complete a Quarterly MDS for 3 of 9 sampled residents (#s 5, 13, and 19) reviewed for nutrition, unnecessary meds, and behavioral health. This placed residents at risk for unmet needs.
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and record review it was determined the facility failed to develop a baseline care plan to provide behavioral health services and prevent pressure ulcers for 2 of 4 sampled residents (#s 12 and 19) reviewed for pressure ulcers and behavioral health. This placed residents at risk for skin breakdown and unmet emotional needs.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review it was determined the facility failed to ensure residents' medications were administered per physician orders for 2 of 5 sampled residents (#s 3 and 5) reviewed for unnecessary medications. This placed residents at risk for ineffective medication regimen.
- D Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview and record review it was determined the facility failed to monitor the arteriovenous(AV) fistula (dialysis access site) for 1 of 2 sampled residents (#3) reviewed for dialysis. This placed residents at risk for dialysis complications.
Fire safety inspections
4 fire safety citations on file: 2 on June 9, 2025, 1 on April 19, 2024, 1 on February 16, 2023.
Every fire safety citation4 citations
- F Have simulated fire drills held at unexpected times.
- F Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- F Have simulated fire drills held at unexpected times.
- D Install noncombustible or limited-combustible interior walls.
Fines and payment denials
| Date | Penalty | Amount or length |
|---|---|---|
| June 9, 2025 | Fine | $25,116 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Staffing
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Oregon | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 4.69 | 5.03 | 3.86 |
| Registered nurses | 0.34 | 0.72 | 0.69 |
| All nursing staff on weekends | 4.28 | 4.51 | 3.42 |
| Nurse aides | 3.46 | ||
| Licensed practical nurses | 0.89 | ||
| Nursing staff turnover (share who left in a year) | 51.1% | 47.4% | 45.8% |
| Registered nurse turnover | 60.0% | 51.6% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.32 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Staffing by quarter, from daily payroll records
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 4.85 on weekdays and 4.28 on weekends, 12% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 22.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.74 in April to June 2025 to 4.69 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 4.69 | 0.34 | 4.85 | 4.28 | 22.0% | 0 of 90 | 89 |
| Oct to Dec 2025 | 4.65 | 0.40 | 4.82 | 4.23 | 23.6% | 0 of 92 | 87 |
| Jul to Sep 2025 | 4.60 | 0.30 | 4.73 | 4.25 | 25.7% | 1 of 92 | 78 |
| Apr to Jun 2025 | 4.74 | 0.35 | 4.91 | 4.31 | 26.7% | 1 of 91 | 71 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Oregon, Jan to Mar 2026 | 4.91 | 0.64 | 5.12 | 4.40 | 6.2% | 0.4% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Quality measures
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Oregon | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 9.5 | 14.9 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 1.5 | 1.4 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.8 | 2.0 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 0.8 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.2 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 16.8 | 20.6 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 6.2 | 5.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 8.2 | 13.9 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 28.1 | 21.4 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 34.8 | 16.1 | 12.0 |
Owners and operators
Legal business name: EVAN TERRACE SNF HEALTHCARE LLC. CMS links this home to PACS Group, a group of 275 nursing homes averaging 2.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Truist Bank | 5% or greater security interest | Organization | 09/01/2024 | |
| Apt, Frederick | Corporate officer | Individual | 09/01/2024 | |
| Jergensen, Joshua | Corporate officer | Individual | 09/01/2024 | |
| Mitchell, John | Corporate officer | Individual | 09/01/2024 | |
| Providence Administrative Consulting Services Inc | Operational/managerial control | Organization | 09/01/2024 | |
| Apt, Frederick | Operational/managerial control | Individual | 01/01/2024 | |
| Jergensen, Joshua | Operational/managerial control | Individual | 05/10/2024 | |
| Kinyon, Robert | Operational/managerial control | Individual | 11/11/2024 | |
| Mitchell, John | Operational/managerial control | Individual | 01/01/2024 | |
| Morris, Christopher | Operational/managerial control | Individual | 09/01/2024 | |
| Reece, Curtis | Operational/managerial control | Individual | 10/10/2024 | |
| Hancock, Mark | Trustee of the SNF | Individual | 01/01/2013 | |
| Murray, Jason | Trustee of the SNF | Individual | 01/01/2013 | |
| McMinnville 421 Realty LLC | Adp of the SNF | Organization | 09/01/2024 | |
| Providence Administrative Consulting Services Inc | Adp of the SNF | Organization | 09/01/2024 | |
| Apt, Frederick | Adp of the SNF | Individual | 01/01/2024 | |
| Kinyon, Robert | Adp of the SNF | Individual | 11/11/2024 | |
| Mitchell, John | Adp of the SNF | Individual | 01/01/2024 | |
| Morris, Christopher | Adp of the SNF | Individual | 09/01/2024 | |
| Reece, Curtis | Adp of the SNF | Individual | 10/10/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Questions to ask on a visit
Chosen from this home's own inspection record.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 22 problems in this area, most recently on July 17, 2026: "Provide care and assistance to perform activities of daily living for any resident who is unable."
- When is the care plan meeting, and can family attend it?Inspectors cited 14 problems in this area, most recently on June 9, 2025: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured."
- How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 8 problems in this area, most recently on July 17, 2026: "Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 5 problems in this area, most recently on June 9, 2025: "Ensure that residents are fully informed and understand their health status, care and treatments."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 4.28 hours per resident per day, below the Oregon average of 4.51.
- How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.
Other nursing homes nearby
- Life Care Center of McMinnville McMinnville, 1.2 mi · 4 of 5 stars · 32 citations
- Village at Hillside McMinnville, 1.9 mi · 5 of 5 stars · 21 citations
- Rivers Edge Rehabilitation and Care Sheridan, 12.5 mi · 2 of 5 stars · 36 citations
- Chehalem Post Acute Newberg, 13 mi · 1 of 5 stars · 58 citations
- Marquis Newberg Newberg, 13.7 mi · 5 of 5 stars · 12 citations
- French Prairie Nursing & Rehabilitation Center Woodburn, 15.7 mi · 1 of 5 stars · 62 citations
- Avamere Court at Keizer Keizer, 16.5 mi · 4 of 5 stars · 18 citations
- Keizer Nursing and Rehabilitation Keizer, 17.7 mi · 3 of 5 stars · 33 citations
Oregon contacts for a concern about a nursing home
These are the official offices in Oregon. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Oregon Department of Human Services, Nursing Facility Licensing, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Oregon Office of the Long-Term Care Ombudsman, (800) 522-2602. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Oregon Licensed Long-Term Care Settings Search, where Oregon publishes its own records on licensed homes.
Common questions
- What is Evan Terrace Post Acute's Medicare star rating?
- CMS rates Evan Terrace Post Acute 1 out of 5 stars overall, with 1 for health inspections, 3 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Evan Terrace Post Acute get at its last inspection?
- 15 health deficiencies at the standard inspection on June 9, 2025. The Oregon average is 9.2.
- Has Evan Terrace Post Acute been fined?
- Yes. CMS lists 1 fine totaling $25,116 in the last three years.
- Does Evan Terrace Post Acute accept Medicaid?
- It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
- Who owns Evan Terrace Post Acute?
- CMS lists 20 owners and managers, and links the home to PACS Group. Legal business name: EVAN TERRACE SNF HEALTHCARE LLC.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.