Evan Terrace Post Acute
421 Se Evans Street · McMinnville, OR · 97128 · 5034723141
96 certified beds For profit - Limited Liability company Chain: Pacs Group
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 4 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 4.65 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.40 | 0.55–0.75 |
| Weekend hours / resident-day | 4.23 | ≈ weekday level |
| Nursing turnover / year | 48% | median 45% |
| Fines (3-yr window) | 1 · $25,116 |
Inspection citations (58 in the current record)
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Potential for harm · D March 16, 2026 · found via complaint
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected March 31, 2026 · Quality of Life and Care
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Potential for harm · D November 18, 2025 · found via complaint
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.
Corrected November 24, 2025 · Quality of Life and Care
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Actual harm · G June 16, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected July 22, 2025 · Quality of Life and Care
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Potential for harm · E June 16, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 22, 2025 · Quality of Life and Care
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Potential for harm · D June 16, 2025 · found via complaint
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected July 22, 2025 · Administration
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Potential for harm · D June 9, 2025
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected July 15, 2025 · Resident Rights
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Potential for harm · D June 9, 2025
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected July 15, 2025 · Resident Rights
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Potential for harm · D June 9, 2025
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected July 15, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D 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.
Corrected July 15, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 9, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 15, 2025 · Quality of Life and Care
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Potential for harm · D June 9, 2025
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.
Corrected July 15, 2025 · Quality of Life and Care
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Potential for harm · D June 9, 2025
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected July 15, 2025 · Quality of Life and Care
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Potential for harm · E June 9, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected July 15, 2025 · Pharmacy Service
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Potential for harm · D June 9, 2025
Provide or get specialized rehabilitative services as required for a resident.
Corrected July 15, 2025 · Quality of Life and Care
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Potential for harm · D June 9, 2025
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected July 15, 2025 · Resident Assessment and Care Planning
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Potential for harm · E June 9, 2025
Provide and implement an infection prevention and control program.
Corrected July 15, 2025 · Infection Control
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Potential for harm · E June 9, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected July 15, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E June 9, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected July 15, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D June 9, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 15, 2025 · Quality of Life and Care
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No harm found · C June 9, 2025
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected July 15, 2025 · Resident Rights
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No harm found · C June 9, 2025
Post nurse staffing information every day.
Corrected July 15, 2025 · Nursing and Physician Services
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Potential for harm · D March 4, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected April 2, 2025 · Quality of Life and Care
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Potential for harm · D March 4, 2025 · found via complaint
Provide or get specialized rehabilitative services as required for a resident.
Corrected April 2, 2025 · Quality of Life and Care
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Potential for harm · D November 26, 2024 · found via complaint
Respond appropriately to all alleged violations.
Corrected January 7, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D November 26, 2024 · found via complaint
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected January 7, 2025 · Resident Assessment and Care Planning
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| June 9, 2025 | Fine | $25,116 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 385225 · certified since September 26, 1991. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.