Evan Terrace Post Acute

In the surveyor’s words

From the most serious findings on record at Evan Terrace Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF610Sep 16, 2022

  Based on observation, interview and record review it was determined the facility failed to thoroughly investigate and report allegations of sexual exploitation and sexual abuse for 1 of 3 sampled residents (#1) reviewed for allegations of abuse. This failure, determined to be an immediate jeopardy situation, resulted in Resident 1 experiencing the potential for ongoing sexual abuse and exploitation. Findings include: The facility Policy and Procedures for Abuse screening, training, identification, investigation, reporting and protection revised 2/2019 included the following: -Investigate allegations of Abuse. -Report allegations of Abuse to appropriate reporting authority. […]

• Actual harm, isolatedF686Jun 16, 2025

  Based 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. Findings include: The 2019 NPIAP (National Pressure Injury Advisory Panel) guidelines indicated when an individual had a pressure injury a comprehensive initial assessment should be completed, treatment goals with input from the individual's informal caregivers set, and a treatment plan developed. […]

• Actual harm, isolatedF686Feb 16, 2023

  Based 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). Findings include: Resident 12 was admitted to the facility 1/13/23 with diagnoses including pneumonia. […]

• No harm, potential for more than minimal, widespreadF838Nov 26, 2024

  Based 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. Findings include: A review of the Facility assessment dated [DATE] through 7/6/24, showed the previous owners listed as Prestige McMinnville and not the current owners as [NAME] Terrace Post-Acute owned by PACs. […]

• No harm, potential for more than minimal, patternF684Jun 16, 2025

  Based 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. Findings include: 1. Resident 25 admitted to the facility in 1/2025, with diagnoses including hypothyroidism (low thyroid hormone levels) and diabetes. A 1/17/25 admission Order for Resident 25 included an order for levothyroxine (a thyroid medication) 1 tablet by feeding-tube daily. A 1/20/25 Physician Progress Note indicated Resident 25 was ordered to have levothyroxine once daily but the order was erroneously entered as three times daily. […]