Evan Terrace Post Acute
421 SE Evans Street, McMinnville, OR 97128 · Yamhill County · 96 certified beds · avg 89 residents/day · certified since Sep 26, 1991
Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)
1/5
Health inspection rating (on-site)
2
Serious findings on record
$25,116
Fines, last 3 years
5.41
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jun 16, 2025 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jul 22, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 16, 2023 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 13, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (58)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 16, 2026 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Nov 18, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Jun 16, 2025 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jun 16, 2025 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jun 16, 2025 | D · Potential for harm, one-off | The facility did not develop, carry out, or maintain an effective training program for all new and existing staff members. · from a complaint |
| Jun 9, 2025 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Jun 9, 2025 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jun 9, 2025 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jun 9, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 9, 2025 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Jun 9, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Jun 9, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Jun 9, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jun 9, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jun 9, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 9, 2025 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Jun 9, 2025 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Jun 9, 2025 | D · Potential for harm, one-off | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. |
| Jun 9, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Jun 9, 2025 | C · Minimal risk, facility-wide | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Jun 9, 2025 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Mar 4, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 4, 2025 | D · Potential for harm, one-off | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. · from a complaint |
| Nov 26, 2024 | F · Potential for harm, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · from a complaint |
| Nov 26, 2024 | E · Potential for harm, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Nov 26, 2024 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Nov 26, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Nov 26, 2024 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint |
| Nov 26, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Nov 26, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Nov 26, 2024 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Apr 19, 2024 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Apr 19, 2024 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Apr 19, 2024 | E · Potential for harm, repeated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint |
| Apr 19, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Apr 19, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Apr 19, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Apr 19, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Apr 19, 2024 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Apr 19, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Dec 20, 2023 | D · Potential for harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Dec 20, 2023 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Dec 20, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Dec 20, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Dec 20, 2023 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint |
| Oct 2, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint |
| Oct 2, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Oct 2, 2023 | D · Potential for harm, one-off | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint |
| Oct 2, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Oct 2, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Feb 16, 2023 | ▲ G · Actual harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Feb 16, 2023 | E · Potential for harm, repeated | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. |
| Feb 16, 2023 | E · Potential for harm, repeated | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Feb 16, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Feb 16, 2023 | D · Potential for harm, one-off | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. |
| Feb 16, 2023 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Feb 16, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Feb 16, 2023 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (9 → 16).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 18 | 1 | G ▲ |
| 2024 | 17 | 0 | F |
| 2025 | 22 | 1 | G ▲ |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $25,116.
| Date | Type | Amount / length |
|---|---|---|
| Jun 9, 2025 | Fine | $25,116 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Oregon avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.41 | 5.42 | 3.95 | top 45% in Oregon; top 8% in the U.S. |
| Registered Nurse hours | 0.40 | 0.78 | 0.69 | bottom 7% in Oregon; bottom 22% in the U.S. |
| Weekend total nurse staffing | 4.94 | 4.85 | 3.50 | top 38% in Oregon; top 7% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.23 | 0.48 | 0.48 | bottom 14% in Oregon; bottom 18% in the U.S. |
| Total nursing staff turnover (%) | 51.1 | 47.4 | 45.8 | bottom 37% in Oregon; bottom 34% in the U.S. |
| RN turnover (%) | 60.0 | 51.6 | 42.9 | bottom 38% in Oregon; bottom 22% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.69, RN 0.34, weekend 4.28. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Apt, Frederick | Individual | Corporate Officer | NOT APPLICABLE | 09/01/2024 |
| Apt, Frederick | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2024 |
| Apt, Frederick | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Hancock, Mark | Individual | Trustee of the SNF | NOT APPLICABLE | 01/01/2013 |
| Jergensen, Joshua | Individual | Corporate Officer | NOT APPLICABLE | 09/01/2024 |
| Jergensen, Joshua | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/10/2024 |
| Kinyon, Robert | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/11/2024 |
| Kinyon, Robert | Individual | ADP of the SNF | NOT APPLICABLE | 11/11/2024 |
| McMinnville 421 Realty LLC | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2024 |
| Mitchell, John | Individual | Corporate Officer | NOT APPLICABLE | 09/01/2024 |
| Mitchell, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/01/2024 |
| Mitchell, John | Individual | ADP of the SNF | NOT APPLICABLE | 01/01/2024 |
| Morris, Christopher | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Morris, Christopher | Individual | ADP of the SNF | NOT APPLICABLE | 09/01/2024 |
| Murray, Jason | Individual | Trustee of the SNF | NOT APPLICABLE | 01/01/2013 |
| Providence Administrative Consulting Services INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Providence Administrative Consulting Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2024 |
| Reece, Curtis | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/10/2024 |
| Reece, Curtis | Individual | ADP of the SNF | NOT APPLICABLE | 10/10/2024 |
| Truist Bank | Organization | 5% or Greater Security Interest | NOT APPLICABLE | 09/01/2024 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "How do you decide when a feeding tube is truly needed, and how do staff care for residents who have one?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "What training do new hires get before working with residents, and what ongoing training do all staff receive?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Life Care Center of McMinnville | 1.2 mi | McMinnville, OR | ★★★★☆ | 3/5 | |
| Village at Hillside | 1.9 mi | McMinnville, OR | ★★★★★ | 5/5 | |
| Rivers Edge Rehabilitation and Care | 12.5 mi | Sheridan, OR | ★★☆☆☆ | 2/5 | |
| Chehalem Post Acute | 13.0 mi | Newberg, OR | ★☆☆☆☆ | 1/5 | |
| Marquis Newberg | 13.7 mi | Newberg, OR | ★★★★★ | 5/5 | |
| French Prairie Nursing & Rehabilitation Center | 15.7 mi | Woodburn, OR | ★☆☆☆☆ | 1/5 | SFF |
| Avamere Court at Keizer | 16.5 mi | Keizer, OR | ★★★★☆ | 4/5 | |
| Keizer Nursing and Rehabilitation | 17.7 mi | Keizer, OR | ★★★☆☆ | 3/5 | |
| Windsor Health and Rehabilitation | 19.9 mi | Salem, OR | ★★★☆☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 385225.