Evergreen Post Acute
8643 NE Beech Street, Portland, OR 97220 · Multnomah County · 55 certified beds · avg 52 residents/day · certified since Jun 1, 1998
Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)
2/5
Health inspection rating (on-site)
1
Serious findings on record
$4,194
Fines, last 3 years
5.84
Nurse hours/resident/day (adjusted)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
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 · Aug 15, 2022 · F-0760
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.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
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: Sep 22, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (41)
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 |
|---|---|---|
| May 14, 2026 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · from a complaint |
| Nov 17, 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 |
| Nov 17, 2025 | D · Potential for harm, one-off | 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 |
| Feb 18, 2025 | E · Potential for harm, repeated | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Feb 18, 2025 | E · Potential for harm, repeated | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Feb 18, 2025 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 18, 2025 | E · Potential for harm, repeated | The facility did not provide or arrange specialized rehabilitation services — such as physical, occupational, or speech therapy — for residents who needed them. |
| Feb 18, 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. |
| Feb 18, 2025 | 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 18, 2025 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Feb 18, 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. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Feb 18, 2025 | 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. |
| Feb 18, 2025 | 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. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not provide care that took into account residents' past trauma or their cultural backgrounds. Care is supposed to be sensitive to what residents have lived through and where they come from. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Feb 18, 2025 | D · Potential for harm, one-off | 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. |
| Feb 18, 2025 | 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 |
| Feb 18, 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. |
| Sep 19, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Oct 23, 2023 | F · Potential for harm, facility-wide | 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. |
| Oct 23, 2023 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Oct 23, 2023 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Oct 23, 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 |
| Oct 23, 2023 | 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. |
| Oct 23, 2023 | 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. |
| Oct 23, 2023 | D · Potential for harm, one-off | The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature. |
| Oct 23, 2023 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Aug 15, 2022 | ▲ G · Actual 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. |
| Aug 15, 2022 | F · Potential for harm, facility-wide | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Aug 15, 2022 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Aug 15, 2022 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Aug 15, 2022 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| Aug 15, 2022 | 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. |
| Aug 15, 2022 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Aug 15, 2022 | 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. |
| Aug 15, 2022 | D · Potential for harm, one-off | 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. |
| Aug 15, 2022 | D · Potential for harm, one-off | 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. |
| Aug 15, 2022 | 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. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (8 → 17).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 11 | 1 | G ▲ |
| 2023 | 8 | 0 | F |
| 2024 | 1 | 0 | D |
| 2025 | 20 | 0 | E |
| 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 $4,194.
| Date | Type | Amount / length |
|---|---|---|
| Dec 11, 2023 | Fine | $4,194 |
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) | 5.84 | 5.42 | 3.95 | top 22% in Oregon; top 5% in the U.S. |
| Registered Nurse hours | 0.42 | 0.78 | 0.69 | bottom 11% in Oregon; bottom 26% in the U.S. |
| Weekend total nurse staffing | 5.25 | 4.85 | 3.50 | top 22% in Oregon; top 5% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.37 | 0.48 | 0.48 | bottom 46% in Oregon; bottom 46% in the U.S. |
| Total nursing staff turnover (%) | 63.3 | 47.4 | 45.8 | bottom 14% in Oregon; bottom 12% 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 4.94, RN 0.36, weekend 4.44. 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: 2/5 · long-stay residents: 2/5 · short-stay residents: —/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Apt, Frederick | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/10/2024 |
| Brzycki, Tracy | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Carnagie, Russell | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/03/2024 |
| Carnagie, Russell | Individual | ADP of the SNF | NOT APPLICABLE | 05/30/2025 |
| Jergensen, Joshua | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/10/2024 |
| Larson, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2024 |
| Larson, David | Individual | ADP of the SNF | NOT APPLICABLE | 05/30/2025 |
| Mitchell, John | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/10/2024 |
| Portland 8643 Realty LLC | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2024 |
| Providence Administrative Consulting Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 09/01/2024 |
| 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.
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What mental health services do you provide on-site, and who delivers them?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How often is each resident's medication list reviewed, and who decides when a drug can be reduced or stopped?"
- "Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
- "Could I join residents for a meal to see the food quality and temperature for myself?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How are therapy services provided here, and how quickly does therapy start after a doctor orders it?"
- "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 |
|---|---|---|---|---|---|
| Rose City Nursing and Rehabilitation | 1.5 mi | Portland, OR | ★★★☆☆ | 3/5 | |
| Glisan Post Acute | 1.7 mi | Portland, OR | ★★☆☆☆ | 2/5 | |
| Gateway Care and Retirement | 1.9 mi | Portland, OR | ★★★☆☆ | 3/5 | |
| Porthaven Post Acute | 2.0 mi | Portland, OR | ★★★☆☆ | 2/5 | |
| Menlo Park Post Acute | 2.1 mi | Portland, OR | ★★☆☆☆ | 2/5 | |
| Providence Child Center | 2.4 mi | Portland, OR | ★★★★★ | 5/5 | |
| Portland Health and Rehabilitation | 2.6 mi | Portland, OR | ★☆☆☆☆ | 1/5 | |
| Marquis Mill Park | 2.6 mi | Portland, OR | ★★★☆☆ | 2/5 | |
| Mt. Tabor Health & Rehabilitation | 2.7 mi | Portland, OR | ★★☆☆☆ | 2/5 | |
| Belmont Care and Rehabilitation | 3.0 mi | Portland, OR | ★☆☆☆☆ | 2/5 | |
| Fernhill Rehabilitation and Care | 3.1 mi | Portland, OR | ★★☆☆☆ | 2/5 | abuse |
| Laurelhurst Post Acute & Rehabilitation | 3.6 mi | Portland, OR | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 385258.