Evan Terrace Post Acute
EVAN TERRACE POST ACUTE in MCMINNVILLE, OR — inspection on November 18, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based 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.
Findings include:The facility's incident report dated 7/29/25 indicated Staff 12 entered Resident 2's room and observed feeding tube formula was running at a rate of 300 ml/hr and observed the resident's formula was coming out of the resident's trach area.Resident 2's Physician Order dated 7/18/25 noted, enteral feed every shift, diet Jevity (liquid nutrition formula for tube feeding) 1.5, 66 ml/hr x 18 hours, on at 4:00 AM and off at 10:00 PM, feeding via pump for a total of 1206 ml. On 10/1/25 at 12:58 PM, Staff 12 (LPN) stated after receiving report from Staff 9 (LPN) she found Resident 2's feeding tube running at a rate of 300 ml/hour.
She stated there was feeding tube formula bubbling out of Resident 2's tracheostomy site.On 10/2/25 at 9:11 AM, Staff 9 stated she had left Resident 2's feeding tube running at a rate of about 300 ml/hour by mistake during her shift on 7/28/25.On 10/2/25 at 9:52 AM, Staff 13 (LPN) stated Staff 12 found Resident 2's tube feeding running at 300 ml/hour on 7/29/25.On 10/2/24 at 10:48 AM, Staff 2 (DNS) stated she expected nurses to follow physician orders for feeding tubes.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID: