Evergreen Post Acute

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Resident 9 stated she/he did not need assistance walking in their room. Resident 9 stated she/he did not use the call light because their roommate would call staff or would go find someone. The resident was observed sitting at the edge of the bed without a call light within reach, no fall mats on either side of the resident's bed, no quarter bilateral enabler bars on the bed, or a wheelchair in the room. Observations throughout the day on 11/14/25 from 8:38 AM through 12:45 PM revealed the call light not within reach of Resident 9. The call light was observed to be stuck behind the bedside table and draped over her/his roommate's bed. On 11/14/25 at 10:37 AM and 3:15 PM Staff 30 (Agency CNA) stated they were given report during shift change from another CNA. Staff 30 stated they looked at the Kardex (a quick reference tool CNAs use to help care for residents) to know what Resident 9's care needs were. Staff 30 stated Resident 9 was independent with care but would let staff know if she/he needed assistance. Staff 30 accessed Resident 9's Kardex and confirmed Resident 9 required moderate assistance from one person with transfers and walking and should have had a wheelchair, floor mats on both sides of bed, and enabler bars attached to the bed. On 11/14/25 at 12:37 PM Staff 25 (CNA) stated Resident 9 got up on her/his own, did not ask for assistance, and, since moving rooms, was independent with walking with a walker. Staff 25 stated she did not know if Resident 9 was at risk for falls and recalled the resident had fall mats at the beginning of her/his admission but could not recall when they were removed. Staff 25 confirmed the call light was not within reach of Resident 9 and found the call light attached to the roommate's bed. On 11/14/25 at 2:47 PM Staff 31 (CNA) stated Resident 9's abilities fluctuated depending on the day, but she/he was mostly independent, if she/he needed to use the bathroom the resident went on her/his own.

Resident 9 only asked for help when she/he could not do something independently.During interviews with Staff 4 (LPN-Resident Care Manager) on 11/14/25 at 10:43 AM and 2:24 PM, and 11/17/25 at 9:07 AM, Staff 4 stated Resident 9's care plan was last reviewed and updated on 11/10/25 and 11/11/25. Staff 4 confirmed the current Kardex/Care Plan was not accurate for all care needs and was not updated related to falls. Staff 4 stated she expected the care plan to be updated regularly with changes and with quarterly assessments. Staff 4 stated Resident 9 currently required hands-on assistance with transfers. Staff 4 confirmed Resident 9's care plan was not updated after the fall on 10/23/25. Staff 4 stated she expected staff to follow the care plan and to let the RCM know if the care plan needed to be updated. Staff 4 confirmed the fall mats, wheelchair, and quarter bilateral enabler bars were not removed from the care plan when they were discontinued. On 11/17/25 at 11:34 AM Staff 14 (CNA) stated they responded to calls for help from Resident 9's roommate on 10/23/25. He stated at the time of the fall Resident 9 would walk and toilet on her/his own, but staff encouraged her/him to call for assist. Staff 14 stated the resident was not impulsive, restless, or having behaviors at the time of the fall on 10/23/25. Staff 14 stated he did not recall what the Kardex stated but the expectation would have been to follow the Kardex/care plan. On 11/17/25 at 10:44 AM Staff 2 (DNS) and Staff 6 (Assistant RN Consultant) were present for an interview. Staff 2 confirmed at the time of the fall on 10/23/25 Resident 9 required moderate assist with transfers and ambulation. Staff 2 and Staff 6 confirmed the care plan was not updated after the fall with new interventions related to fall prevention. Staff 2 stated she expected staff to follow and implement the care plan. Staff 2 stated they removed the fall mats, but did not confirm when they were removed, and discussed the interventions they planned on implementing but did not change the care plan.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Post Acute

8643 NE Beech Street Portland, OR 97220

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

methadone. On 11/14/25 at 8:19 AM, Staff 38 (Respiratory Therapist) stated on 1/10/25, he saw Staff 9, Staff 33 and Resident 3 huddled near the entrance to his office. Staff 38 stated Staff 9 and Resident 3 were upset because Staff 33 opened all of Resident 3's bottles of methadone. Resident 3 was concerned she/he would not be able to get her/his dose of methadone that day and Staff 9 promised she would take care of it.

Staff 38 reported he escorted Resident 3 to the methadone clinic and watched as the resident took her/his dose of methadone. Later that day, Resident 3 was provided a second dose of methadone. Staff 38 stated

he provided a breathing treatment later in the day and there was no change from her/his baseline after the resident received the second dose. On 11/14/25 at 11:38 AM, Staff 5 (RN Consultant) confirmed on 1/10/25 at 11:51 AM, Resident 3 was provided with an extra dose of methadone after her/his return from the methadone clinic. Staff 5 verified the resident was prescribed 20 ml of methadone daily. On 11/17/25 at 8:28 AM, Staff 33 stated Resident 3 had several bottles of methadone in her/his methadone lock box, but

she could not read the labels on the bottles because they were smeared. Staff 33 stated she opened the bottles which she estimated to be 2 ml to 4 ml of methadone, each. Staff 33 stated when she came to the last two bottles, she realized there was not enough methadone to equal 20 ml so she asked Staff 9 what to do. Staff 9 asked Staff 33 why she opened all of Resident 3's methadone bottles. Staff 33 stated Resident 3's physician order indicated the resident was to receive 20 ml of methadone but that was wrong, the order should have been for 2 ml. Staff 33 stated Staff 9 confirmed to her, Resident 3's methadone order was for 20 ml. Staff 33 stated she and Staff 9 went to Resident 3's room to explain the situation and the resident slumped to the floor because she/he was upset. Staff 33 reported around 10:48 AM, Resident 3's new methadone was delivered to the facility and around 11:00 she went to Resident 3's room with a dose of methadone. Resident 3 stated are you sure I haven't received this already and Staff 33 answered no so Resident 3 took the dose. Staff 33 stated she was sure each bottle contained 2 ml and the physician order was wrong because it should have read 2 ml not 20 ml. Staff 33 stated she administered an extra dose of methadone to Resident 3 on 1/10/25 because staff did not communicate to her that Resident 3 went to the methadone clinic earlier in the day and received a dose at the clinic.

Event ID:

Facility ID:

If continuation sheet