Print Violation: 00445797-AP-397804

Provider Information

Evergreen Senior Living Community

3760 N CLAREY ST
Eugene, OR 97402

Date: 11/14/2025
Report number: 00445797-AP-397804
Type: Abuse: Neglect
Level: 3 - Moderate harm or potential for serious harm
Allegation: Failed to provide a safe medication administration system
Result: Substantiated
Rule(s) Violated: External site: 411-054-0025(1)(a) and (b)
External site: 411-054-0027(1)(g) and (s)
External site: 411-054-0028(2)
External site: 411-054-0055(1)(a) and (f)
Findings: On or about November 14, 2025, Alleged Perpetrator 2 (AP2) discontinued Alleged Victim's (AV) routine calcium channel blocker, and AV did not receive this daily medication from November 14, 2025, to December 15, 2025. Based on facility documentation and interviews, AP2 discontinued AV's medication in error due to reading AV's electronic medication administration record (EMAR) incorrectly. AP2 did not communicate in AV's communication log that AP2 discontinued this medication. AV experiences lower kidney functioning and not taking this medication as ordered put AV at elevated risk for cardiac event and/or increased risk of kidney damage or failure. AP2's actions is considered neglect of care which constitutes abuse. The facility failed to provide adequate oversight of the facility's Medication Administration System which placed AV at risk of moderate harm, which is a violation of resident rights, is considered neglect of care and constitutes abuse.
Sanction: ALFCP26-00164 $1013.00 fine assessed