Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: CALMS - 00096733
Provider Information
Evergreen Memory Care Community
3720 N CLAREY ST
Eugene, OR 97402
- Provider ID
- 50R279
- Administrator
- Tamara Wright
- Phone
- (541) 689-3900
- mced@evergreensl.com
Violation Details
- Date
- 10/8/2025
- Report number
- CALMS - 00096733
- Type
- Licensing Violation
- Level
- 2 - Minor harm or potential for moderate harm
- Allegation
- Failed to provide a safe medication administration system
- Result
- Substantiated
- Rule(s) Violated
-
External site: 411-054-0055(1)(f)
- Findings
- Based on interview and record review, conducted during a site visit on October 8, 2025, the facility’s failure to carry out medication and treatment orders as prescribed was substantiated for 1 of 1 sampled resident (#1). Resident 1 was not administered his/her mood stabilization medication for approximately one month. Resident 1 experienced increased agitation. Findings include, but are not limited to: Service plan dated July 10, 2025, indicated: - Diagnosis of post-traumatic stress disorder, psychotic disturbance, mood disturbance and anxiety; and - Required staff assistance with all medication orders and administration Physician orders dated April 15, 2025, indicated: - Olanzapine, 5mg tablet every day at bedtime for steady mood Interview Staff 2: - Med tech staff discovered the medication was gone but did not reorder the medication nor did they document a conversation with the pharmacy regarding the refill request. - Medication Administration Record (MAR) dated August 2025, indicated s/he had not been administered his/her Olanzapine 25 times, with notes that said the medication was unavailable. Progress notes indicated: - On August 31, 2025, Resident 1’s irritation with staff had increased over the last week with “today being the worst”; - On September 1, 2025, Staff 2 was informed that Resident 1 had not received Olanzapine for two weeks. Staff 3(RCC) stated a priority refill of Olanzapine was requested and it will be administered to Resident 1 in the evening on 09/01/25; and - On September 3, 2025, staff reported Resident 1's Olanzapine was not reordered because the prescription bottle was thrown away and staff did not have the prescription number to order a refill. There was no documented evidence the facility had attempted to contact Resident 1's pharmacy to request a refill for Olanzapine in 08/2025. The facility's failure to carry out medication and treatment orders is a violation of Oregon Administrative Rules.