Inspection Reports for Evergreen Community of Johnson County
11875 S. SUNSET DRIVE, SUITE 100, OLATHE, KS, 66061-2793
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 8, 2013, included deficiencies related to care planning, medication administration, and failure to report allegations of abuse to the state agency. Earlier inspections showed similar issues with care plan development, medication management, resident privacy, and food safety, along with a substantiated complaint regarding inadequate pressure ulcer care. Complaint investigations mostly found allegations unsubstantiated except for the failure to report abuse allegations timely, which led to policy updates and staff education. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility showed some corrective actions over time, but recurring deficiencies in care planning and regulatory compliance suggest ongoing challenges.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
17.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
192% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
109 residents
Based on a November 2013 inspection.
Census over time
Inspection Report
Follow-Up
Deficiencies: 1
Date: Nov 8, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report shows that the previously reported deficiencies under regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4) were corrected as of 11/08/2013.
Deficiencies (1)
Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2) - (4)
Report Facts
Deficiency correction date: Nov 8, 2013
Inspection Report
Follow-Up
Deficiencies: 3
Date: Nov 8, 2013
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously cited deficiencies identified by their regulation numbers and prefix codes have been corrected as of the revisit date.
Deficiencies (3)
Deficiency related to regulation 483.20(d), 483.20(k)(1)
Deficiency related to regulation 483.20(d)(3), 483.10(k)(2)
Deficiency related to regulation 483.60(a),(b)
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 8, 2013
Visit Reason
This document is a Plan of Correction submitted in response to a complaint investigation regarding allegations of abuse and neglect at the facility.
Complaint Details
Resident #1's and Resident #2's allegations were thoroughly investigated and found to be unsubstantiated.
Findings
The allegations for Resident #1 and Resident #2 were thoroughly investigated and found to be unsubstantiated. The facility updated policies and provided mandatory staff education on abuse, neglect, and reporting suspicion of a crime. Ongoing monitoring and audits will be conducted to ensure compliance.
Deficiencies (1)
Allegations of abuse and neglect investigated and found unsubstantiated; corrective actions include policy updates and staff education.
Report Facts
Plan of Correction completion date: Nov 8, 2013
Audit frequency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Varner | Executive Director | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Nov 8, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report, addressing compliance with federal Medicare and Medicaid requirements.
Findings
The plan outlines corrective actions including audits of care plans for comprehensiveness, mandatory in-service training for staff, medication administration observation, and ongoing quality assurance monitoring to ensure compliance and address any negative trends.
Deficiencies (3)
Care plan for Resident #54 could not be updated due to discharge; Resident #35's care plan updated to include occasional incontinence.
Care plan for Resident #56 reviewed and revised appropriately.
Medication administration to residents will continue according to Physician Orders with mandatory staff in-service and observation.
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 2
Date: Nov 7, 2013
Visit Reason
The inspection was conducted as a complaint investigation (#KS 70297) due to allegations of abuse involving two residents, including an allegation of rape and staff abuse.
Complaint Details
The complaint investigation #KS 70297 involved allegations of abuse for two residents. Resident #1 alleged rape on 11/4/13, was sent to the hospital, and the facility failed to report the allegation to the state agency. Resident #2 alleged staff abuse on 10/28/13, describing being hit by a staff member, and the facility also failed to report this allegation to the state agency. The facility conducted investigations but did not notify the state agency as required.
Findings
The facility failed to report two resident allegations of abuse to the state agency as required. Resident #1 alleged rape, and resident #2 alleged staff abuse. The facility conducted investigations but did not notify the state agency within the required timeframe. The facility's policy lacked evidence of compliance with federal reporting requirements.
Deficiencies (2)
Failed to report to the state agency two resident allegations of abuse, including an allegation of rape and staff abuse.
Facility policy lacked evidence of compliance with Section 1150B of the Social Security Act regarding reporting crimes to law enforcement.
Report Facts
Census: 109
Resident sample size: 3
BIMS score: 12
BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Reported facility staff finishing a report, unaware of reporting time limits, and confirmed administrator or director of nursing responsible for reporting incidents. | |
| Administrative nursing staff D | Attempted to call state agency on 11/4/13, confirmed facility did not notify state agency of resident #1's allegation. | |
| Direct care staff O | Provided personal care to resident #1 and reported willingness to report abuse signs to charge nurse. | |
| Direct care staff K | Provided personal care to resident #1. | |
| Licensed nursing staff H | Reported staff would initiate investigation and notify administrative staff and social worker upon resident abuse allegation. | |
| Licensed nursing staff J | Reported resident recognized staff but not necessarily names. | |
| Social services staff EE | Reported initiation of investigation on 11/4/13 and described staff gathering resident interviews. | |
| Social services staff FF | Reported resident refused visual or physical genital examination at hospital. | |
| Social services staff GG | Reported initiation of facility investigation on 10/28/13 and described reporting of events/incidents to administrative staff. |
Inspection Report
Annual Inspection
Census: 111
Deficiencies: 3
Date: Oct 29, 2013
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations for Evergreen Community of Johnson County.
Complaint Details
The inspection included complaint investigations KS00069989 and KS00066134.
Findings
The facility failed to develop and revise comprehensive care plans for residents, including individualized interventions for behavioral issues, pain management, and changes in continence status. Additionally, the facility failed to administer medications according to physician orders for one resident.
Deficiencies (3)
Failed to develop individualized and comprehensive care plans for residents regarding behavioral status, incontinence, and administration of anti-anxiety medication.
Failed to revise care plans to include individualized interventions for behaviors and changes in incontinence status.
Failed to administer medications according to physician's orders, specifically Lorazepam given too close together.
Report Facts
Census: 111
Sample size: 17
Medication administration timing: 2.93
Medication administration timing: 4.07
Incontinence episodes: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Direct care staff O | Interviewed regarding resident #54's pain and medication administration | |
| Direct care staff P | Interviewed regarding resident #54's pain and medication administration | |
| Licensed staff H | Licensed Nurse | Interviewed regarding resident #54's pain medication administration |
| Licensed staff J | Licensed Nurse | Interviewed regarding care plan updates |
| Administrative licensed staff D | Administrator | Interviewed regarding care plan updates and medication administration |
| Direct care staff Q | Interviewed regarding resident #36's ADLs and continence | |
| Licensed nurse I | Licensed Nurse | Interviewed regarding resident #36's continence and ADL status |
| Direct care staff R | Interviewed regarding resident #56's behaviors | |
| Social services staff HH | Social Services | Interviewed regarding resident #56's behavioral history and care plan |
| Licensed nurse K | Licensed Nurse | Interviewed regarding resident #56's behavior status |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 18, 2012
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously reported deficiencies had been corrected.
Findings
The report shows that the deficiency identified under regulation 483.25(c) with ID prefix F0314 was corrected as of 09/03/2012. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Deficiency under regulation 483.25(c) previously cited
Report Facts
Deficiency correction date: Sep 3, 2012
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 1
Date: Aug 13, 2012
Visit Reason
The inspection was conducted as a complaint investigation (#KS 58879) to assess the facility's compliance with treatment and services to prevent and heal pressure sores.
Complaint Details
Complaint investigation #KS 58879. The facility failed to prevent development of pressure ulcers and provide appropriate care for resident #2 as substantiated by observations, record review, and interviews.
Findings
The facility failed to provide necessary treatment and services to prevent pressure ulcers, promote healing, and prevent infection for a sampled resident (#2). The resident developed two pressure ulcers, and staff did not adequately reposition or care for the resident, leading to wet briefs and dressings removed prematurely. The facility policy and clinical guidelines for pressure ulcer prevention were not properly followed.
Deficiencies (1)
Failure to provide necessary treatment and services to prevent pressure ulcers, promote healing, and prevent infection for resident #2.
Report Facts
Census: 108
Sample size: 3
Braden Scale score: 15
Pressure ulcer measurements: 3.8
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 1.8
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 0.2
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 0.7
Duration without repositioning: 155
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff B | Performed wound care, measurements, dressing application, and assisted resident during the inspection. | |
| Direct care staff C | Assisted resident with shower, repositioning, and care during the inspection. | |
| Direct care staff D | Assisted resident to bathroom and wheelchair during the inspection. | |
| Direct care staff E | Provided incontinent care and removed soiled dressing. | |
| Administrative licensed nursing staff A | Notified about dressing removal and provided policy information. |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 8, 2012
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation related to pressure ulcer care and prevention at the facility.
Complaint Details
This Plan of Correction is linked to the Evergreen 081312 Complaint, indicating the visit was complaint-related.
Findings
Resident #2 had pressure ulcers described as 'shearing' wounds which were assessed and treated, resulting in healing. The facility updated its Pressure Ulcer Prevention Policy, educated staff, and implemented monitoring and reporting procedures to ensure compliance and prevent recurrence.
Deficiencies (1)
Pressure ulcer care and prevention deficiencies related to Resident #2's wounds and policy implementation
Report Facts
Wound measurement: 0.5
Observation frequency: 3
Date: Aug 21, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Varner | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Mary Jane Kennedy | Modified the Plan of Correction | |
| Irina Strakhova | Added the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 7
Date: Jul 16, 2012
Visit Reason
This is a post-certification revisit conducted to verify that previously reported deficiencies have been corrected and to document the dates such corrective actions were accomplished.
Findings
All previously cited deficiencies identified by their regulation numbers and prefix codes were corrected as of the revisit date, July 16, 2012.
Deficiencies (7)
Deficiency identified under regulation 483.10(e), 483.75(l)(4)
Deficiency identified under regulation 483.15(f)(1)
Deficiency identified under regulation 483.20(d), 483.20(k)(1)
Deficiency identified under regulation 483.20(d)(3), 483.10(k)(2)
Deficiency identified under regulation 483.25(l)
Deficiency identified under regulation 483.35(i)
Deficiency identified under regulation 483.60(c)
Report Facts
Deficiencies corrected: 7
Inspection Report
Plan of Correction
Deficiencies: 6
Date: Jul 16, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, addressing compliance with federal Medicare and Medicaid requirements.
Findings
The plan outlines corrective actions related to resident privacy, careplan comprehensiveness, behavioral monitoring, safe food handling, and staff education. It includes weekly and monthly audits, mandatory inservices, and ongoing monitoring by the Quality Assurance committee.
Deficiencies (6)
Resident's right to privacy of information not adequately protected.
Careplans not comprehensive or updated to reflect resident conditions and interventions.
Careplan revisions and resident involvement in careplan meetings not consistently documented.
Behavioral issues, medication side effects, and black box warnings not fully incorporated or monitored in careplans.
Food served not consistently safe and sanitary; staff required additional training on hand washing and food handling.
Behavioral monitoring and careplan audits not consistently completed or documented.
Report Facts
Date of Plan of Correction completion: Jul 16, 2012
Number of residents referenced in careplan updates: 8
Number of weeks for weekly audits: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Varner | Executive Director | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 109
Deficiencies: 6
Date: Jul 3, 2012
Visit Reason
The inspection was a Health Resurvey to assess compliance with previously identified deficiencies and overall regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to protect resident privacy, failure to develop individualized and revised comprehensive care plans, failure to monitor behaviors and side effects of psychotropic medications including Black Box Warnings, failure to distribute food in a sanitary manner, and failure to conduct proper drug regimen reviews and act on irregularities.
Deficiencies (6)
Failure to provide privacy for residents' care information on 3 units over 4 days.
Failure to develop individualized comprehensive care plans for 6 of 15 residents reviewed.
Failure to revise care plans for 3 of 15 residents reviewed.
Failure to ensure drug regimen free from unnecessary drugs; failure to monitor behavior, side effects, and Black Box Warnings for psychotropic medications for 8 of 10 residents reviewed.
Failure to distribute food in a safe and sanitary manner on one hall affecting approximately 28 residents.
Failure to review drug regimen monthly by pharmacist and act on irregularities for 1 of 10 residents reviewed.
Report Facts
Residents reviewed for care plans: 15
Residents affected by privacy deficiency: 109
Residents affected by food distribution deficiency: 28
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nursing Staff H | Licensed Nurse | Acknowledged privacy issues and care plan deficiencies; provided interviews regarding medication monitoring |
| Administrative Nursing Staff E | Administrative Nurse | Acknowledged lack of behavior monitoring system and care plan revision failures |
| Licensed Nursing Staff J | Licensed Nurse | Acknowledged medication monitoring deficiencies and side effect documentation issues |
| Direct Care Staff R | Direct Care Staff | Provided interviews regarding resident behaviors and care |
| Administrative Staff A | Administrative Staff | Provided interview regarding care plan meetings and dental program |
| Pharmacy Consultant Staff B | Pharmacy Consultant | Reviewed medication side effects and monitoring |
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