Inspection Reports for
Evergreen Community of Johnson County
11875 S. SUNSET DRIVE, SUITE 100, OLATHE, KS, 66061-2793
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
42% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
16
12
8
4
0
Occupancy
Latest occupancy rate
83% occupied
Based on a May 2024 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 7
Date: May 1, 2024
Visit Reason
Annual inspection of Evergreen Community of Johnson County nursing home to assess compliance with regulatory standards related to resident care, safety, medication use, dietary practices, and hospice services.
Findings
The facility was found deficient in multiple areas including failure to provide assistive devices as care planned, inadequate assistance with activities of daily living, failure to provide residents with opportunities to attend activities, unsafe heat therapy practices resulting in a burn, malfunctioning fall prevention alarms, lack of physician rationale for extended psychotropic medication use, unsanitary dietary practices, and poor coordination with hospice services.
Deficiencies (7)
F 0558: The facility failed to provide Resident R47 with a wheelchair lap meal tray as care planned and failed to ensure R39's call light was within reach while unsupervised, placing both at risk for impaired quality of life and care.
F 0676: The facility failed to ensure Resident R39 received required assistance with activities of daily living, placing her at risk for skin breakdown, discomfort, and impaired psychosocial well-being.
F 0679: The facility failed to provide Resident R39 the opportunity to attend activities she enjoyed, placing her at risk for decreased psychosocial well-being.
F 0689: The facility failed to utilize safe heat therapy practices for Resident R64, resulting in a second-degree burn, and failed to maintain functioning fall prevention alarms for Resident R22, placing both at risk for injury.
F 0758: The facility failed to ensure physician-documented rationale for extended use of as-needed psychotropic medication for Residents R29 and R40, placing them at risk for unnecessary medication administration and harmful side effects.
F 0812: The facility failed to follow sanitary dietary standards related to cleaning, food storage, equipment storage, and food preparation practices, placing residents at risk for food-borne illnesses and food safety concerns.
F 0849: The facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for Resident R47, placing the resident at risk for delayed services and uncommunicated care needs.
Report Facts
Residents in sample: 19
Residents reviewed for ADLs: 5
Residents reviewed for accidents: 7
Residents reviewed for unnecessary medication: 5
Residents reviewed for hospice services: 1
Burn size: 2.1
Burn size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant GG | Therapy Consultant | Named in heat therapy burn incident for Resident R64 |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding lap tray use, fall alarm maintenance, and hospice coordination |
| Licensed Nurse G | Licensed Nurse | Provided statements regarding lap tray use and fall risk |
| Certified Nurse's Aide P | Certified Nurse Aide | Mentioned in relation to lap tray use and fall alarm functionality |
| Certified Nurse Aide N | Certified Nurse Aide | Provided statements about resident care and toileting |
| Certified Nurse Aide O | Certified Nurse Aide | Provided statements about resident activity participation |
| Licensed Nurse H | Licensed Nurse | Provided statements about medication review and physician decisions |
Inspection Report
Annual Inspection
Census: 70
Deficiencies: 7
Date: May 1, 2024
Visit Reason
Annual inspection of Evergreen Community of Johnson County nursing home to assess compliance with regulatory standards including resident care, safety, medication use, dietary practices, and hospice services.
Findings
The facility failed to provide care as planned for residents including assistive devices and call light accessibility, failed to assist residents with activities of daily living and participation in activities, failed to ensure safe heat therapy practices resulting in a burn, failed to maintain functional fall prevention alarms, failed to document physician rationale for extended psychotropic medication use, failed to follow sanitary dietary standards, and failed to coordinate hospice services effectively.
Deficiencies (7)
F 0558: The facility failed to provide Resident 47 with a wheelchair lap meal tray as care planned and failed to ensure Resident 39's call light was within reach while unsupervised, placing both at risk for impaired quality of life and care.
F 0676: The facility failed to ensure Resident 39 received required assistance with activities of daily living, placing her at risk for skin breakdown, discomfort, and impaired psychosocial well-being.
F 0679: The facility failed to provide Resident 39 the opportunity to attend activities she enjoyed, placing her at risk for decreased psychosocial well-being.
F 0689: The facility failed to utilize safe heat therapy practices for Resident 64, resulting in a second-degree burn, and failed to maintain functional fall prevention alarms for Resident 22, placing both at risk for injury.
F 0758: The facility failed to ensure physician-documented rationale for extended use of as-needed psychotropic medication for Residents 29 and 40, placing them at risk for unnecessary medication administration and harmful side effects.
F 0812: The facility failed to follow sanitary dietary standards related to cleaning, food storage, equipment storage, and food preparation practices, placing residents at risk for food-borne illnesses and food safety concerns.
F 0849: The facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for Resident 47, placing the resident at risk for delayed services and uncommunicated care needs.
Report Facts
Residents in sample: 19
Resident census: 70
Burn size: 2.1
Burn size: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Consultant GG | Therapy Consultant | Named in finding related to unsafe heat therapy causing burn to Resident 64 |
| Administrative Nurse D | Administrative Nurse | Named in multiple findings including failure to ensure lap tray use, fall alarm maintenance, and hospice coordination |
| Licensed Nurse G | Licensed Nurse | Named in findings related to lap tray use and fall risk management |
| Certified Nurse's Aide P | Certified Nurse Aide | Named in findings related to lap tray use and fall alarm maintenance |
| Certified Nurse Aide M | Certified Nurse Aide | Named in finding related to call light placement for Resident 39 |
| Certified Nurse Aide N | Certified Nurse Aide | Named in finding related to assistance with toileting and repositioning for Resident 39 |
| Licensed Nurse I | Licensed Nurse | Named in finding related to CNA assignments and care plan adherence for Resident 39 |
| Certified Nurse Aide O | Certified Nurse Aide | Named in finding related to failure to take Resident 39 to activities |
| Licensed Nurse H | Licensed Nurse | Named in findings related to medication review and physician decision making for Residents 29 and 40 |
| Dietary Staff CC | Dietary Staff | Named in finding related to poor food handling and hygiene practices |
| Dietary Staff BB | Dietary Staff | Named in finding related to food storage and hygiene expectations |
| Social Service X | Social Service | Named in finding related to activities oversight for Resident 39 |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Date: Oct 3, 2023
Visit Reason
The inspection was conducted following a complaint investigation related to a resident fall incident where staff failed to follow care plan interventions to prevent falls.
Complaint Details
The investigation was triggered by a fall incident on 09/22/23 involving Resident 1. The complaint was substantiated as staff failed to follow the care plan, leading to injury. Corrective actions included suspension of the involved CNA, staff education on falls, and care plan updates.
Findings
The facility failed to ensure staff followed Resident 1's care plan interventions to prevent falls, resulting in a fall with major injury. The investigation revealed staff did not properly assist the resident during transfers, leading to fractures and injury.
Deficiencies (1)
F 0689: The facility failed to ensure staff followed Resident 1's care plan interventions to prevent falls. This deficient practice resulted in a fall with major injury for Resident 1.
Report Facts
Resident census: 78
Date of fall incident: Sep 22, 2023
Date of care plan update: Sep 27, 2023
Date of staff education: Sep 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA M | Certified Nurse Aide | Involved in the fall incident and named in the deficiency for failing to follow care plan |
| LN G | Licensed Nurse | Witnessed the fall incident and provided care immediately after |
| LN H | Licensed Nurse | Provided statements regarding staff knowledge and care plan adherence |
| Administrative Nurse D | Administrative Nurse | Provided statements about the incident and staff education |
| Administrative Nurse E | Administrative Nurse | Provided statements about staff education and care plan competency |
Inspection Report
Annual Inspection
Census: 72
Deficiencies: 14
Date: Sep 19, 2022
Visit Reason
Annual inspection of Evergreen Community of Johnson County to assess compliance with healthcare regulations and resident care standards.
Findings
The facility failed to ensure dignified care during dining and catheter management, proper wheelchair equipment, discharge documentation, weight monitoring, splint application, safe transfers, bed safety, catheter care, hydration, medication reconciliation, medication monitoring, appropriate psychotropic medication use, food safety, and infection control practices. These deficiencies placed residents at risk for psychosocial harm, injury, infection, and adverse medication effects.
Deficiencies (14)
F 0550: The facility failed to ensure dignified dining assistance for residents R15 and R68 and dignified urinary catheter care for R9 during transfers.
F 0558: The facility failed to ensure R10's Broda chair had foot pedals to prevent feet dragging on the floor.
F 0661: The facility failed to document a recapitulation of R74's stay upon discharge, risking continuity of care.
F 0684: The facility failed to follow physician orders for weekly weights for R17 and daily weights for R6, risking complications related to heart failure.
F 0688: The facility failed to apply R66's physician-ordered resting splint to her right hand, risking decreased range of motion.
F 0689: The facility failed to follow care plans for transfers for R67 and maintain R36's bed at a safe height, risking falls and injuries.
F 0690: The facility failed to provide adequate catheter care for R36 and R9, resulting in urinary retention and risk of infection.
F 0692: The facility failed to ensure fluids were within reach for R68, placing her at risk of dehydration.
F 0755: The facility failed to ensure consistent reconciliation of controlled drugs at shift changes, risking medication misappropriation.
F 0756: The facility failed to acknowledge and act on the consultant pharmacist's recommendation to obtain a pulse rate hold parameter for R17's digoxin.
F 0757: The facility failed to monitor blood pressure and pulse for R36 receiving Metoprolol, risking adverse medication effects.
F 0758: The facility failed to ensure appropriate diagnosis for antipsychotic medication use for R8 and R10, risking unnecessary medication side effects.
F 0812: The facility failed to ensure proper storage, labeling, dating, and discarding of expired food in satellite kitchen refrigerators, risking foodborne illness.
F 0880: The facility failed to ensure infection control practices during personal care for R9, R10, and R67 and during laundry services, risking preventable infections.
Report Facts
Census: 72
Missed daily weights: 27
Medication reconciliation missing dates: 8
Expired food items: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide M | CNA | Named in dignified dining and catheter care findings |
| Licensed Nurse H | LN | Named in dignified dining, catheter care, weight monitoring, medication monitoring, and psychotropic medication findings |
| Administrative Nurse D | Administrative Nurse | Named in dignified dining, wheelchair equipment, discharge documentation, weight monitoring, splint application, transfer care, bed safety, catheter care, hydration, medication reconciliation, medication monitoring, psychotropic medication, and infection control findings |
| Certified Medication Aide R | CMA | Named in dignified dining, catheter care, medication reconciliation, medication monitoring, and hydration findings |
| Certified Nurse Aide O | CNA | Named in wheelchair equipment and infection control findings |
| Administrative Nurse E | Administrative Nurse | Named in infection control findings |
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 7
Date: Apr 29, 2021
Visit Reason
Annual inspection of Evergreen Community of Johnson County nursing home to assess compliance with regulatory requirements and resident care standards.
Findings
The facility failed to accurately reflect resident assessments, provide restorative care, ensure proper respiratory care, conduct thorough medication reviews, monitor behavior and bowel movements consistently, follow insulin administration orders, and maintain infection control practices including hand hygiene.
Deficiencies (7)
F0641: The facility failed to accurately reflect the status of residents' dialysis, IV medication, and hospice services in Minimum Data Set assessments, risking inappropriate care planning.
F0688: The facility failed to provide restorative care to residents, resulting in risk for decline in functional mobility and ability to perform activities of daily living.
F0695: The facility failed to change oxygen tubing and humidifier bottle as ordered, and lacked an oxygen therapy policy, placing a resident at risk for infection and complications.
F0756: The facility failed to ensure the consultant pharmacist identified and reported missing documentation of behavior and bowel movement monitoring, risking adverse medication consequences and delayed constipation treatment.
F0757: The facility failed to ensure residents' drug regimens were free from unnecessary drugs by not holding insulin as ordered when blood sugar was low, risking unwarranted side effects.
F0758: The facility failed to implement gradual dose reductions and non-pharmacological interventions for psychotropic medications and failed to document behavior monitoring, risking unnecessary medication use and side effects.
F0880: The facility failed to ensure staff practiced hand hygiene consistently, increasing risk for transmission of infectious disease.
Report Facts
Resident census: 81
Sample size: 22
Insulin given outside parameters: 9
Behavior monitoring missing shifts: 48
Bowel movements missing days: 35
Coreg held without provider notification: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrative Nurse D | Provided multiple interviews regarding restorative care, medication administration expectations, and infection control practices | |
| Certified Nurse Aide P | Interviewed about restorative care and oxygen tubing changes | |
| Certified Nurse Aide M | Interviewed about behavior and bowel movement charting | |
| Licensed Nurse I | Interviewed about medication administration and behavior monitoring | |
| Certified Medication Aide S | Interviewed about blood pressure monitoring and medication administration | |
| Consultant Pharmacist GG | Interviewed about medication review and monitoring practices | |
| Licensed Nurse H | Interviewed about insulin administration practices | |
| Certified Nurse Aide Q | Interviewed about restorative care documentation | |
| Dietary BB | Interviewed about hand hygiene practices in kitchen |
Inspection Report
Follow-Up
Deficiencies: 2
Date: Mar 9, 2015
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report documents that previously identified deficiencies under regulations 483.25(h) and 483.70(f) were corrected as of the revisit date.
Deficiencies (2)
Regulation 483.25(h): Previously cited deficiency was corrected by the revisit date.
Regulation 483.70(f): Previously cited deficiency was corrected by the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Mar 9, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses securing chemicals and the hydroculator, maintaining a functional call system, and staff education and audits to prevent hazards and ensure safety.
Deficiencies (2)
F323-E: Chemicals and hydroculator were immediately securely locked and will remain securely locked when not supervised by a staff member. The Director of Therapy or designee will conduct daily and random checks to ensure security and provide correction and education if unsecured.
F463-D: The facility will maintain a functional call system; the malfunctioning bathroom call light was fixed immediately. Mandatory in-servicing and random audits will be conducted to ensure call light functionality and timely repairs.
Inspection Report
Re-Inspection
Census: 106
Deficiencies: 2
Date: Feb 10, 2015
Visit Reason
The inspection was a Health Facility Resurvey combined with complaint investigations KS00081445 and KS00079032.
Complaint Details
The inspection included complaint investigations KS00081445 and KS00079032.
Findings
The facility failed to secure the hydroculator and chemicals, creating accident hazards for 33 cognitively impaired residents. Additionally, the facility failed to provide a functional bathroom call light affecting 2 residents in one shared bathroom.
Deficiencies (2)
483.25(h) The facility failed to securely lock the hydroculator and chemicals, exposing 33 cognitively impaired residents to potential injury. The hydroculator water temperature was 164 degrees Fahrenheit and the cabinet under the sink contained hazardous chemicals that were not secured.
483.70(f) The facility failed to provide a functional bathroom call light affecting 2 residents in one shared bathroom on one of four hallways. The call light did not notify staff pagers or the nurses' station.
Report Facts
Resident census: 106
Residents affected by unsecured hydroculator and chemicals: 33
Residents affected by nonfunctional bathroom call light: 2
Water temperature: 164
Chemical quantity: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physical Therapist HH | Stated the hydroculator and cabinet were usually locked tighter | |
| Occupational Therapist II | Stated the hydroculator and cabinet were usually locked tighter | |
| Administrative Nursing Staff D | Expected staff to secure the hydroculator and chemicals | |
| Administrative Nursing Staff H | Acknowledged the bathroom call light did not work and would notify maintenance | |
| Maintenance Staff X | Stated he/she would check the call light and contact IT if needed | |
| Maintenance Staff Y | Checked the function of all room and bathroom call lights monthly |
Inspection Report
Life Safety
Deficiencies: 1
Date: Jun 12, 2014
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility complied with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiency to be an 'F' level deficiency, widespread, with no harm but potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Deficiencies (1)
The facility was found to have an 'F' level deficiency that was widespread, indicating noncompliance with Life Safety Code requirements with potential for more than minimal harm but no immediate jeopardy.
Report Facts
Effective date for denial of payments: Sep 12, 2014
Effective date for provider agreement termination: Dec 12, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
| Irina Strakhova | Enforcement Coordinator | Signed enforcement letter |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Nov 8, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) deficiency was corrected by 11/08/2013.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Nov 8, 2013
Visit Reason
This is a post-certification revisit 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 the deficiency identified under regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) deficiency was corrected by the revisit date of 11/08/2013.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Nov 8, 2013
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that all previously cited deficiencies identified by regulation numbers F0279, F0280, and F0425 were corrected as of 11/08/2013.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 8, 2013
Visit Reason
The 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
Resident #1 and Resident #2 allegations were thoroughly investigated and found to be unsubstantiated. The facility updated policies and provided staff education on abuse, neglect, and reporting suspicion of a crime.
Deficiencies (1)
F225-D: Resident #1's and Resident #2's allegations of abuse were investigated and found unsubstantiated. Policies on abuse, neglect, and reporting suspicion of a crime were updated and staff received mandatory education.
Inspection Report
Plan of Correction
Deficiencies: 3
Date: Nov 8, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses deficiencies related to comprehensive care plans and medication administration, outlining corrective actions including audits, staff education, and ongoing monitoring.
Deficiencies (3)
F279-D: Resident #54 was discharged and care plan cannot be updated. Resident #35's care plan was updated to include occasional incontinence. The Director of Health will audit care plans weekly for 4 weeks then monthly and provide education as needed.
F280-D: Resident #56's care plan was reviewed and revised appropriately. Weekly audits and mandatory staff in-service will be conducted to ensure care plan comprehensiveness.
F425-D: Residents will continue to have medications administered per physician orders. Mandatory in-servicing and weekly then monthly observation of medication administration will be conducted with corrective actions as needed.
Inspection Report
Complaint Investigation
Census: 109
Deficiencies: 1
Date: Nov 7, 2013
Visit Reason
The inspection was conducted as a complaint investigation (#KS 70297) regarding allegations of abuse at the facility.
Complaint Details
The complaint investigation #KS 70297 found the facility did not report two resident abuse allegations to the state agency and failed to thoroughly investigate these allegations. Resident #1 alleged rape on 11/4/13 and was sent to the hospital. Resident #2 alleged staff abuse on 10/28/13. The facility did not notify the state agency of either allegation.
Findings
The facility failed to report two resident allegations of abuse to the state agency, including an allegation of rape by resident #1 and an allegation of staff abuse by resident #2. The facility also failed to thoroughly investigate and report these allegations as required by policy and law.
Deficiencies (1)
483.13(c)(1)(ii)-(iii), (c)(2)-(4) - The facility failed to report and investigate allegations of abuse, including a resident's allegation of rape and another resident's allegation of staff abuse, to the state agency as required.
Report Facts
Resident census: 109
Sample size: 3
Inspection Report
Complaint Investigation
Census: 111
Deficiencies: 3
Date: Oct 29, 2013
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation for the facility.
Complaint Details
The visit was triggered by complaints resulting in a Health Resurvey and Complaint Investigations KS00069989 and KS00066134.
Findings
The facility failed to develop and revise comprehensive care plans for residents with 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)
F279: The facility failed to develop and implement individualized comprehensive care plans for residents with behavioral status, incontinence, and administration of anti-anxiety medication.
F280: The facility failed to revise care plans to include individualized interventions for behaviors and changes in incontinence status for residents.
F425: The facility failed to administer medications according to physician orders, administering Lorazepam too frequently for one resident.
Report Facts
Resident census: 111
Sample size: 17
Lorazepam administration interval: 176
Lorazepam administration interval: 244
Resident urinary incontinence episodes: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| administrative licensed staff D | Stated medication should not have been given that close together and unit managers update care plans. | |
| licensed staff J | Stated direct nursing staff did not update care plan; unit managers updated them. | |
| direct care staff O | Interviewed regarding resident behaviors and medication administration. | |
| direct care staff P | Interviewed regarding resident behaviors and medication administration. |
Inspection Report
Follow-Up
Deficiencies: 1
Date: Sep 18, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.25(c) with ID prefix F0314 was corrected as of 2012-09-03. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 483.25(c) deficiency identified by ID prefix F0314 was corrected on 2012-09-03.
Report Facts
Deficiency correction date: Sep 3, 2012
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 13, 2012
Visit Reason
This document is a plan of correction submitted in response to deficiencies cited during a complaint investigation at the facility.
Complaint Details
This plan of correction is related to a complaint investigation identified as Evergreen 081312 Complaint.
Findings
Resident #2 had pressure ulcers described as shearing wounds measuring 0.5cm by 0.5cm, which were treated and documented as healed by 8/13/12. The facility updated its Pressure Ulcer Prevention Policy and educated staff on prevention and treatment.
Deficiencies (1)
F314-G: Resident #2 had pressure ulcers described as shearing wounds measuring 0.5cm by 0.5cm. New treatment orders were implemented and the wound was documented as healed on 8/13/12.
Report Facts
Wound measurement: 0.5
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 1
Date: Aug 13, 2012
Visit Reason
The inspection was conducted as a complaint investigation (#KS 58879) regarding the facility's treatment and services to prevent and heal pressure sores.
Complaint Details
The visit was triggered by complaint investigation #KS 58879. The complaint was substantiated as the facility failed to prevent pressure ulcers and provide adequate care for the resident.
Findings
The facility failed to provide necessary treatment and services to prevent pressure ulcers, promote healing, and prevent infection for a sampled resident. The resident developed two pressure ulcers that were not properly managed, and staff failed to reposition the resident or maintain dressings appropriately.
Deficiencies (1)
F 314: The facility failed to provide necessary treatment and services to prevent pressure ulcers, promote healing, and prevent infection for resident #2 who developed two Stage II pressure ulcers. Staff did not reposition the resident for over two hours and failed to maintain dressings properly.
Report Facts
Resident census: 108
Sample size: 3
Pressure ulcer measurements: 3.8
Pressure ulcer measurements: 1.8
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 0.7
Braden Scale score: 15
Duration without repositioning: 155
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 16, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies had been corrected as indicated in the plan of correction.
Findings
All previously reported deficiencies were corrected as of the revisit date. The report lists multiple regulatory citations with correction completion dates on 07/16/2012.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 16, 2012
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as of the revisit date.
Findings
All deficiencies previously cited on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected by the revisit date of 07/16/2012.
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 and state regulations.
Findings
The plan outlines corrective actions for multiple deficiencies related to resident privacy, careplan comprehensiveness, behavioral monitoring, safe food handling, and documentation updates. The facility commits to staff education, audits, and ongoing monitoring to ensure compliance and quality assurance.
Deficiencies (6)
F164: Resident's right to privacy of information was not adequately protected. The facility relocated CNA careplan notebooks and provided staff inservices on privacy and confidentiality.
F279: Resident careplans lacked comprehensiveness and updates for behavioral issues, diagnoses, and care interventions. The facility implemented weekly audits and mandatory staff education to improve careplan accuracy.
F280: Resident careplans did not fully reflect current oral care status and participation in careplan meetings. Updates and invitations to residents and families were documented.
F329: Behavioral symptoms, medication side effects, and black box warnings were not consistently updated in careplans. Weekly audits and monitoring through CareTracker were initiated.
F371: Food was not consistently served in a safe and sanitary manner. Staff received mandatory inservicing on hand washing and safe food handling, with ongoing observations planned.
F428: Behavioral issues and medication side effects were not fully documented or monitored in careplans. Weekly audits and neighborhood reviews were established to ensure completeness.
Inspection Report
Re-Inspection
Census: 109
Deficiencies: 6
Date: Jul 3, 2012
Visit Reason
Health resurvey inspection to evaluate compliance with regulatory requirements and follow up on previous deficiencies.
Findings
The facility failed to protect resident privacy, develop individualized and revised comprehensive care plans, monitor behaviors and side effects of psychotropic medications including Black Box Warnings, and maintain sanitary food handling practices.
Deficiencies (6)
F164: The facility failed to provide privacy for residents' care information on 3 of 4 units during 4 days on site.
F279: The facility failed to develop individualized comprehensive care plans for 6 of 15 residents reviewed, including failure to address falls, hospice coordination, use of splints, behavioral issues, and oral care.
F280: The facility failed to revise care plans for 3 of 15 residents reviewed, including failure to involve residents in care planning and update plans for oral care.
F329: The facility failed to monitor behavior, medication side effects, and Black Box Warnings for 8 of 10 residents reviewed receiving psychotropic medications.
F371: The facility failed to distribute food in a safe and sanitary manner, including failure to wash hands before handling food.
F428: The facility failed to monitor resident behaviors, medication side effects, and Black Box Warnings for 1 of 10 residents reviewed, including failure to act on pharmacist reports.
Report Facts
Deficiencies cited: 6
Resident census: 109
Sample size: 15
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N046029 POC 00PG11
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory finding for the facility identified as ASPEN with State ID N046029.
Findings
No deficiency details or findings are included in this document. It serves solely as a record of the Plan of Correction submission.
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