Evergreen Community of Johnson County

Inspectors wroteThe facility identified a census of 79 residents with one kitchen and two kitchenettes. Based on observation, record review, and interviews, the facility failed to maintain sanitary dietary standards related to food storage.

Inspectors wroteThe facility identified a census of 79 residents. The sample included 18 residents, with one resident reviewed for tube feeding (administration of nutritionally balanced liquefied foods or nutrients through a tube). Based on observation, record review, and interview, the facility failed to ensure R2's tube feeding was labeled with content in the feeding bag and dated with the date the feeding was given. Finding Included:- R2's electronic medical record (EMR), under the Diagnosis tab, recorded diagnoses of muscle weakness, difficulty in walking, hypertension (elevated blood pressure), dementia (a progressive mental disorder characterized by failing memory and confusion), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). [...]

Inspectors wroteThe facility identified a census of 70 residents. The sample included 19 with seven reviewed for accidents. Based on record review, interviews, and observations, the facility failed to utilize safe heat therapy practices for Resident (R) 64. This deficient practice resulted in a second degree (potentially painful burn which affects the first and second layer of the skin) burn on R64's right knee. The facility additionally failed to ensure a safe environment related to maintaining R22's wheelchair and bed fall-prevention alarm. This deficient practice placed R22 at risk for preventable accidents and injuries. Findings Included: [...]

Inspectors wroteThe facility identified a census of 70 residents with one kitchen and two main dining rooms. Based on observation, record review, and interviews, the facility failed to follow sanitary dietary standards related to cleaning, food storage, equipment storage, and food preparation practices. These deficient practices placed the residents at risk related to food-borne illnesses and food safety concerns. Finding Included: - On 04/29/24 at 07:04 AM an initial walkthrough of the kitchen was completed. An inspection of a utensil storage rack next to the kitchen main entry revealed two Crock-pot lids and a water pitcher lid stored with the food/beverage side upward. An inspection of the kitchen's fryer station revealed old crumbs and food particles covering the outside of the fryer and the side of the baking oven next to it. [...]

Inspectors wroteThe facility identified a census of 70 residents. The sample included 19 residents with two residents reviewed for accommodation of needs related to assistive devices. Based on observation, record review, and interviews, the facility failed to provide Resident (R)47 with a wheelchair lap meal tray as care planned for his meals. The facility additionally failed to ensure R39's call light remained within reach while unsupervised in her room. This deficient practice placed both residents at risk for impaired quality of life and care. Findings Included: [...]

Inspectors wroteThe facility identified a census of 70 residents. The sample included 19 residents with five residents reviewed for activities of daily living (ADLs). Based on observation, record review, and interviews, the facility failed to ensure Resident (R)39 received the required assistance with ADLs. This placed R39 at risk for complications including skin breakdown, discomfort, and impaired psychosocial well-being.

Inspectors wroteThe facility identified a census of 70 residents. The sample included 19 residents, with one resident reviewed for activities. Based on observation, record review, and interviews, the facility failed to provide Resident (R)39 the opportunity to go to the activities she enjoys. This deficient practice placed R39 at risk for decreased psychosocial well-being.

Inspectors wroteThe facility identified a census of 70 residents. The sample included 19 residents with five residents reviewed for unnecessary medication. Based on observation, record review, and interviews, the facility failed to ensure a physician-documented rationale for extended use of an as-needed psychotropic (alters mood or thought) medication for Resident (R) 29, and R40. This deficient practice placed these residents at risk for unnecessary medication administration thus leading to possible harmful side effects.

Inspectors wroteThe facility identified a census of 70 residents. The sample included 19 residents with one resident reviewed for hospice services. Based on observation, record review, and interviews, the facility failed to ensure collaboration between the nursing home and hospice services to identify hospice-supplied services, supplies, medication, and equipment for Resident (R)47. This deficient practice placed the resident at risk for delayed services and uncommunicated care needs. Findings Included: [...]

Inspectors wroteThe facility identified a census of 78 residents. The sample included three residents reviewed for falls. Based on observations, record review, and interviews, the facility failed to ensure staff followed Resident (R) 1's care planned interventions to prevent falls. As a result of this deficient practice, R1 fell and sustained fractures of the right superior (upper) and inferior (lower) pubic rami (two sections of bone that branch off the pubic body).

Inspectors wroteThe facility identified a census of 72 residents. The facility had one main kitchen and three satellite kitchens. Based on observation and interview the facility failed to ensure food stored in the satellite kitchen refrigerator was properly stored, labeled and dated. The facility failed to ensure that expired items in the satellite refrigerators were discarded. The deficient practice left the resident at risk of food borne illnesses.

Inspectors wrote- On 09/14/22 at 12:03 PM R15 sat in a Broda chair (special wheelchair) in the dining room. Her drink on the table was placed out of her reach. R15 sat in the dining room table from 12:03 PM to 12:25 PM with a drink she was unable to reach until staff sat down next R15 to assist her with lunch. On 09/14/22 at 12:14 PM Certified Nurse Aide (CNA) M stood beside R68 in the dining room as she assisted R68 with her lunch. On 09/19/22 at 02:01 PM Certified Medication Aide (CMA) R stated staff should sit down next to the resident that they are assisting at meals times and talk to the resident not other staff members. CMA R stated the staff try to deliver the food to everyone at the table around the same time. On 09/19/22 at 02:18 PM Licensed Nurse (LN) H stated staff should always sit next to the residents at meal time to encourage and assist them if needed. [...]

Inspectors wroteThe facility identified a census of 72 residents. The sample included 18 residents with two reviewed for accommodation of needs. Based of observations, record review, and interviews, the facility failed to ensure R10's Broda chair (specialized wheelchair with the ability to tilt and recline) had foot pedals/rests. This deficient practice placed R10 at risk for injuries related to the lack of foot pedals.

Inspectors wroteThe facility identified a census of 79 residents. The sample included 18 residents. Based on record review and interviews, the facility failed to document a recapitulation of the facility stay upon discharge from the facility for Resident (R) 74, sampled for discharge. This placed R74 at risk for an interruption in the continuity of care and/or unidentified care needs.

Inspectors wroteThe facility identified a census of 72 residents. The sample included 18 residents with two reviewed for quality of care. Based of observations, record review, and interviews, the facility failed to follow the physician's orders to complete daily weights for Resident (R)6 and weekly weights for R17 in order to monitor for fluid retention related to heart disease. This deficient practice placed the residents at risk for complications related to heart failure. Findings Included: [...]

Inspectors wroteThe facility identified a census of 70 residents. The sample included 18 residents with two residents reviewed for limited range of motion (ROM). Based on observation, record review and interview the facility failed to ensure that staff obtained and applied Resident (R)66's physician ordered splint to her right hand. This placed R66 at risk for further decrease in ROM.

Inspectors wroteThe facility identified a census of 72 residents. The sample included 18 residents with five residents reviewed for accidents. Based on observation, record review and interview the facility failed to ensure resident (R)36's bed was placed at a safe level while occupied. The facility failed to ensure R67 was transferred with the required assistance as directed in the plan of care. This deficient practice placed R36 and R67 at risk for accidents and related injuries.

Inspectors wroteThe facility identified a census of 72 residents. The sample included 18 residents with two reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) care. Based of observations, record review, and interviews, the facility failed to provide care and services required for catheter care for Residents (R) 9 and R36. This deficient practice placed both residents at risk for complications related to urinary tract infections and catheter related complication. Findings Included: - The Medical Diagnosis section within R9's Electronic Medical Records (EMR) included diagnoses of urinary tract infection (UTI's), bladder obstruction, abdominal pain, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), and pyelonephritis (sudden and severe inflammation of kidney due to a bacterial infection). [...]

Inspectors wroteThe facility identified a census of 72 residents. The sample included 18 residents which two residents reviewed for hydration. Based on observation, record review, and interviews, the facility failed ensure fluids were available within reach for Resident (R) 68, which placed her at risk of dehydration and adverse consequences.

Inspectors wroteThe facility identified a census of 79 residents. The sample included 18 residents. Based on observation, record review, and interviews, the facility failed to ensure consistent reconciliation of controlled drugs at the end of daily work shifts. This placed residents at risk for misappropriation of medications by staff.

Inspectors wroteThe facility identified a census of 72 residents. The sample included 18 residents with seven sampled residents reviewed for unnecessary medication review. Based on observation, record review and interview the facility failed to acknowledge and/or act upon the Consultant Pharmacist (CP) recommendation to obtain a hold pulse rate parameter for digoxin (a medication used to treat heart failure and certain types of irregular heartbeats) for Resident (R)17. This deficient practice had the potential risk for unnecessary medication administration and unwarranted side effects for those two sampled residents.

Inspectors wroteThe facility identified a census of 72 residents. The sample included 18 residents with seven reviewed for unnecessary medication review. Based on observation, record review and interview the facility failed to ensure adequate monitoring for Resident (R) 36's of Metoprolol (a medication used to lower the blood pressure and/or pulse). This placed the resident at risk for adverse medication effects.

Inspectors wroteThe facility identified a census of 72 residents. The sample included 18 residents with seven residents review for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure an appropriate diagnosis for antipsychotic medication (class of medications used to treat psychosis (any major mental disorder characterized by a gross impairment in reality testing) and other mental emotional conditions) use for Resident (R)8 and R10, who had a diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion). This placed R8 and R10 at risk for unnecessary medications leading to adverse side effects.

Inspectors wroteThe facility identified a censes of 72 residents. Based of observations, record review, and interviews, the facility failed to ensure infection control practices were followed while providing personal care to Residents (R)9, R10, and R67. The facility additionally failed to ensure infection control practices were followed for laundry services. This deficient practice placed the residents at risk for preventable infections. Findings Included: - On 09/14/22 at 08:15 AM Housekeeping Staff U pushed the laundry cart down the 100's hallway. The cart was full of personal clothing for the residents. The cart was only covered by a small cloth at the top leaving the clothing fully exposed to the environment during transport. She then hung up a tan pair of pants outside of R20's door. She then hung up a blue shirt and brown pants outside of R11's door. [...]