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Evergreen Community Of Johnson County

11875 S Sunset Drive, Suite 100, Olathe, KS 66061 · Non profit - Corporation · 44 certified beds · (913) 477-8227 Medicare & Medicaid certified

Call the home — (913) 477-8227 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)1 actual-harm citation1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$22,913 in federal fines1 Medicare payment denial
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (5/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has 1 actual-harm citation
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (24) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $22,913 in federal fines (most recent 2024-05-01)
  • its facility-reported quality-measure rating is low (2/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 2 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
2090 W Dartmouth St · (913) 356-8300 · Call to confirm hours
Pharmacy
395 N K 7 Hwy · (913) 764-7165 · Call to confirm hours
Grocery
395 N K 7 Hwy · (913) 522-3368 · Call to confirm hours
Park
475 S Ward Cliff Dr · (913) 971-8563 · Typically dawn to dusk
Place of worship
2323 W Johnston St

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 2 of 5
Long-stay residentspeople who live here 2 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased22.2%17.9%15.4%worse
Long-stay residents who lose too much weight6.7%4.9%5.4%worse
Long-stay residents with a catheter left in their bladder2.1%1.6%0.9%worse
Long-stay residents with a urinary tract infection5.4%2.9%2.0%worse
Long-stay residents with depressive symptoms5.4%6.5%6.5%better
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury5.6%4.3%3.3%worse
Long-stay residents whose ability to walk worsened24.7%16.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication24.2%23.2%18.9%worse
Long-stay residents given the seasonal flu vaccine98.8%95.5%95.3%typical
Long-stay residents with pressure ulcers1.7%4.4%4.7%better
Long-stay residents with worsening bladder/bowel control34.3%22.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table8.6%18.1%17.1%better
Short-stay residents who newly got an antipsychotic medication5.0%1.9%1.4%worse
Long-stay hospitalizations per 1,000 resident days1.651.801.67typical
Long-stay outpatient ER visits per 1,000 resident days1.582.131.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

0.12U.S. median 0.31
Therapy hours / resident / day
0.05hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 4% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.81
RN hours/ resident / day
0.80
LPN hours/ resident / day
3.64
Aide hours/ resident / day
5.26
Total nurse hours/ resident / day
0.59
RN hoursweekends
45.3%
Total nursing turnover
28.6%
RN turnover

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 5.26 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.81 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.64 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.68 hrs/resident/day on weekends vs 5.49 on weekdays — 15% thinner on weekends. RN hours go from 0.90 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 45% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

2
deficiencies at the latest standard inspection (2026-02-25)
7
at the previous standard inspection (2024-05-01)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

24 citations, most serious first. The 12 most serious are shown; the remaining 12 are one tap away and print in full.

  • Actual harm · Gcited before2024-05-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The 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: - The Medical Diagnosis section within R64's Electronic Medical Records (EMR) included diagnoses of epilepsy (brain disorder characterized by repeated seizures), seizures (violent involuntary series of contractions of a group of muscles), osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain), muscle weakness, and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). R64's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-10-03 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The 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). Findings included: - The Diagnoses tab of R1's Electronic Medical Record (EMR) documented diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion) moderate without behavioral disturbance, dizziness and giddiness, fracture of left pubis (pair of bones forming two sides of the pelvis) subsequent encounter for fracture with routine healing, orthostatic hypotension (blood pressure dropping with change of position), need for assistance with personal care, lack of coordination, and unsteadiness on feet. The admission Minimum Data Set (MDS) dated 03/24/23 documented R1 had a Brief Interview for Mental…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Past Non-Compliance
  • Potential for harm · Fcited before2026-02-25 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The 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. Findings included: - On 02/23/26 at 11:03 AM, during the kitchen initial tour, observation in the walk-in freezer revealed the following:One resealable bag of three fish fillets that was not labeled and dated.One opened bag of pepperoni, which was not labeled and dated. One opened bag of tater tots placed in a resealable bag; the bag was not dated. One opened bag of cauliflower florets, which was not labeled and dated. On 02/23/26 at 11:10 AM an observation in the kitchen's dry food storage room revealed one opened and undated bag of egg noodles. On 02/23/26 at 11:16 AM an observation in the kitchen's walk-in refrigerator revealed one metal bowl with plastic wrap covering the top. The bowl contained several slices of molded cheddar cheese. On 02/23/26 at 11:21 AM an observation in the kitchen's walk-in produce refrigerator revealed the following:One bag of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-25 · tag F0693 — failed to provide proper feeding-tube care — isolated
    Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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). R2's Quarterly Minimum Data Set (MDS) dated [DATE] recorded a Brief Interview for Mental Status score of 15, which indicated intact cognition. The MDS documented R2 had impairment on both sides of her lower body. The MDS documented R6 was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2024-05-01 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The 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. An inspection of the kitchen's dry food storage revealed old pieces of food on the floor throughout the storage room. On 04/30/24 at 02:30 PM Dietary Staff CC completed hand hygiene and prepped the dinner puree meal. Dietary Staff CC prepared to make pureed tuna noodle…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-01 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The 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: -The Medical Diagnosis section within R47's Electronic Medical Records (EMR) included diagnoses of senile degeneration of the brain, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), dysphagia (swallowing difficulty), memory deficit, left-sided hemiplegia (paralysis of one side of the body), left-sided hemiparesis (muscular weakness of one half of the body), and dementia (progressive mental disorder…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-01 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The 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. Findings included: - R39's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory), dysplasia oropharyngeal phase (difficulty initiating a swallow), combined systolic and diastolic heart failure (the heart cannot effectively contract with each heartbeat in diastolic heart failure your heart cannot relax between heartbeats), hypertension (HTN-elevated blood pressure), and anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes). R39's Quarterly Minimum Data Set dated 02/06/24 documented that a Brief Interview of Mental Status (BIMS) was not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-01 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - R39's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of dementia (a progressive mental disorder characterized by failing memory), dysplasia oropharyngeal phase (difficulty initiating a swallow), combined systolic and diastolic heart failure (the heart cannot effectively contract with each heartbeat in diastolic heart failure your heart cannot relax between heartbeats), hypertension (HTN-elevated blood pressure), and anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes). R39's Significant Change Minimum Data Set (MDS) dated [DATE] lacked documented the interview for…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-01 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - R29's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), delusion (untrue persistent belief or perception held by a person although evidence shows it was untrue), and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). The Annual Minimum Data Set (MDS) dated [DATE] documented a staff interview that indicated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-05-01 · tag F0849 — isolated
    Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The 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: - The Medical Diagnosis section within R47's Electronic Medical Records (EMR) included diagnoses of senile degeneration of the brain, Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremor, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness), dysphagia (swallowing difficulty), memory deficit, left-sided hemiplegia (paralysis of one side of the body), left-sided hemiparesis (muscular weakness of one half of the body), and dementia (progressive mental disorder characterized by failing memory, confusion). R47's Quarterly Minimum…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-09-19 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The 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. Findings included: - An inspection of a satellite kitchen/dining closest to the main lobby on 09/13/22 at 08:29 AM revealed the following: One gallon jug of milk sat directly on the serving counter without a cooling ice bath or any way to maintain adequate temperature. A large bin of ice sat on a wheeled cart with the ice scoop stuck directly in the ice. A dish storage cart was stored in the dining room with the clean dishes (plates and bowls) stored eating surface up and uncovered. An inspection of a satellite kitchen area refrigerator on 09/13/22 at 08:49 AM revealed the following: Several pieces of bacon wrapped in a paper towel that was not in a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-19 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    - 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. LN H stated the staff tried to serve everyone at the same table at the same time. On 09/19/22 at 04:35 PM Administrative Nurse D stated staff should sit down next to the resident when they assist with a meal. Administrative Nurse D…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 12 citations
  • Potential for harm · Dcited before2022-09-19 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The 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. Findings included: - The Medical Diagnosis section within R10's Electronic Medical Records (EMR) included diagnoses of dementia (progressive mental disorder characterized by failing memory, confusion), hypertension (high blood pressure), Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), insomnia (inability to sleep), major depressive disorder (major mood disorder), and morbid obesity (severely overweight). R10's Quarterly Minimum Data Set (MDS) dated 07/20/22 noted a Brief Interview for Mental Status (BIMS) assessment could not be completed due to severe cognitive impairment. The MDS indicated that she required extensive assistance…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-19 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - R74's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure) and osteoarthritis (degenerative changes to one or many joints characterized by swelling and pain). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R74 required supervision of one staff member for activities of daily living (ADL's). R74's Psychotropic Drug Use Care Area Assessment (CAA) dated 04/07/22 documented she received an antidepressant medication (class of medications used to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-19 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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: - The Medical Diagnosis section within R6's Electronic Medical Records (EMR) included diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), hypertension (high blood failure), chronic kidney disease, heart failure, edema (swelling resulting from an excessive accumulation of fluid in the body tissues), type two diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), cardiovascular disease (any abnormal condition…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-19 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - The electronic medical record (EMR) documented diagnoses of cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), hypertension (elevated blood pressure), hemiplegia (paralysis of one side of the body, and kidney failure (the kidney is no longer able to function on its own). The Annual Minimum Data Set (MDS) dated [DATE] documented R66 had both long and short-term memory loss. R66 required extensive assist of two staff members for her activities of daily living (ADLS). R66 required the use of a wheelchair for mobility. R66 had one fall since the last assessment. The Fall Care Area Assessment…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-19 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: -The electronic medical record for R36 documented diagnoses of obstructive and reflux uropathy (obstruction prevents flow of urine), benign prostatic hyperplasia (BPH-a non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), spinal stenosis (a degenerative condition of the spine that could cause weakness and loss of use of extremities), and malignant neoplasm of prostate (a cancerous tumor of the prostate). The Annual Minimum Data Set (MDS) dated…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-19 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolated
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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). R9's Quarterly Minimum Data Set (MDS) dated 07/18/22 noted a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-19 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - R68's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), lack of coordination, and need for personal care. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 99, staff interview documented moderately impaired cognition. The MDS documented that R68 required supervision of one staff member assistance for consumption of nourishment and fluids. The MDS documented R68 pocketed food in her mouth during the look back period. The Quarterly MDS dated 06/23/22 documented a BIMS score of zero…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-19 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The 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. Findings included: - On 09/13/22 observation on the 200-hall medication room revealed a binder with reconciliation sheets. The sheets, reviewed from 09/06/22 through 09/13/22, revealed lack of documentation of signed reconciliation on 09/06/22, 09/08/22, 09/09/22, 09/11/22, 09/13/22. On 09/19/22 further review of the 200-hall controlled medication reconciliation sheets revealed lack of evidence of reconciliation, 09/14/22, 09/16/22, and 09/17/22. On 09/19/22 at 02:08 PM Licensed Nurse (LN) H stated the expectation was for the off going LN or Certified Medication Aide (CMA) count the scheduled controlled medication with the oncoming LN or CMA. On 09/19/22 at 04:34 PM Administrative Nurse D stated she expectated the off going LN or CMA to count the scheduled controlled…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-19 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: -The electronic medical record for R17 documented diagnosis of congestive heart failure (CHF-a condition with low heart output and the body becomes congested with fluid), hypertension (an elevated blood pressure), and atrial fibrillation (A-fib: a rapid, irregular heartbeat). The admission Minimum Data Set (MDS) dated [DATE] documented R17 had a Brief Interview for Mental Status (BIMS) score of…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-19 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: -The electronic medical record (EMR) for R36 documented diagnoses hypertension (HTN-an elevated blood pressure), obstructive and reflux uropathy (obstruction prevents flow of urine), benign prostatic hyperplasia (BPH-a non-cancerous enlargement of the prostate which can lead to interference with urine flow, urinary frequency and urinary tract infections), spinal stenosis (a degenerative condition of the spine that could cause weakness and loss of use of extremities), and malignant neoplasm of prostate (a cancerous tumor of the prostate). The Annual Minimum Data Set (MDS) dated [DATE] documented R36…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2022-09-19 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The 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. Findings included: - R8's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), and dementia (progressive mental disorder characterized by failing memory, confusion). The admission Minimum Data Set (MDS) dated [DATE]…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-09-19 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    The 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. On 09/14/22 at 11:09 AM soiled bed linens were observed on the hall floor outside of R49's room. On 09/15/22 at 08:10 AM R10 sat at the Mount Chalet dining hall waiting to be assisted with her breakfast. Certified Nurses Aid (CNA) O donned…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$22,913 in federal fines across 2 penalties. 1 Medicare payment denial on record.

  • $12,854 — penalty dated 2024-05-01
  • $10,059 — penalty dated 2023-10-03
  • Medicare payment denial — starting 2024-05-28 for 3 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleShareSince
EVERGREEN LIVING INNOVATIONS INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 01/01/2003
DAUGHERTY, DIANNEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/06/2025
DWYER, MARKIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
GALLAGHER, LINDAIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/06/2025
GASH, MARKIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/06/2025
GASH, MARYIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/06/2025
PARISE, BRETTIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2022
SWEARINGEN-LYLES, DEBRAIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROLsince 01/06/2025
AMOS, PATRICKIndividualCORPORATE OFFICERsince 01/01/2022
DUPRIEST, JESSICAIndividualCORPORATE OFFICERsince 01/01/2024
HOLLAND, CHRISIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/06/2025
OSBORN, CHRISTOPHERIndividualCORPORATE OFFICERsince 05/01/2011
PLOWMAN, ANDREAIndividualCORPORATE OFFICERsince 01/01/2024
ROBERTS, CHARLAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/09/2023

CMS files one row per role, so the 24 rows in the source record cover these 14 parties — each is shown once here with every role it holds. Nothing is omitted.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$9.6M
Net patient revenuemost recent cost report
-20.0%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 75%Medicare 1%Other / private 24%

About 75% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$410per resident / day
operating cost
$12,458per month
≈ monthly operating cost
$342per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in KS

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Kansas Medicaid page.

Typical monthly cost in Kansas
$8,669/mo
Nursing home (semi-private)
$9,064/mo
Nursing home (private)
$5,975/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 175355. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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