Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evergreen Community Of Johnson County during CMS and state inspections, most recent first.
Surveyors identified a failure to follow sanitary food storage and labeling practices in the main kitchen and two kitchenettes serving 79 residents. Multiple opened and undated food items were found in the walk-in freezer, dry storage, and refrigerators, including fish fillets, pepperoni, tater tots, cauliflower, egg noodles, molded cheddar cheese, expired or spoiled produce, and undated choy noodles. In the kitchenettes, undated mixed fruit, prunes, and pretzels were observed, along with unlabeled and undated resident food items such as pizza and a plate with a hamburger and tater tots. Dietary staff acknowledged that facility policy required all opened and leftover foods to be stored in covered or sealed containers, clearly labeled and dated, and that dietary aides were responsible for checking for spoiled food and proper labeling, which did not occur as required.
A resident with multiple medical conditions, including dementia and dependence on staff for ADLs, received a significant portion of nutrition via PEG tube with detailed MD orders and a care plan for enteral feeding. Over several observations, surveyors noted that the resident’s enteral feeding bags, running on a pump at the ordered rate, were not labeled with the formula contents or the date and time they were started, despite facility policy and staff statements that night-shift nurses were responsible for labeling bags with date, time, rate, and formula.
The facility failed to utilize safe heat therapy practices, resulting in a second-degree burn on a resident's knee, and did not maintain functional fall-prevention alarms for another resident, placing them at risk for preventable falls and injuries.
The facility failed to follow sanitary dietary standards related to cleaning, food storage, equipment storage, and food preparation practices. Observations included improper storage of utensils, unclean kitchen equipment, and unlabeled food items. A dietary staff member was also observed not following proper hand hygiene and food handling procedures.
The facility failed to provide a resident with a wheelchair lap meal tray as care planned, and another resident's call light was out of reach while unsupervised. Both residents had significant medical conditions and required assistance, but staff did not follow the care plans, leading to impaired quality of life and care.
The facility failed to ensure that a resident received the required assistance with ADLs as directed in her care plan. The resident, who had multiple diagnoses and was dependent on two staff members for all ADLs, was left in the same position for extended periods without being repositioned or checked for incontinence. Staff interactions were minimal and did not include the necessary care actions, placing the resident at risk for complications.
The facility failed to ensure a resident was invited, encouraged, and assisted to attend activities she enjoyed, despite her care plan indicating her preferences for spiritual and music-related activities. Staff admitted to forgetting and not noticing the updated activity calendar, and the facility lacked a policy for activities.
The facility failed to ensure a physician-documented rationale for the extended use of as-needed psychotropic medication for two residents with severely impaired cognition, placing them at risk for unnecessary medication administration and potential harmful side effects. Staff interviews and record reviews confirmed the absence of required documentation for the extended use of lorazepam.
The facility failed to ensure collaboration with hospice services to identify hospice-supplied services, supplies, medication, and equipment for a resident with multiple medical diagnoses. The care plan lacked detailed hospice information, and the resident struggled to access his drink due to an ill-fitting lap tray. Staff interviews confirmed the absence of detailed hospice information in the care plans.
Failure to Maintain Sanitary Food Storage and Labeling Practices
Penalty
Summary
The deficiency involves failure to maintain sanitary dietary standards and proper food storage practices in the main kitchen and two kitchenettes serving 79 residents. During an initial kitchen tour, surveyors observed multiple opened, undated food items in the walk-in freezer, including a resealable bag with three fish fillets, an opened bag of pepperoni, an opened bag of tater tots placed in a resealable bag, and an opened bag of cauliflower florets, none of which were labeled or dated. In the dry food storage room, there was an opened and undated bag of egg noodles. In the walk-in refrigerator, surveyors found a metal bowl covered with plastic wrap containing several slices of molded cheddar cheese. In the walk-in produce refrigerator, they observed a bag of broccoli with a manufacturer “best if used by” date that had passed, three bags of coleslaw mix that were soft, mushy, and appeared spoiled, with one bag containing brown fluid, and multiple peppers (jalapeno, green, red, and yellow) that were moldy, soft, wilted, wrinkled, or had blackened, moldy spots. Additional observations in the main kitchen and kitchenettes showed further failures to follow food storage policies. In the kitchen’s main area, there was a plastic container of choy noodles that was not dated. In one kitchenette refrigerator, two plastic bins of mixed fruit were not labeled or dated, and in a kitchenette cabinet, an opened bag of prunes and an opened bag of pretzels were also not dated. In a resident refrigerator within a kitchenette, surveyors found a box of pizza and a plate with a hamburger and tater tots covered in plastic wrap, neither of which were dated or labeled with a resident’s name. Dietary staff later stated that all opened food items were expected to be labeled and dated, that opened bags should be placed in resealable plastic bags and labeled and dated, and that dietary aides were responsible for checking kitchenettes after each meal to look for spoiled food and ensure items were labeled and dated. The facility’s Food Storage policy required all leftover and stored foods to be in covered or sealed containers, clearly labeled and dated, and used within specified time frames or discarded, which was not followed in these instances.
Unlabeled Enteral Feeding Bags for Tube-Fed Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enteral feeding bags were labeled with the contents and the date and time the feeding was started, as required by facility policy. The resident had diagnoses including muscle weakness, difficulty in walking, hypertension, dementia, and anxiety, with a BIMS score of 15 indicating intact cognition. The MDS documented that the resident had bilateral lower body impairment, was dependent on staff for toileting and bathing, had a feeding tube, and received 51 percent of her calories through tube feedings. The care plan and physician orders specified detailed enteral feeding procedures, including elevating the head of bed, checking tube placement and residuals, flushing the PEG tube with specified amounts of water, and changing and labeling the feeding syringe daily with name and date. The facility’s policy for administering nutritional formulas through an enteral tube required staff to label the bag and tubing with the date and time. Surveyor observations on multiple mornings showed the resident in bed with the head of bed elevated and the enteral feeding running via pump at the ordered rate, but the feeding bags were not labeled with the contents or the date and time the feeding was started. On one observation, the enteral feeding bags were hung on the feeding pump without any markings, and on subsequent observation the pump was running at 70 ml/hr with the bags still unlabeled. Interviews with a licensed nurse and an administrative nurse confirmed that night-shift nurses were responsible for hanging and labeling the bags with the date, time, rate, and formula, and that the bags should be marked on the back with the date and contents. Despite these stated responsibilities and the written policy, the resident’s feeding bags remained unlabeled during the surveyor’s observations, constituting the identified deficiency.
Failure to Ensure Safe Heat Therapy and Maintain Fall-Prevention Alarms
Penalty
Summary
The facility failed to utilize safe heat therapy practices for a resident, resulting in a second-degree burn on the resident's right knee. The resident had a history of epilepsy, seizures, osteoarthritis, muscle weakness, and Alzheimer's disease. During a therapy session, the resident complained of knee pain, and the consultant applied a moist heating pack without a protective cover, using multiple layers of towels instead. This led to a blister and a second-degree burn on the resident's knee. The consultant reported the injury to nursing services, the resident's medical practitioner, and the resident's representative. The facility's investigation revealed that the correct protective covers were available, but the consultant did not ask staff where they were located. The facility's policy required the use of appropriate equipment and placement for heat therapy, which was not followed in this instance. The facility also failed to ensure a safe environment related to maintaining another resident's wheelchair and bed fall-prevention alarm. This resident had a history of dementia, anxiety disorder, cognitive-communication deficit, muscle weakness, and required assistance with personal care. The resident's care plan included the use of pressure sensor pads for the bed and wheelchair to prevent falls. However, during an observation, the resident was seen attempting to transfer herself from her bed to her wheelchair without staff intervention. Tests revealed that the pressure sensor pads were not functioning correctly, and the alarms did not relay to the nurse's station. Staff acknowledged that the alarms should have been checked each shift to ensure functionality, but this was not done consistently. The facility's Fall Prevention and Management policy indicated that staff were to ensure environmental conditions remained safe for residents at risk and that equipment remained in working order. The failure to maintain the pressure sensor pads and ensure their functionality placed the resident at risk for preventable falls and injuries. The facility's inaction in maintaining the alarms and ensuring their proper function directly contributed to the deficiency.
Failure to Follow Sanitary Dietary Standards
Penalty
Summary
The facility failed to follow sanitary dietary standards related to cleaning, food storage, equipment storage, and food preparation practices. During an initial walkthrough of the kitchen, surveyors observed two Crock-pot lids and a water pitcher lid stored with the food/beverage side upward, old crumbs and food particles covering the outside of the fryer and the side of the baking oven, and old pieces of food on the floor throughout the dry food storage room. Additionally, a dietary staff member was observed preparing a pureed meal without completing proper hand hygiene and using a scoop that was placed directly on a dirty food preparation area without a clean barrier. Inspections also revealed six opened and unlabeled quart containers of ice cream, an opened bag of tater tots in the dining room refrigerator, and an opened but undated bag of breaded chicken in the walk-in freezer. Dietary Staff BB confirmed that staff were expected to ensure clean hygienic food preparation, use clean utensils, and store cooking utensils and plates with the food or eating surface downward. The facility's Food Services and Nutrition policy indicated that all surfaces within the dining room and kitchen were to be cleaned and sanitized per professional standards, and that food would be labeled, dated, and stored in a manner that is safe and maintains nutritional value. The policy also required staff to complete hand hygiene between touching surfaces related to direct food preparation, handling, and serving, and to store kitchen and dining equipment in a manner that prevents soiling or contamination of clean items. The facility's failure to adhere to these standards placed residents at risk of food-borne illnesses and food safety concerns.
Failure to Provide Assistive Devices and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to provide a resident with a wheelchair lap meal tray as care planned for his meals. The resident, who had diagnoses including Parkinson's disease, dementia, and left-sided paralysis, required the lap tray to independently eat his food. Despite the care plan indicating the need for the lap tray, observations showed that the tray was not used, and the resident struggled to reach his drink. Staff were unaware that the lap tray did not fit the resident's new Broda chair, and no action was taken to replace it, leading to the resident's impaired quality of life and care. Another resident's call light was found to be out of reach while she was unsupervised in her room. This resident had diagnoses including dementia, heart failure, and anxiety, and was dependent on staff for all activities of daily living. Despite the care plan indicating that the call light should be within reach, observations showed that the call light was placed in the middle of the bed, out of the resident's reach. Staff acknowledged that the call light should be within reach and that the resident was unable to push the button, requiring periodic checks. The facility's policies on assistive devices and call light monitoring were not followed, leading to deficiencies in the care provided to both residents. The failure to provide the necessary assistive devices and ensure the call light was within reach placed the residents at risk for impaired physical, mental, and psychosocial well-being.
Failure to Assist Resident with ADLs as Directed in Care Plan
Penalty
Summary
The facility failed to ensure that Resident 39 received the required assistance with activities of daily living (ADLs) as directed in her care plan. Resident 39, who had diagnoses including dementia, dysphagia, heart failure, hypertension, and anxiety, was documented as being dependent on two staff members for all toileting, positioning, transfers, and ADLs. Observations revealed that Resident 39 was left in the same position in her Broda chair for extended periods without being repositioned or checked for incontinence, contrary to the care plan instructions that required repositioning every two hours during the day and every four hours at night, as well as regular checks and changes for incontinence. Staff interactions with Resident 39 were minimal and did not include the necessary care actions as outlined in her care plan. On one occasion, Resident 39 was observed from 08:14 AM to 11:36 AM without being repositioned or checked for incontinence, despite the care plan's directives. Staff members were present in the room at various times but did not perform the required care tasks. Additionally, a Certified Nursing Aide (CNA) acknowledged knowing the care plan requirements but did not follow through with the necessary actions. Interviews with staff, including a Licensed Nurse and an Administrative Nurse, confirmed that the expectation was for CNAs to follow the care plan, but this was not adhered to in Resident 39's case. This failure placed Resident 39 at risk for complications such as skin breakdown, discomfort, and impaired psychosocial well-being.
Failure to Facilitate Resident Participation in Enjoyed Activities
Penalty
Summary
The facility failed to provide Resident 39 the opportunity to participate in activities she enjoys, which placed her at risk for decreased psychosocial well-being. Resident 39 has multiple diagnoses, including dementia, dysplasia oropharyngeal phase, combined systolic and diastolic heart failure, hypertension, and anxiety. Her care plan indicated that she enjoyed spiritual and religious activities, as well as music, and should be invited to such events. However, on the day of observation, staff did not invite or assist her to attend Bible Study or a live music event, despite these activities being listed on the facility's activity calendar. Staff interviews revealed that the CNAs were aware of the activities each resident liked to attend but failed to take Resident 39 to the activities she enjoyed. One CNA admitted to forgetting to take her to the activities and not noticing the updated activity calendar. The Social Service staff responsible for activities on Resident 39's unit also failed to ensure she attended the live music event, despite the activity calendars being posted in multiple locations. The facility did not provide a policy for activities, further contributing to the oversight in Resident 39's care.
Lack of Physician-Documented Rationale for Extended Use of As-Needed Psychotropic Medication
Penalty
Summary
The facility failed to ensure a physician-documented rationale for the extended use of as-needed psychotropic medication for two residents, R29 and R40. R29, diagnosed with Alzheimer's disease, delusion, and anxiety, had severely impaired cognition and was receiving multiple psychotropic medications, including lorazepam. The facility's records lacked evidence of a physician-documented rationale for the extended duration of as-needed lorazepam, and staff were unable to provide this documentation upon request. Observations noted R29 asleep in a reclined position in a specialized wheelchair, and staff interviews confirmed that the physician reviewed and decided on medication durations but did not document the rationale for the extended use of lorazepam. Similarly, R40, diagnosed with Alzheimer's disease, anxiety, depression, and dementia, also had severely impaired cognition and was receiving multiple psychotropic medications, including lorazepam. The facility's records for R40 also lacked evidence of a physician-documented rationale for the extended duration of as-needed lorazepam. Staff interviews revealed that the physician reviewed monthly pharmacy reviews and made changes to medication durations but did not document the rationale for the extended use of lorazepam. Observations noted R40 lying in bed with eyes closed, and staff confirmed the absence of documented rationale for the extended use of lorazepam. The facility's policy on antipsychotic drug use required a comprehensive assessment and documentation of the necessity for such medications, including the consideration of non-pharmacologic interventions. However, the facility failed to adhere to this policy, resulting in the lack of documented physician rationale for the extended use of as-needed lorazepam for both residents. This deficiency placed the residents at risk for unnecessary medication administration and potential harmful side effects.
Failure to Ensure Collaboration with Hospice Services
Penalty
Summary
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. The resident had multiple medical diagnoses, including senile degeneration of the brain, Parkinson's disease, dysphagia, memory deficit, left-sided hemiplegia, left-sided hemiparesis, and dementia. The resident's care plan indicated he was on hospice services, but it lacked documentation related to the hospice equipment, medications, services, and scheduled visits from hospice staff. Observations revealed that the resident struggled to reach his drink due to the absence of a properly fitting lap tray for his new Broda chair, which was replaced by hospice. Staff interviews confirmed that the care plans did not include detailed hospice information other than the name of the hospice company. The facility's policy indicated that it would coordinate with the selected hospice agency to provide necessary end-of-life care services. However, the facility did not ensure this coordination, as evidenced by the lack of detailed hospice information in the care plans and the resident's difficulty in accessing his drink due to the ill-fitting lap tray. This deficient practice placed the resident at risk for delayed services and uncommunicated care needs.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Olathe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Healthcare Resort Of Olathe | 2.9 mi | ★★★★★ | 0 | 0 |
| Azria Health Olathe | 3.1 mi | ★★★★★ | 28 | 1 |
| Good Samaritan Society - Olathe | 3.2 mi | ★★★★★ | 10 | 0 |
| Hoeger House | 3.3 mi | ★★★★★ | 0 | 0 |
| Aberdeen Village | 4.8 mi | ★★★★★ | 7 | 0 |
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