Deficiency Records for Evergreen Community of Johnson County
Updated as of April 01, 2024
A list of the most recent deficiencies for Evergreen Community of Johnson County. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-03 | 2023-09-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-27 | 2022-12-15 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-10-26 | 2022-11-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-10-26 | 2022-11-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-10-26 | 2022-11-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-10-26 | 2022-11-28 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-10-26 | 2022-11-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-26 | 2022-11-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-26 | 2022-11-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-19 | 2022-10-31 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-19 | 2022-10-31 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-09-19 | 2022-10-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-19 | 2022-10-31 | Y |
| 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. | Health | 2022-09-19 | 2022-10-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-19 | 2022-10-31 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-09-19 | 2022-10-31 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-19 | 2022-10-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-19 | 2022-10-31 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-09-19 | 2022-10-31 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-19 | 2022-10-31 | Y |
| 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. | Health | 2022-09-19 | 2022-10-31 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-19 | 2022-10-31 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-19 | 2022-10-31 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-29 | 2021-05-21 | N |
| 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. | Health | 2021-04-29 | 2021-05-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-29 | 2021-05-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-04-29 | 2021-05-21 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-04-29 | 2021-05-21 | N |
| 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. | Health | 2021-04-29 | 2021-05-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-29 | 2021-05-21 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2020-03-05 | 2020-03-20 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-03-05 | 2020-03-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-03-05 | 2020-03-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-05 | 2020-03-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-03-05 | 2020-03-20 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-03-05 | 2020-03-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-05 | 2020-03-20 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-12-14 | 2019-01-07 | N |
