Olathe, KS

Evergreen Community Of Johnson County

3-star overall rating with 3-star inspections with $22,913 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle

11875 S Sunset Drive, Suite 100, Olathe, KS

(913) 477-8227

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1996-01-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.79

Registered nurse staffing · state 0.72 · national 0.68

LPN hours / resident day

0.78

Licensed practical nurse staffing · state 0.67 · national 0.87

Aide hours / resident day

3.40

Nurse aide staffing · state 2.69 · national 2.35

Total nurse hours

4.96

All reported nurse hours · state 4.07 · national 3.89

Licensed hours

1.56

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

4.23

Weekend nurse staffing · state 3.58 · national 3.43

Weekend RN hours

0.58

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.04 · national 0.07

Adjusted RN hours

0.85

CMS adjusted RN staffing hours

Adjusted total hours

5.36

CMS adjusted total nurse staffing hours

Case-mix index

1.27

Higher values indicate more complex resident acuity

RN turnover

55%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

50%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

2,152

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

51.43

Composite VBP score used to determine payment impact.

Payment multiplier

1.0058

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

3.35

Baseline 53.92% · Performance 50.00% · Measure score 3.35 · Achievement 3.35 · Improvement 0.85

Adjusted total nurse staffing

6.94

Baseline 4.50 hours · Performance 5.05 hours · Measure score 6.94 · Achievement 6.94 · Improvement 3.83

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	Not Available	1.02	Too few residents or stays to report publicly.
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 11 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	19.74%	8.2% 11.5 pts better	Numerator 30 · Denominator 152
Staff flu vaccination coverage	56.92%	42% 14.9 pts better	Numerator 148 · Denominator 260
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.8	1.8 About the same	1.9 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.2 · Expected 1.3 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.8	2.2 0.4 pts better	1.8 About the same	Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.4 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	88.4%	91.8% 3.4 pts worse	93.4% 5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 86.8% · Q3 80.3% · Q4 86.7% · 4Q avg 88.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	98.8%	95.5% 3.3 pts better	95.5% 3.3 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8%
Percentage of long-stay residents experiencing one or more falls with major injury	5.9%	4.4% 1.5 pts worse	3.3% 2.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 5.3% · Q3 6.6% · Q4 8.0% · 4Q avg 5.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	6.8%	5.6% 1.2 pts worse	11.4% 4.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 10.6% · Q3 3.0% · Q4 6.3% · 4Q avg 6.8%
Percentage of long-stay residents who lose too much weight	5.8%	5.0% 0.8 pts worse	5.4% 0.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 3.5% · Q3 9.4% · Q4 1.8% · 4Q avg 5.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	23.2%	23.2% About the same	19.6% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.3% · Q2 28.1% · Q3 22.2% · Q4 24.6% · 4Q avg 23.2%
Percentage of long-stay residents who received an antipsychotic medication	9.8%	19.8% 10 pts better	16.7% 6.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.5% · Q3 14.3% · Q4 8.7% · 4Q avg 9.8% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	25.6%	18.4% 7.2 pts worse	16.3% 9.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 38.0% · Q3 28.9% · Q4 8.8% · 4Q avg 25.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	22.5%	18.8% 3.7 pts worse	14.9% 7.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 20.4% · Q3 24.0% · Q4 24.1% · 4Q avg 22.5% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	2.3%	1.8% 0.5 pts worse	1.0% 1.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.3% · Q3 1.3% · Q4 3.5% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	8.3%	3.1% 5.2 pts worse	1.7% 6.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 10.5% · Q3 4.0% · Q4 9.5% · 4Q avg 8.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	28.6%	23.2% 5.4 pts worse	19.8% 8.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 26.6% · Q3 34.6% · Q4 28.8% · 4Q avg 28.6%
Percentage of long-stay residents with pressure ulcers	2.2%	4.6% 2.4 pts better	5.1% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.7% · Q3 2.6% · Q4 0.7% · 4Q avg 2.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	43.4%	75.6% 32.2 pts worse	81.7% 38.3 pts worse	Short Stay · 2024Q4-2025Q3 · 4Q avg 43.4%

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-05-01 · Fire 2024-05-01

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

7 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2022-09-19 · Fire 2022-09-19

14 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

7 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2021-04-29 · Fire 2021-04-29

8 health deficiencies

Top issue: Pharmacy Service (3 deficiencies)

7 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-05-01

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2024-04-12

F · Potential for more than minimal harm 2024-05-01

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-05-02

F · Potential for more than minimal harm 2024-05-01

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-04-12

F · Potential for more than minimal harm 2024-05-01

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-05-01

F · Potential for more than minimal harm 2024-05-01

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-04-12

F · Potential for more than minimal harm 2024-05-01

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-05-02

E · Potential for more than minimal harm 2024-05-01

K325 · Smoke Deficiencies

Fire Safety

Have properly installed hallway dispensers for alcohol-based hand rub.

Corrected 2024-04-12

F · Potential for more than minimal harm 2022-09-19

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2022-11-28

F · Potential for more than minimal harm 2022-09-19

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2022-11-28

F · Potential for more than minimal harm 2022-09-19

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2022-11-28

F · Potential for more than minimal harm 2022-09-19

K901 · Electrical Deficiencies

Fire Safety

Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.

Corrected 2022-11-28

F · Potential for more than minimal harm 2022-09-19

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-11-28

E · Potential for more than minimal harm 2022-09-19

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2022-11-28

E · Potential for more than minimal harm 2022-09-19

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-11-28

F · Potential for more than minimal harm 2021-04-29

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2020-03-20

F · Potential for more than minimal harm 2021-04-29

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2020-03-20

F · Potential for more than minimal harm 2021-04-29

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2020-03-20

F · Potential for more than minimal harm 2021-04-29

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2020-03-20

F · Potential for more than minimal harm 2021-04-29

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2020-03-20

E · Potential for more than minimal harm 2021-04-29

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2020-03-20

E · Potential for more than minimal harm 2021-04-29

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2020-03-20

Inspection history

Recent health citations

G · Actual harm 2024-05-01

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-05-31

F · Potential for more than minimal harm 2024-05-01

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-05-01

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-05-01

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-05-01

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-05-01

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2024-05-31

D · Potential for more than minimal harm 2024-05-01

F849 · Administration Deficiencies

Health

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.

Corrected 2024-05-31

G · Actual harm 2023-10-03

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-09-29

E · Potential for more than minimal harm 2022-09-19

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-10-31