Evergreen Community of Johnson County

In the surveyor’s words

From the most serious findings on record at Evergreen Community of Johnson County, in the surveyor’s own words.

• Actual harm, isolatedF689May 1, 2024

  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. […]

• Actual harm, isolatedF689Oct 3, 2023

  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… […]

• Actual harm, isolatedF689Dec 27, 2022

  The facility identified a census of 70 residents. The sample included three residents. Based on observations, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from accidents when Certified Nurse Aide (CNA) M transferred R1 from R1's wheelchair to the bed alone though R1's plan of care directed a two-person transfer. This deficient practice resulted in R1's right leg getting trapped under the bed and she suffered a fracture that required surgical intervention. […]

• Actual harm, isolatedF689Jan 26, 2021

  The facility reported a census of 78 residents. The sample included six residents reviewed for accidents. Based on observation, record review, and interviews the facility failed to ensure one resident was free from injury when staff failed to provide the necessary services as directed by Resident (R) 1s' plan of care. R1 required physical assistance from two staff members with the Hoyer lift (total body mechanical lift used to transfer residents) to transfer R1 from one location to another safely. The Hoyer lift was used by one staff member to transfer R1 between the bed and Broda (specialized wheelchair with the ability to tilt and recline) chair. […]

• No harm, potential for more than minimal, widespreadF812Feb 25, 2026

  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. […]