Evergreen Health and Rehab: Expired Insulin, Unsecured Narcotics - GA
The pen had already been used. One hundred eighty units of insulin were gone.
Inspectors documented the finding on September 4, 2025, during a complaint investigation at the facility on Moran Lake Road. What they found across two days of observations went well beyond one unlabeled pen.
On the South Hall long medication cart, inspectors found five separate insulin problems at once. A Tresiba pen had expired on August 21, 2025, two weeks before inspectors arrived. A Lantus vial had been opened on July 18 and expired on August 18, more than two weeks before the inspection. A Lispro vial had been opened and used but had no date written on it at all, making it impossible to know when it had expired. A second Lispro vial had been opened July 30 and expired August 27. And two additional insulin vials, one Lantus and one Lispro, were sitting on the cart unrefrigerated despite labels that said they were to be refrigerated until opened.
The nurse working that cart, identified in the report as LPN 8, confirmed the findings herself. She told inspectors the insulins were expired and should not have been used. She also said insulin should be refrigerated until opened. Both of those things were true. Neither had been done.
Insulin loses potency when it expires. A resident with diabetes who receives degraded insulin may not get the blood sugar control their physician intended. The consequences can range from elevated glucose levels to a diabetic crisis, depending on the resident's condition and how far outside the therapeutic range their blood sugar climbs. None of that is theoretical for residents whose insulin was coming from vials that had been expired for weeks.
The narcotic storage problems ran alongside the medication failures, separate in kind but similar in character: things that were supposed to be secured, weren't.
On September 3, inspectors walked through the South Hall medication room with LPN 7. The refrigerator was unlocked. Inside it sat the facility's narcotic lock box, which contained five vials of lorazepam, a controlled substance used to treat anxiety and agitation. The lock box itself was locked. But it was not attached to anything. It was sitting loose inside an unlocked refrigerator. LPN 7 confirmed both facts to the inspector on the spot.
The refrigerator had other problems. The shelves on the door were dirty. The floor of the refrigerator was dirty. There was a yellowish sticky substance on the surfaces. LPN 7 confirmed that too.
Fifteen minutes later, inspectors walked through the North Hall medication room with LPN 5. The same situation: refrigerator unlocked, narcotic lock box inside, not affixed to the shelf. That box held twelve vials of lorazepam. LPN 5 confirmed the lock box was not secured to the shelving.
Lorazepam is a Schedule IV controlled substance, meaning it carries recognized potential for abuse and dependence. The concern inspectors flagged in their report was diversion, the possibility that narcotics stored in an unsecured, unanchored box inside an unlocked refrigerator could be accessed by someone who shouldn't have access, whether a staff member, a visitor, or a resident. An unaffixed lock box inside an unlocked refrigerator is not meaningfully secured. Anyone who could open the refrigerator could pick up the box.
The facility's own written policy, dated June 2018, said controlled medications were to be stored in a locked drawer or compartment designated for that purpose. The policy dated February 2020 said injectable medications dispensed by pharmacy would be discarded thirty days after the initial dose or according to the manufacturer's recommended discard date, and that the date of first use would be written on the medication. The nurse would check the expiration date before administering it. No expired medications would be given to a resident.
Those policies described a system. What inspectors found was the system not operating.
On September 5, the Assistant Director of Nursing told inspectors that insulins should not be used after the expiration date and that the medication room refrigerators were supposed to be locked. There was no indication in the report that the ADON disputed any of the findings. The statement read less like a defense than a confirmation.
The inspection covered four medication carts total. Problems were found on two of them. It covered two medication room refrigerators. Problems were found on both of them.
The unlabeled insulin pen on the South Hall short cart is worth sitting with. A pen with 180 units of insulin already administered from it, no name, no date, no expiration marking. The nurse who pulled medications from that cart every day didn't know whose pen it was. She didn't know who had been using it. She could only guess, based on which resident was prescribed that type of insulin, that the doses had probably gone to R17.
Probably.
That's the word that describes the level of certainty around what a nursing home resident had been receiving, in their body, for an unknown period of time, from an unlabeled vial that nobody could account for.
The inspection report classified the overall harm level as minimal harm or potential for actual harm. That classification reflects the regulatory framework inspectors use, not a judgment that nothing bad happened. It means inspectors did not document an actual adverse outcome tied directly to these findings, not that the practices were safe. Expired insulin administered to a diabetic resident for an unknown number of days, from a pen no one could trace, produces a harm level that becomes visible only when something goes wrong.
Whether something went wrong for R17 is not something the inspection report addresses. The report ends where the documentation ends.
What it does document is a medication room refrigerator with a yellowish sticky substance on its shelves, a controlled substance lock box sitting loose and unanchored inside it, twelve vials of a sedative in a box on the other hall that anyone with access to an unlocked refrigerator could have lifted out, and a cart full of insulin vials, some expired for weeks, some with no dates at all, still in rotation.
LPN 8 said the expired insulins should not have been used. She was right. They should have been pulled before they expired, or caught on a check before any dose was drawn. The facility's own policy required nurses to verify expiration dates before administering any medication.
The pen with 180 units already gone had no date, no name, and no expiration. There was no way to verify anything about it. Someone had used it anyway.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evergreen Health and Rehabilitation Center from 2025-09-05 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 24, 2026 · Our methodology
EVERGREEN HEALTH AND REHABILITATION CENTER in ROME, GA was cited for violations during a health inspection on September 5, 2025.
One hundred eighty units of insulin were gone.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.