Evergreen Nursing & Rehab: Wrong Insulin Given to Resident - IL
The nurse, identified in inspection records only as V5, administered 30 units of fast-acting insulin to the resident, referred to as R1, instead of the 30 units of long-acting insulin that had been prescribed. The resident's blood sugar, which had been at 75 around 11:40 p.m., dropped to 70 by midnight. V5 gave her a glucagon pen to bring it back up.
At 1 a.m., the sugar had risen to 125. At 1:30 a.m., V5 went home.
The nurse left instructions with the incoming registered nurse to call if the resident got worse. She also sent text messages to the Director of Nurses and Assistant Director of Nurses describing what had happened. She returned to the facility the next morning to explain in person.
The resident's physician was not notified of the error until 9 a.m. on October 1, roughly 13 hours after the wrong insulin was given. The physician later told inspectors that staff gave R1 food during the night and got her glucose stabilized, and that her status returned to baseline.
The Director of Nurses told inspectors on October 16 that R1's glucose had historically been difficult to control. She said the rapid drop made it likely R1 received the wrong insulin, and that staff would have sought an emergency room transfer if the glucose had gotten critically low.
R1, who was alert and oriented when inspectors interviewed her on October 15, said she knew she had received the wrong insulin because her blood sugar bottomed out shortly after the injection. She said she was not certain whether V5 had told her directly, but she believed it was true. She said she had not seen V5 since that night, and thought the nurse had been fired.
The facility's own medication error policy requires prompt physician notification of significant errors. Whether that policy was followed, given the 13-hour gap, was not addressed in the inspection findings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evergreen Nursing & Rehab Center from 2025-10-17 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 23, 2026 · Our methodology
EVERGREEN NURSING & REHAB CENTER in EFFINGHAM, IL was cited for violations during a health inspection on October 17, 2025.
The resident's blood sugar, which had been at 75 around 11:40 p.m., dropped to 70 by midnight.
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.