Evergreen Nursing & Rehab: Wrong Insulin Given to Resident - IL
The resident, identified in the report as R1, was prescribed Tresiba, a long-acting insulin, at bedtime. On the night of September 30, the nurse, identified as V5, gave her 30 units of fast-acting insulin instead. The error went unrecognized until V5 moved on to the next patient.
It was only when V5 reached a second resident, R3, who was also scheduled for Tresiba at bedtime, that something clicked. "It triggered a memory," V5 wrote in a note later summarized in the inspection report, "that I believed I gave R1 the wrong insulin."
V5 checked R1's blood sugar at approximately 11:30 p.m. It had dropped to 135. By midnight, when a registered nurse identified as V10 arrived for the overnight shift, it had fallen to 70. Fifteen minutes before that, at 11:40 p.m., it had been 75. The number was moving in one direction.
Because R1 refused to eat, V10 administered a glucagon pen to bring her glucose back up. By 1 a.m. the reading had climbed to 125. When V5 left the facility at 1:30 a.m., it was 141.
V5 texted the Director of Nurses, V2, and the Assistant Director of Nurses, V3, that night to describe what had happened, then returned to the facility the next morning for a meeting. The written account in the inspection report came out of that meeting.
R1 told inspectors she knew something had gone wrong almost immediately. When interviewed on October 15, she said her blood glucose "bottomed out" shortly after receiving the injection on the evening of September 30. She said her sugar didn't stabilize until the morning hours of October 1. She told inspectors she wasn't certain whether V5 had told her about the error directly, but she knew it was true because of what her body did afterward.
She also said she hadn't seen V5 since that night. She thought V5 had been fired.
The physician, V4, was not notified until 9 a.m. the following morning, roughly nine hours after V5 first suspected the error and at least seven hours after R1's blood sugar hit 70. V4 told inspectors his understanding was that R1 had received fast-acting insulin instead of long-acting, that staff gave her food and stabilized her glucose during the night, and that her status returned to baseline.
The Director of Nurses, V2, acknowledged to inspectors on October 16 that R1's glucose had historically been difficult to control and sometimes dipped below normal on its own. But V2 said the speed of the drop that night made the cause clear. "Given the glucose's rapid drop, it is likely R1 got the wrong insulin," V2 said. V2 added that if R1's glucose had gotten critically low, staff would have sought an order to send her to the emergency room.
That threshold was never reached. But a blood sugar of 70 is the floor of the normal range, and R1 had been falling toward it for at least an hour before anyone administered the glucagon pen.
The inspection was triggered by a complaint. Inspectors cited the facility for a medication error under federal tag F0760, classifying the level of harm as minimal or potential, with few residents affected.
R1 was alert and oriented to person and place when inspectors spoke with her two weeks after the incident. She was not oriented to time. She told them she had not seen V5 since the night of the error, and she believed the nurse was gone.
What she knew for certain was what her blood had told her.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 24, 2026 · Our methodology
EVERGREEN NURSING & REHAB CENTER in EFFINGHAM, IL was cited for violations during a health inspection on October 17, 2025.
The resident, identified in the report as R1, was prescribed Tresiba, a long-acting insulin, at bedtime.
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.