Evergreen Nursing & Rehab Center
EVERGREEN NURSING & REHAB CENTER in EFFINGHAM, IL — inspection on October 17, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Definition: Change in condition is defined as an improvement or decline in the resident's physical,
physical or medical condition, this includes, A.
Accident involving the resident; B.
Deterioration on
existing form of treatment due to adverse consequences or to commence a new form of treatment; 5.
The resident's designated medical contact or guardian will also be notified.
145628 10/17/2025
Evergreen Nursing & Rehab Center 1115 North Wenthe Effingham, IL 62401
concerned. At 12am, (V10, Registered Nurse)) came in to relieve me and I informed her of what I
nursing measure because resident refused to eat, I gave her a glucagon pen to bring sugar up. At 1am
contact me at home if resident became worse and I would return to the facility. I spoke with the resident, she informed me that I told her I gave the wrong insulin, I had not told her that. I then explained that I thought I might have when I was giving (R3) his Tresiba but was not sure. I realized I did when her sugar continues to drop significantly. (R1) was very upset with me at this point. I went home and (V10) called and explained the resident was very upset with me.
She also let me know (R1) sugar was good. I texted (V2, Director of Nurses, and V3, Assistant Director of Nurses), regarding the event and explained all that had transpired. I then went into the facility in the morning to explain.
This note is a result of that meeting with (V2 and V3).On 10/15/25 at 10am, R1 was alert and oriented to person and place but not time. R1 stated on 9/30/25, around 8pm, V5 gave her 30 units of fast acting insulin instead of 30 units of the long-acting insulin that was prescribed. R1 stated she is not sure if V5 told her this or not, but she knows it's true because her blood glucose bottomed out shortly after receiving the insulin. R1 stated her blood sugar stabilized during the morning hours of 10/1/25. R1 stated she has not seen V5 since then and she thinks V5 was fired.On 10/16/25 at 10:20am, V2 stated R1's glucose has been historically difficult to control and at times it dips below the normal range. V2 stated given the glucose's rapid drop, it is likely R1 got the wrong insulin. V2 stated staff closely monitored R1 during the early morning hours, and if R1's glucose had gotten critically low, staff would have gotten an order to send R1 to the Emergency Room. V2 stated the next morning at 9am, staff notified V4 (Physician) of the error.On 10/16/25 at 11:45am, V4 stated his understanding of the medication error is that R1 received 30 units of fast acting insulin instead of 30 units of long-acting insulin as ordered. V4 stated staff gave R1 food and got her glucose level stabilized during the night, and R1's status was then baseline.A facility policy titled Preventing and Detecting Adverse Consequences and Medication Errors (undated) stated, G.
The attending Physician is notified promptly of any significant error or adverse consequence.
Facility staff monitor the resident for possible medication related adverse consequences, including mental status and level of consciousness, when the following conditions occur: 6.
Medication error example given, wrong or expired medication.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.