Evergreen Nursing & Rehab Center
Inspection Findings
F-Tag F0580
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
the error was discovered. V4 stated normally the facility does a good job keeping him updated about his residents.An undated Preventing and Detecting Adverse Consequences and Medication Errors Policy dated 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.A Change in Condition Policy dated February 2012 documented, It is the policy of (the facility) that resident change in condition will be assessed promptly and follow up activity will occur as appropriate and in a timely manner. Definition: Change in condition is defined as an improvement or decline in the resident's physical, mental, or psychosocial status that affects two or more activities of daily living. Procedure: 4. The residents primary Physician or designated alternative will be notified of any change in resident's physical or medical condition, this includes, A. Accident involving the resident; B. Deterioration on health mental, or psychosocial status; C. Need to alter treatment (in example, need to discontinue an 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.
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/17/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evergreen Nursing & Rehab Center
1115 North Wenthe Effingham, IL 62401
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0760
F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
resulting in resident receiving scheduled Tresiba 30u I then gave her medications. I proceeded to gather the other residents' medications and administer, when I got to (Resident R3), he also received Tresiba at bedtime at this time it triggered a memory that I believed I gave (Resident R1) the wrong insulin. At approximately 11:30pm I asked to see her blood sugar again and it had dropped to 135, I became concerned. At 12am, (V10, Registered Nurse)) came in to relieve me and I informed her of what I believed I had done. (V10) then went into (Resident R1) room and checked blood sugar and it had fallen to 70. I had checked it at approximately 11:40pm and it was
- 75. Her sugar was dropping significantly, as a nursing measure because resident refused to eat, I gave her
a glucagon pen to bring sugar up. At 1am her sugar had risen to 125, when I left facility at 1:30am her sugar was 141. I spoke with (V10) to 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 (Resident R3) his Tresiba but was not sure. I realized I did when her sugar continues to drop significantly. (Resident 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 (Resident 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, Resident R1 was alert and oriented to person and place but not time. Resident 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. Resident 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. Resident R1 stated her blood sugar stabilized during the morning hours of 10/1/25. Resident R1 stated she has not seen V5 since then and she thinks V5 was fired.On 10/16/25 at 10:20am, V2 stated Resident 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 Resident R1 got the wrong insulin. V2 stated staff closely monitored Resident R1 during the early morning hours, and if Resident R1's glucose had gotten critically low, staff would have gotten an order to send Resident 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 Resident R1 received 30 units of fast acting insulin instead of 30 units of long-acting insulin as ordered. V4 stated staff gave Resident R1 food and got her glucose level stabilized
during the night, and Resident 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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EVERGREEN NURSING & REHAB CENTER in EFFINGHAM, IL inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EFFINGHAM, IL, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from EVERGREEN NURSING & REHAB CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.