Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evergreen Nursing & Rehab Center during CMS and state inspections, most recent first.
A resident with ESRD, CHF, and acute respiratory failure did not consistently receive timely and complete hemodialysis treatments due to repeated late arrivals and shortened sessions linked to transportation problems, confusion about arrival times, and poor communication between the facility and the dialysis center. Staff at times attempted to cancel or move treatments, did not reliably obtain and document pre‑treatment weights and vitals, and could not reproducibly identify who transported the resident. The nephrologist was not notified of shortened treatments, dialysis communication forms were inconsistently returned, and family concerns about the life‑critical nature of full dialysis were minimized by staff. The resident subsequently developed edema, was treated for possible pneumonia and fluid overload, and was hospitalized with acute hypoxic respiratory failure.
A resident with diabetes received the wrong type of insulin, resulting in hypoglycemia and the need for close monitoring. The LPN involved did not immediately notify the physician or the resident's POA about the medication error, and both were only informed the following morning, contrary to facility policy.
A resident with diabetes was administered the wrong type of insulin by an LPN, resulting in a significant drop in blood glucose levels and requiring close monitoring and intervention. The error occurred after the nurse was interrupted during medication preparation, and the mistake was only realized later. The incident was confirmed by the resident, nursing leadership, and the physician, with documentation showing the resident's blood sugar dropped to a concerning level following the administration.
A resident with severe cognitive impairment and multiple medical conditions sustained a right femoral neck fracture due to improper positioning during a reweighing procedure. The resident's foot hit the scale bar while being pushed in a wheelchair without foot pedals, causing pain. Despite initial assessments showing no abnormalities, later observations revealed grimacing and pain, leading to an x-ray confirming the fracture.
The facility failed to ensure call lights were within reach for three residents, including one with recent hip surgery and moderate cognitive impairment, leading to unmet needs and prolonged periods without assistance. Observations showed call lights placed out of reach for residents with varying levels of cognitive and physical abilities, contrary to facility policy.
Two residents experienced delayed call light responses, leading to incontinence and feelings of embarrassment. One resident reported waiting over an hour, resulting in incontinence in bed, while another faced similar issues with a 45-minute wait. The facility's DON attributed the problem to perception, despite policy requiring prompt responses.
A resident with a femur fracture and chronic pain conditions did not receive timely pain medication, leading to unresolved pain and anxiety. Despite physician orders for pain management, the resident experienced significant delays in receiving medication, resulting in her leaving the facility against medical advice. The night nurse was overwhelmed and did not recall the resident's request for medication, and the facility did not investigate the complaint.
Two residents with fractured femurs and dependent on staff for ADLs reported significant delays in call light responses, leading to incontinence incidents. The DON attributed the issue to residents' perceptions, despite the facility's policy for prompt call light responses. A family member corroborated the delays, and staffing issues were suggested as a contributing factor.
A resident with severe cognitive impairment and multiple diagnoses, including a pressure ulcer, received a dressing change where the LPN failed to change gloves or perform hand hygiene after removing the old dressing, contrary to facility policy. The Assistant Director of Nursing confirmed the lapse in following infection control procedures, and the Administrator expected adherence to these practices.
Failure to Ensure Timely, Complete Dialysis Treatments and Adequate Transportation/Communication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident requiring hemodialysis consistently received timely and complete dialysis treatments in accordance with professional standards of practice. The resident had end-stage renal disease, stage 5 chronic kidney disease, congestive heart failure, and acute respiratory failure with hypoxia, and was care planned as being at risk for complications due to ESRD and hemodialysis. The resident’s MDS documented continuous oxygen use and dialysis treatment, and the resident was cognitively intact with a BIMS score of 15. The dialysis center established a 5:30 a.m. chair time with a required 5:15 a.m. arrival and a 3.5‑hour treatment duration. The dialysis administrator reported multiple instances in March when the resident arrived late and started dialysis between 6:00 and 6:15 a.m., including one date when treatment did not start until 6:53 a.m. and ended at 9:11 a.m., resulting in a treatment of less than three hours. The dialysis administrator stated that facility staff more than once attempted to cancel or move the resident’s treatments and had to be told repeatedly that cancelling or skipping treatments was not an option. The administrator also stated that shortened treatments prevented full removal of toxins from the resident’s blood and that dialysis patients who miss or shorten treatments are at high risk of hospitalization. The resident’s nephrologist confirmed that the facility did not notify him of the shortened treatments, that even 10–15 minutes of missed treatment is clinically significant, and that repeated shortened treatments increase the risk of complications and hospitalization. Facility staff and family interviews revealed confusion and inconsistent practices around transportation and communication for dialysis. The facility administrator acknowledged that there was confusion about the resident’s required arrival time, initially believing 5:30 a.m. was the arrival time rather than the treatment start time, and that there was no dialysis communication book, only forms that were not consistently returned. CNAs and RNs reported issues with the facility van lift malfunctioning, causing late arrivals, and one CNA described general confusion about arrival time and destination. The resident and family members reported repeated lateness to dialysis, staff minimizing concerns, and staff comments characterizing the brother as “dramatic” for insisting on full dialysis treatments. The resident described being stuck in the van and being manually lifted out in his chair by two staff, resulting in a staff fall and a very late arrival to treatment. Documentation further showed gaps in monitoring and recordkeeping related to dialysis care. The facility could not provide reproducible evidence of which staff were responsible for transporting the resident to dialysis appointments. The Continuity of Care Document lacked a pretreatment weight for the resident on one of the key dates when transportation issues occurred, despite the facility’s own posted instructions that weight and vitals must be obtained prior to leaving for dialysis. Progress notes documented that on one date the resident arrived to dialysis at approximately 6:45 a.m. due to transportation issues and would receive only partial treatment. Subsequent notes described mild bilateral lower extremity edema, and emergency room records documented concern for fluid overload and possible pneumonia, with significantly elevated BNP and a diagnosis of acute hypoxic respiratory failure. The facility’s dialysis transfer agreement required the facility to arrange suitable transportation, and its ESRD policy stated that residents with ESRD would be cared for according to recognized standards of care, but the pattern of late and shortened treatments, transportation failures, incomplete communication, and lack of consistent documentation led to the resident experiencing fluid overload and hospitalization.
Failure to Promptly Notify Physician and POA After Medication Error
Penalty
Summary
A medication error occurred involving a resident with diabetes and hypertension, who was prescribed both long-acting and rapid-acting insulin. On the evening in question, the resident received 30 units of insulin, but the nurse administering the medication was interrupted multiple times and later could not recall which type of insulin was given. The resident subsequently experienced a significant drop in blood glucose levels, requiring close monitoring and intervention throughout the night. Documentation shows that the resident was alert and oriented during the incident, and her blood sugar was stabilized after several checks and interventions. Despite the seriousness of the medication error and the resident's change in condition, the facility failed to promptly notify the resident's physician and the resident's Power of Attorney (POA) at the time the error was discovered. The physician was not informed until the following morning during office hours, and the POA only learned of the incident after being contacted by the resident herself later that morning. Interviews with facility staff confirmed that the notifications were not made immediately upon discovery of the error, contrary to facility policy and standard practice. Facility policies require prompt notification of the attending physician and the resident's representative in the event of significant medication errors or changes in condition. The failure to notify both the physician and the POA in a timely manner was confirmed through interviews, record review, and statements from those involved. The deficiency centers on the lack of immediate communication regarding the medication error and the resident's subsequent hypoglycemic episode.
Significant Medication Error: Wrong Insulin Administered
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of Type 2 Diabetes and Hypertension did not receive insulin as prescribed by the physician. The resident was ordered to receive Tresiba (long-acting insulin) 30 units subcutaneously at bedtime and Insulin Aspart (rapid-acting insulin) 10 units with meals. On the evening in question, the LPN responsible for medication administration was interrupted multiple times while preparing medications and subsequently administered the wrong type of insulin to the resident. The medication administration record indicated that the scheduled Tresiba dose was signed off as given, but the resident later experienced a significant drop in blood glucose levels, with readings as low as 70. The resident reported feeling unwell, and nursing staff documented a series of low blood sugar readings throughout the night, requiring interventions such as administration of cranberry juice and glucagon. The LPN later admitted uncertainty about which insulin was administered and recalled the error only after administering insulin to another resident. The incident was further corroborated by statements from the resident, who reported receiving the wrong insulin, and by the DON and physician, who both acknowledged the likelihood of a medication error based on the rapid decline in blood glucose. The facility's policy required prompt physician notification and monitoring for adverse consequences in the event of a medication error, which was not fully documented at the time of the incident.
Improper Positioning Leads to Resident Injury
Penalty
Summary
The facility failed to properly position a resident, leading to an injury. The resident, who had severe cognitive impairment and multiple medical conditions including Alzheimer's disease, osteoarthritis, and osteoporosis, was dependent on staff for mobility and required extensive assistance with activities of daily living. On the day of the incident, the resident was being reweighed due to a previous weight inconsistency. During this process, the resident's right foot made contact with the bar on the scale, causing the resident to express pain. The incident occurred when the resident was being pushed onto the scale in a wheelchair without foot pedals, and the resident's legs were crossed. The Licensed Practical Nurse (LPN) involved in the incident noted that the resident said 'ouch' when her foot hit the bar, prompting the LPN to back up and reposition the wheelchair. An initial assessment showed no visible abnormalities or pain, but later observations revealed the resident grimacing and experiencing pain, leading to an x-ray that confirmed a right femoral neck fracture. Interviews with staff indicated that the resident had been weaker than usual and had complained of hip pain prior to the incident. The Certified Nursing Assistant (CNA) assisting the resident noted the resident's right leg appeared to turn inward, and the resident expressed discomfort when being transferred. Despite these signs, the resident was not adequately monitored or positioned to prevent injury, resulting in the fracture.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three residents, leading to significant issues in meeting their needs. One resident, who had undergone recent hip surgery and had moderate cognitive impairment, was unable to reach her call light during the night. She needed to use the bathroom but was afraid to get up due to her surgery. Despite hearing staff nearby, she did not call out for help, fearing she would be a bother. She eventually called her son for assistance, but he was unable to reach the facility by phone. The resident remained in a wet brief until staff attended to her hours later. Another resident, who was severely cognitively impaired and dependent on staff for transfers, was observed with her call light out of reach while sitting in a recliner. She was unable to access the call light independently, which could have prevented her from requesting assistance when needed. Similarly, a third resident, who was cognitively intact but required supervision for transfers, was found with her call light placed four feet away while she was sleeping in a recliner. The facility's policy requires that call lights be within easy reach of residents, especially when they are in bed or confined to a chair. However, observations and interviews revealed that this policy was not consistently followed, resulting in residents being unable to call for help when needed. This deficiency highlights a failure to accommodate the needs and preferences of residents, particularly those with mobility and cognitive impairments.
Delayed Call Light Response Affects Resident Dignity
Penalty
Summary
The facility failed to treat residents with dignity by not answering call lights in a timely manner, affecting two residents. One resident, who was admitted with a fractured femur and other medical conditions, reported that call lights routinely took over an hour to be answered. This delay led to the resident experiencing incontinence in bed, which she described as humiliating and embarrassing. The resident also mentioned that a CNA had advised her to relieve herself in bed, promising to clean her up later. Another resident, admitted with a fractured femur and other health issues, also reported long wait times for call lights, typically around 45 minutes. This resident, who was dependent on staff for transfers and had been experiencing loose stools, expressed embarrassment over having accidents while waiting for assistance. The resident's family member corroborated these accounts, noting that they had witnessed several such incidents. The facility's Director of Nurses acknowledged the issue but attributed it to residents' perceptions rather than actual delays. The facility's policy on answering call lights emphasized prompt responses, yet the problem persisted, as noted in resident council meeting minutes. The Ombudsman confirmed that complaints about call light wait times were a recurring issue at these meetings.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to formulate a Care Plan to address a resident's pain management needs, resulting in the resident experiencing unresolved excruciating pain from a femur fracture. The resident, who had a history of fibromyalgia, polyneuropathy, depression, and anxiety disorder, was admitted to the facility for rehabilitation following a fall that resulted in a displaced comminuted fracture of the left femur. Despite having physician orders for hydrocodone-acetaminophen and methocarbamol to manage pain and muscle spasms, the resident did not receive these medications in a timely manner, leading to significant pain and anxiety. On one occasion, the resident requested pain medication during the night but did not receive it until several hours later, despite repeated attempts to alert staff using the call light. The resident reported that the delay in receiving medication made her pain more difficult to control and increased her anxiety. The resident's pain was documented as zero at the beginning of the day shift, but she reported it as a ten, indicating a discrepancy in pain assessment and documentation. The night nurse, who was new and overwhelmed, did not recall the resident asking for pain medication, and the facility's Director of Nurses did not investigate the complaint. The resident ultimately left the facility against medical advice due to her dissatisfaction with the care received, particularly the delay in pain management. The facility's Pain Prevention and Treatment Policy emphasizes the importance of assessing and managing pain to help residents maintain their highest practicable level of well-being, which was not adhered to in this case.
Delayed ADL Assistance for Residents
Penalty
Summary
The facility failed to provide timely assistance with Activities of Daily Living (ADL) for two residents who were dependent on staff. One resident, who had a fractured femur and was unable to ambulate, reported that call lights routinely took over an hour to be answered. This resident experienced incontinence while waiting for assistance and was told by a CNA to relieve herself in bed, promising to clean her up later. Another resident, also with a fractured femur and unable to ambulate, reported similar delays in call light response, leading to accidents due to loose stools. This resident's family member corroborated the account of delayed assistance. The Director of Nurses acknowledged the issue but attributed it to residents' perceptions rather than actual delays. The facility's policy on answering call lights emphasized prompt responses, yet the residents' experiences indicated a failure to adhere to this policy. The Director mentioned that complaints had decreased following the departure of a particular CNA, suggesting that staffing issues may have contributed to the deficiency.
Failure to Maintain Aseptic Technique During Dressing Change
Penalty
Summary
The facility failed to maintain aseptic technique during a dressing change for a resident with a pressure ulcer on the left heel. The resident, who had severe cognitive impairment and multiple diagnoses including type 2 diabetes mellitus and congestive heart failure, was observed receiving a dressing change by an LPN and the Assistant Director of Nursing. The LPN did not change gloves or perform hand hygiene after removing the old dressing and before cleaning the wound, which was against the facility's policy and procedure. The LPN acknowledged not changing gloves during the procedure, and the Assistant Director of Nursing confirmed that the facility's policy required changing gloves and washing hands between removing the old dressing and cleaning the wound. The facility's policy on dressing changes clearly outlined the steps for maintaining aseptic technique, which were not followed in this instance. The Administrator also stated that the expectation was for staff to adhere to the facility's infection control practices.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Effingham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeland Rehab & Healthcare Center | 0.7 mi | ★★★★★ | 10 | 0 |
| Effingham Healthcare & Senior Living | 0.9 mi | ★★★★★ | 6 | 0 |
| Lutheran Care Center | 12 mi | ★★★★★ | 7 | 1 |
| Heartland Senior Living | 13.8 mi | ★★★★★ | 4 | 0 |
| The Haven Of St. Elmo | 17.3 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.