Inspection·October 17, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (V5) is unable to recall which insulin she gave. Resident was closely monitored and did not appear to be in any distress. Resident is alert and oriented during this entire situation. (V4) was notified, Medical Director was notified, (V2, Director of Nurses) and (V1, Administrator) notified and (V11) notified and texted to notify. Nurse was wrote up and educated. A written statement from V5 in this investigation documented, Approximately 10pm on 9/30/25 I was at the medication cart getting meds (medications) together for (R1) she was to also get insulin, Tresiba 30u which is a long-acting insulin. During the time of getting medications together, I was interrupted by CNA (Certified Nursing Assistant) multiple times. I got (R1) medications ready along with the insulin. Went into room to get CBG (Capillary Blood Glucose), according to her (trade name continuous monitoring glucose system) her blood sugar was 296, 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 (R3), he also received Tresiba at bedtime at this time it triggered a memory that I believed I gave (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 (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 (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 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 10/15/25 at 11:55am, V11(Power of Attorney for R1) stated he did not find out about the medication error until R1 called him after 11:30am on the morning of 10/1/25. V11 stated he came to the facility before noon on 10/1/25 and confronted V2 about the facility not contacting him when the error was discovered, and V2 did not have a reason as to why he had not been contacted immediately upon discovering the error.On 10/16/25 at 10:20am, V2 (Director of Nurses) stated V11 presented to the facility the morning of 10/1/25 as R1 had informed him of what happened, so staff explained the situation to him in full. V2 stated staff should have notified V4 and V11 at the time the error was discovered. V2 stated on 10/1/25 in the morning hours, R1's blood sugar had stabilized, and no further action was needed and there were no adverse consequences.On 10/16/25 at 11:45am, V4 (Physician) 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. V4 stated he was notified about the error the next morning during office hours. V4 stated he is not sure why the facility did not contact him at the time (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145628 If continuation sheet Page 2 of 5 Printed: 05/15/2026 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 145628 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 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. Event ID: Facility ID: 145628 If continuation sheet Page 3 of 5 Printed: 05/15/2026 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 145628 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer insulin according to physicians' orders for 1 of 9 residents (R1) reviewed for medication errors in the sample of nine.The findings include:R1's Face Sheet documented an admission Date of 6/6/25 and listed Diagnoses including Diabetes Type 2 and Hypertension. The Face Sheet also identified V11 as R1's Power of Attorney.R1's Minimum Data Set, dated [DATE] documented that R1 has no deficits in cognition.R1's Care Plan dated 8/25/25 documented a problem area, Resident is at risk for complications due to Diabetes Diagnosis, with corresponding intervention, Administer meds(medications) as ordered and/or sliding scale.R1's September 2025 Physicians Order Sheet documented orders for Tresiba Flextouch U-100 (insulin degludec) (long acting) insulin pen 100/u (units) per ml (milliliter) administer 30u subcutaneously at bedtime, 7pm to 10pm, and Insulin Aspart (rapid acting) u100 pen give 10 u with meals.R1's Medication Administration Record (MAR) for September 2025 documented that on 9/30/25, R1 received Tresiba Flextouch 30u at bedtime from 7pm to 10pm, with V5, Licensed Practical Nurse, signing off on the administration. The MAR documented that the insulin aspart 3pm to 6pm dose was not administered as R1 refused it. There was no further documentation of the insulin aspart on 9/30/25.R1's Nursing Progress Notes documented the following:10/1/25, 1:04am. Blood sugar alarm at 70. Cranberry sauce given per patient request. Will recheck. A/O (Alert and oriented) x 4 (to person, place, time, and purpose).10/1/25, 1:22am: BS (Blood Sugar) 108. Resident states she is tired. Laying in bed call light in reach. PWD (Pink, Warm, Dry Skin), A/O x4. Resident stated, maybe she gave me too much insulin. Insulin charted as ordered on previous shift. Will continue to monitor.10/1/25, 2:09am: BS 179. Pt (patient) resting comfortably in bed. Arouses easily. PWD. Call (light)in reach.10/1/25, 3:03am: BS 144 currently. Resident resting comfortably in bed with call light in reach. PWD. Arouses easily. will continue to monitor.10/1/25, 4:42am: BS 156 resting comfortably, rouses easily. PWD. Call light in reach.10/1/25, 5:55am: BS 114. Resident resting in bed, arouses easily. PWD. Call light in reach.10/1/25, 9:08am: (V4, Physician) office called a short while ago and updated of resident condition and the thought of resident probably receiving wrong insulin last night at bedtime. Spoke to nurse at office that will pass to (V4). Nurse updated of resident BS and checked every hour and resident remained stable.10/1/25, 1:29pm: Medical Director also made aware and updated earlier as well this morning. Also, (V11, Power of Attorney) was here this morning and updated as well. Resident remains stable at this time and no issues noted. No new orders received from (V4) either at this time. Will continue to monitor.There were no Nursing Progress Notes in R1's chart for 9/30/25.An Incident Report dated 10/1/25 documented, Detailed incident summary: Resident notified staff of not feeling well around 1am. Once checking blood sugar, blood sugar level was 70. Resident was given cranberry juice and checked several times throughout the night. Resident stated to the nurse that came on at midnight that maybe she got the wrong dose of insulin. Staff nurse who is (V5) is unable to recall which insulin she gave. Resident was closely monitored and did not appear to be in any distress. Resident is alert and oriented during this entire situation. (V4) was notified, Medical Director was notified, (V2, Director of Nurses) and (V1, Administrator) notified and (V11) notified and texted to notify. Nurse was wrote up and educated. A written statement from V5 in this investigation documented, Approximately 10pm on 9/30/25 I was at the medication cart getting meds together for (R1) she was to also get insulin, Tresiba 30u which is a long-acting insulin. During the time of getting medications together, I was interrupted by CNA (Certified Nursing Assistant) multiple times. I got (R1) medications ready along with the insulin. Went into room to get CBG (Capillary Blood Glucose) according to her (trade name continuous monitoring glucose system) her blood sugar was 296, Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145628 If continuation sheet Page 4 of 5 Printed: 05/15/2026 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 145628 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 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 (R3), he also received Tresiba at bedtime at this time it triggered a memory that I believed I gave (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 (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 (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. Event ID: Facility ID: 145628 If continuation sheet Page 5 of 5