Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
EVERGREEN NURSING & REHAB CENTER
EFFINGHAM, IL · 120 certified beds · Last Life Safety survey October 18, 2024
CMS Certification Number 145628 · first certified July 1989
Ownership
Operated by HELIA HEALTHCARE · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IL
17 citations — more than 56% of the 666 certified nursing homes in IL. Compared within IL rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 6 citations; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (September 2025 to November 2025), and past the point by which nine in ten IL facilities have been surveyed. This facility’s last Life Safety survey was October 2024. Facilities in IL are typically surveyed 11–13 months after the last one (median 12), measured over 759 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
6 of the 17 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
3 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 17 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in IL, and nationally. Surveyors differ markedly between states, so the IL figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 17 |
| Median facility in IL | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 29, 2022 | 6 |
| September 1, 2023 | 5 |
| October 18, 2024 | 6 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2024-10-18 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2024-10-18 |
| E-0024 | Establish policies and procedures for volunteers. | 1 | 2023-09-01 |
| E-0026 | Establish roles under a Waiver declared by secretary. | 1 | 2023-09-01 |
| E-0041 | Implement emergency and standby power systems. | 1 | 2024-10-18 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2022-09-29 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2022-09-29 |
| E-0025 | Create arrangements with other facilities to receive patients. | 1 | 2024-10-18 |
What the citations cover
- Emergency Preparedness Deficiencies 6
- Smoke Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Miscellaneous Deficiencies 3
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 6 |
| Smoke Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 18, 2024 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (November 4, 2024) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (November 4, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (November 9, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 9, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 4, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 4, 2024) |
September 1, 2023 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (September 25, 2023) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (September 25, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (September 25, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (September 25, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (September 25, 2023) |
September 29, 2022 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (October 9, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (October 24, 2022) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 24, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 24, 2022) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (October 24, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 24, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.