Cycle 1
Health 2024-10-18 · Fire 2024-10-18
3 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Effingham, IL
Evergreen Nursing & Rehab Center
4-star overall rating with 4-star inspections with $10,358 in total fines with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1115 North Wenthe, Effingham, IL
(217) 347-7121
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
46
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Helia Healthcare
Operator or chain grouping
Approved since
1989-07-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 3 overall / 3 health / 1 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.56
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.49
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.76
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
2.81
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.04
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.60
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
2.81
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,346
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
20.71
Composite VBP score used to determine payment impact.
Payment multiplier
0.9824
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.06
Baseline 22.50% · Performance 21.10% · Measure score 2.06 · Achievement 0.72 · Improvement 2.06
Healthcare-associated infections
5.48
Baseline 9.71% · Performance 6.89% · Measure score 5.48 · Achievement 3.16 · Improvement 5.48
Total nurse turnover
0.74
Baseline 70.37% · Performance 64.71% · Measure score 0.74 · Achievement 0 · Improvement 0.74
Adjusted total nurse staffing
0
Baseline 2.72 hours · Performance 2.24 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.98% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 11.39% · Lower 95% interval 7.53% |
| Discharge to community | 49.45% |
50.57%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 44.12% · Lower 95% interval 38.54% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 51 · Denominator 51 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 51 |
| Discharge self-care score | 45.83% |
53.69%
7.9 pts worse
|
Numerator 22 · Denominator 48 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 24 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 1.96% |
2.29%
0.3 pts better
|
Numerator 1 · Denominator 51 · Adjusted rate 1.68% |
| Healthcare-associated infections requiring hospitalization | 6.89% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 6% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 47 |
| Staff flu vaccination coverage | 26.67% |
42%
15.3 pts worse
|
Numerator 16 · Denominator 60 |
| Discharge function score | 64.58% |
56.45%
8.1 pts better
|
Numerator 31 · Denominator 48 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 93.55% |
96.28%
2.7 pts worse
|
Numerator 29 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 24.24% |
25.2%
1 pts worse
|
Numerator 8 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
2.0
0.4 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.7 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
2.3
0.7 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.8% |
89.6%
7.2 pts better
|
93.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.3% · Q3 92.9% · Q4 97.6% · 4Q avg 96.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.0% |
91.6%
3.4 pts better
|
95.5%
0.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.3%
0.8 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.4% · Q3 0.0% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 14.9% |
50.3%
35.4 pts better
|
11.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 17.1% · Q3 14.7% · Q4 15.4% · 4Q avg 14.9% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
6.5%
1.1 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 16.7% · Q3 12.1% · Q4 2.9% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.3% |
18.5%
2.2 pts better
|
19.6%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 6.2% · Q3 18.9% · Q4 28.2% · 4Q avg 16.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.1% |
22.8%
7.7 pts better
|
16.7%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 13.3% · Q3 21.2% · Q4 17.1% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.0% |
17.2%
7.8 pts worse
|
16.3%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.2% |
15.0%
6.2 pts worse
|
14.9%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 25.0% · Q3 22.9% · Q4 26.3% · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.1%
1.1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.1% |
1.7%
0.4 pts worse
|
1.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 5.3% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.4% |
21.3%
7.1 pts worse
|
19.8%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 31.0% · Q3 22.3% · Q4 42.1% · 4Q avg 28.4% |
| Percentage of long-stay residents with pressure ulcers | 0.7% |
5.2%
4.5 pts better
|
5.1%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.0% |
68.8%
22.2 pts better
|
81.7%
9.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.6% · Q2 84.7% · Q3 94.5% · Q4 97.4% · 4Q avg 91.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.7% |
14.0%
3.7 pts worse
|
12.0%
5.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.7% · Observed 17.6% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.3%
2.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.1% |
63.0%
25.1 pts better
|
79.7%
8.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.0% |
26.2%
0.8 pts worse
|
23.9%
3.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.0% · Observed 27.9% · Expected 24.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-01 · Fire 2023-09-01
10 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (3 deficiencies)
Cycle 3
Health 2022-09-29 · Fire 2022-09-29
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-10-18
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2024-11-04
F · Potential for more than minimal harm
2024-10-18
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-11-04
F · Potential for more than minimal harm
2024-10-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-11-04
E · Potential for more than minimal harm
2024-10-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-11-09
E · Potential for more than minimal harm
2024-10-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-09
E · Potential for more than minimal harm
2024-10-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-11-04
F · Potential for more than minimal harm
2023-09-01
E24 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2023-09-25
F · Potential for more than minimal harm
2023-09-01
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2023-09-25
F · Potential for more than minimal harm
2023-09-01
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-09-25
F · Potential for more than minimal harm
2023-09-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-25
E · Potential for more than minimal harm
2023-09-01
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-25
F · Potential for more than minimal harm
2022-09-29
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2022-10-09
F · Potential for more than minimal harm
2022-09-29
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-10-24
F · Potential for more than minimal harm
2022-09-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-24
F · Potential for more than minimal harm
2022-09-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-10-24
F · Potential for more than minimal harm
2022-09-29
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-10-24
F · Potential for more than minimal harm
2022-09-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-17
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-10-18
D · Potential for more than minimal harm
2025-10-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-18
G · Actual harm
2025-02-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-23
D · Potential for more than minimal harm
2025-02-25
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-02-28
G · Actual harm
2024-12-20
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-01-10
G · Actual harm
2024-12-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-20
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-10-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-05
F · Potential for more than minimal harm
2023-09-01
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-09-21
F · Potential for more than minimal harm
2023-09-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-09-21
E · Potential for more than minimal harm
2023-09-01
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-09-01
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-09-21
D · Potential for more than minimal harm
2023-09-01
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-09-21
D · Potential for more than minimal harm
2022-09-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-10-03
Penalties and ownership
What sits behind the stars
$10,358
2025-02-25
Fine
Fine · fine $10,358
Fine
Ownership
Miller, Stephen
5% Or Greater Direct Ownership Interest · Individual
Miller, Stephen
Corporate Officer · Individual
Miller, Stephen
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Lakeland Rehab & Healthcare Center
Effingham, IL
4-star overall rating with 4-star inspections with $70,203 in total fines with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Effingham Healthcare & Senior Living
Effingham, IL
1-star overall rating with 2-star inspections with $175,159 in total fines with 20 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Lutheran Care Center
Altamont, IL
5-star overall rating with 4-star inspections with $19,208 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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