Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Evervella Of White Hall during CMS and state inspections, most recent first.
Two cognitively intact residents reported that they did not consistently receive water or other fluids during the night shift, with one stating there was nothing to drink from early evening until breakfast and another stating that water was not passed at night. Resident council minutes also documented that water was not being passed on the night shift. The DON stated she expected staff to pass water/fluids at night, and the facility’s hydration policy requires offering sufficient fluids, including between meals, to maintain proper hydration and health.
Failure to keep a resident’s records private and confidential when an LPN took a photo of a narcotic count sheet on a personal phone and printed copies of the MAR and narcotic sheet for her own records. The resident had dementia, severe cognitive impairment, and had died under hospice care. Facility interviews and a prior HIPAA-related report documented that the LPN said she wanted proof of the narcotic count issue and saved the records for herself.
Failure to assist a resident with feeding during breakfast. The resident had Parkinson's Disease with dyskinesia and moderate cognitive impairment, and needed dining assistance per the MDS. During observation, the resident could not manipulate a spoon, had a shaky arm and hand, and repeatedly struggled to eat and drink while staff provided only brief verbal encouragement and limited help. The resident remained unable to eat the cereal until physical assistance was finally provided later.
Failure to Investigate and Implement Fall Prevention Interventions: A resident with dementia, impaired cognition, weakness, and gait difficulty was identified as a high fall risk with prior falls and minor injuries. After being found on the floor bleeding from the head, she required 5 sutures for a facial laceration and had bruising to the hand; staff could not describe specific fall prevention measures beyond moving her closer to the nurse's station, and PT said her last evaluation had been months earlier.
Expired and unlabeled medications were found in medication storage areas, and food items were stored in a medication refrigerator. A TB vial, vitamin B-12, docusate, a lispro insulin pen, and an inhaler were observed with labeling or expiration issues, and an undated Tubersol vial and Med Pass were also found in the refrigerator. The DON stated nurses were expected to date opened meds, discard expired meds, properly label each medication, and keep food items out of the medication refrigerator.
Failure to follow hand hygiene and PPE requirements during resident care. CNAs and an RN/wound nurse were observed not cleaning hands between glove changes, handling food with bare hands, and providing wound care without the required gown and other EBP PPE for residents with wounds and complex medical conditions, including DM, MRSA, and severe cognitive impairment.
A facility failed to review UA/culture results and complete McGreer criteria before notifying the MD and starting antibiotics for several residents under antibiotic stewardship review. Residents with dementia, CKD, and a hx of stroke had urine studies and McGreer evaluations showing UTI criteria were not met, yet antibiotics were ordered and administered; the IP stated the culture should have been reviewed and the MD notified, and that McGreer was often completed after the fact.
Failure to Provide Dignity During Meals: Two residents with severe cognitive impairment and therapeutic diets were observed being fed in a manner that did not maintain dignity. An LPN stood while feeding one resident and then fed another resident while standing, and another LPN also stood while feeding the second resident before getting a chair. The DON stated staff should sit while feeding residents, perform hand hygiene, and not use bare hands to feed food items.
The facility failed to follow through on consultant pharmacist MRRs for 3 residents receiving psychotropic meds, including antipsychotic and antianxiety agents. Pharmacy recommendations for physician review, AIMS monitoring, and lab follow-up were not documented as completed in a timely manner, and the facility could not provide the pharmacist’s recommendations, physician responses, or medication changes for several reviews.
Failure to document limited ROM in MDS assessments for two residents. One resident with cerebral palsy had hand contractures and stated he was not getting arm or hand exercises, while the DON agreed he had limited ROM and the LPN/MDS said the MDS should have reflected it. Another resident with stroke-related hemiplegia/hemiparesis had an MDS that did not note limited ROM, reported she could not move her right side and was not receiving PT or ROM, and her care plan lacked restorative therapy or ROM exercises despite PT discharge instructions for a restorative ROM program.
Failure to develop care plans for two residents with ROM and restorative needs. One resident with CP had contracted fingers and limited arm movement, but the care plan did not include restorative programming or limited ROM. Another resident with stroke-related hemiplegia/hemiparesis had no care plan for ROM or exercises, despite PT discharge instructions for a restorative ROM program and staff reports that no restorative program was currently in place.
Failure to Provide Feeding Assistance: A resident with dementia, abnormal weight loss, and hospice status required partial/moderate help with eating per the MDS and care plan, but was repeatedly observed struggling to use utensils, spilling food, and using her fingers to eat while staff walked away or provided no further assistance. Interviews confirmed that residents who have difficulty eating are expected to be assisted, cued, or prompted.
Failure to provide ROM for two residents with limited mobility and contractures. One resident with cerebral palsy had curled fingers and stated he was not getting arm or hand exercises, while the care plan lacked restorative programming despite OT instructions for a ROM program. Another resident with stroke-related hemiplegia/hemiparesis stated she was not receiving PT or ROM, and the care plan lacked restorative services even though PT had recommended a restorative ROM program; staff reported the program was not set up.
Failure to follow through with pharmacist MRR recommendations affected 3 residents. Pharmacy notes called for physician review, lab monitoring, and quarterly AIMS testing for residents receiving psychotropic and antipsychotic medications, but the facility could not provide the pharmacist’s recommendations, physician responses, or medication changes for several reviews. In one case, AIMS testing and ordered labs were completed months after the pharmacy requests, and in another, the pharmacy raised concerns about hydroxyzine use and requested documentation of the risk-benefit review, but no response could be produced.
Failure to review urine culture results and clarify ongoing antibiotic use for two residents. One resident with dementia and a stroke history received Augmentin after a UA/culture showed low growth of gram negative rods, and another resident with CKD received cefuroxime despite a urine culture showing mixed genital flora not indicative of UTI. An RN/IP stated the MD should have been notified and the antibiotics stopped.
Insufficient resident room space in 3-bed rooms. Surveyors observed that eight rooms each had three beds but provided only 77 sq ft per resident bed, below the required 80 sq ft. Nineteen residents were housed in these rooms, and the Administrator stated that resident compatibility and behaviors are evaluated before placement in a 3-person room; all eight rooms were Medicare/Medicaid certified.
A resident with a rare blood cancer experienced a deficiency in care due to the facility's failure to coordinate with the oncology provider. Despite critical lab findings and the need for a Jak-2 mutation test, the facility did not complete the necessary lab work or communicate results, delaying treatment. The oncologist's office repeatedly stressed the importance of the lab and treatment, but the facility staff failed to act, resulting in a significant delay in the resident's care.
A resident with Myeloproliferative, a rare blood cancer, had a critical lab test ordered to determine treatment dosing. The facility failed to notify the Oncologist and Attending Physician of the lab results, which were crucial for the resident's treatment. Despite multiple attempts by the Oncology RN to stress the importance of the lab, the results were not communicated, delaying the resident's treatment since June. The facility's policy for notifying physicians of abnormal lab results was not followed.
The facility failed to ensure RN coverage for at least 8 consecutive hours a day, potentially affecting all 106 residents. An LPN confirmed the shift timings, but records showed missing RN coverage on specific dates. The administrator attributed this to a new scheduler's misunderstanding of shift timings.
The facility failed to follow proper hand hygiene and medication handling protocols, as an LPN did not sanitize hands before and after glove use and administered medications that had fallen on a cart. Additionally, the facility lacked an effective system to monitor and track infections, with several residents receiving antibiotics for UTIs without meeting criteria, and the infection control log missing organism documentation. The Infection Preventionist was unaware of facility-wide organisms, relying on monthly pharmacy reports.
The facility failed to effectively implement an antibiotic stewardship program, as four residents were prescribed antibiotics for UTIs without meeting clinical criteria, and the infection control log lacked documentation of the organisms involved. The Infection Preventionist/RN was unaware of the organisms present, except on the rehab unit, and tracking was only done monthly. This deficiency contradicts the facility's program requirements for infection tracking and antibiotic use monitoring.
A resident with cognitive impairment was subjected to a physical altercation when another resident, frustrated by repetitive behavior, threw a liquid on them during lunch. Staff interviews revealed the aggressor had a history of irritability and verbal conflicts, and the facility acknowledged insufficient supervision to prevent the incident.
The facility experienced a medication error rate of 8% due to an LPN administering incorrect doses to two residents. One resident received a lower dose of Famotidine than prescribed, while another was given a double dose of Vitamin D3. The errors occurred because the LPN did not adhere to the facility's guidelines requiring multiple checks against the MAR during medication preparation and administration.
The facility did not provide the required 80 square feet of floor space per resident in eight three-bed rooms, affecting 23 residents. These rooms only offered 77 square feet per resident bed, despite being Medicaid certified. The administrator noted that resident compatibility and behaviors are evaluated before room assignments.
Failure to Provide Night-Shift Hydration
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of fluids during the night shift, based on resident interviews, record review, and facility documents. One cognitively intact resident (R6) reported on the morning of 2/23/2026 that she does not always have water at her bedside and that from approximately 6–7 p.m. until breakfast she has nothing to drink. Another cognitively intact resident (R9) reported on 2/24/2026 that water is not passed on the night shift. Resident council minutes from 2/2026 documented that water was not being passed on the night shift. The Director of Nursing (V1) stated on 2/25/2026 that she would expect staff to be passing water and fluids on the night shift. The facility’s 2023 hydration policy states that the facility will offer each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health, and that interventions will be individualized and include offering a variety of fluids during and between meals. These findings show that, despite the facility’s written hydration policy and the DON’s stated expectations, residents reported not receiving water or fluids during the night shift, and resident council documentation corroborated that water was not being passed at night.
Failure to Keep Resident Records Confidential
Penalty
Summary
The facility failed to keep a resident’s personal and medical records private and confidential when an LPN took a photo of R11’s narcotic count sheet on a personal phone and also printed copies of the MAR and narcotic count sheet. R11’s face sheet documented a diagnosis of dementia, the MDS documented severe cognitive impairment, and the nurse’s note documented that R11 had died under hospice care. The report states the LPN said she took the photo to help write a statement about a morphine count discrepancy and deleted the photo later, while another LPN reported that the photo was taken because the narcotic count sheet was wrong and that she wanted proof for her records. The record review and interviews also showed that the DON and other facility leaders were aware of the issue and described it as a math error rather than an actual drug divergence. The facility’s Final Report - Potential HIPPA documented that the LPN was observed making a photocopy of the resident’s narcotic sheet and MAR and stated she was saving them in case she needed proof. The policy in the record required employees to receive training on the secure and confidential receipt, transmission, storage, use, and disclosure of PHI.
Failure to Assist Resident With Feeding During Meals
Penalty
Summary
The facility failed to assist one resident with feeding during breakfast. The resident had diagnoses of Parkinson's Disease with Dyskinesia and Major Depressive Disorder with severe psychotic symptoms, and the Minimum Data Set documented moderate cognitive impairment and the need for set up/clean up assistance for dining, along with other assistance needs for toileting, hygiene, and transfers. During observation, the resident was seated in the dining room with a meal and beverages in front of her, but she was unable to manipulate her spoon, had an extremely shaky left arm and hand, and repeatedly attempted to grasp food and drinks without being able to eat or drink independently. At 7:48 AM, a RN asked why the resident was not eating, and the resident stated, "I can't get my silverware." The RN placed the spoon in the cereal bowl, but the resident still could not scoop cereal. The resident's food remained untouched while staff walked away after brief verbal encouragement and limited assistance, including offering a banana and placing it on the resident's plate. The resident was only able to take a few bites of banana and one bite of muffin after prolonged struggle, and physical assistance with eating the cereal was not provided until 8:25 AM. The Administrator stated that if someone needs assistance with eating, staff should assist them, and the RN stated that if someone is struggling to eat, staff needs to assist the resident.
Failure to Investigate and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to investigate and provide progressive interventions to prevent falls for one resident who was reviewed for accidents and supervision. The resident had diagnoses including dementia, muscle weakness, difficulty walking, and need for assistance with personal care. Her MDS documented that she was rarely or never understood, had memory problems, and had severely impaired cognitive skills for daily decision-making. A fall risk assessment documented that she was a high fall risk and required high fall risk interventions, and the care plan documented prior falls with minor injury and interventions such as redirecting her from crowded spaces and assisting her out of the dining room chair after dinner and with toileting as tolerated. On 6/15/25 at 2:31 AM, staff found the resident on the floor bleeding from her head, observed her at a 90-degree angle on the floor, and noted an actively bleeding wound that could not be measured at the time, along with bruising to the back of her right hand. Later that morning, the facility documented that the resident received 5 sutures for a laceration and had an x-ray of the right hand showing no fracture, with a diagnosis of contusion. During interviews, staff could not state what specific fall prevention measures were in place for the resident beyond moving her closer to the nurse's station, and physical therapy stated the resident's last evaluation was on 1/7/25. The facility's fall reduction protocol required fall risk evaluation on admission and implementation of selected interventions into the plan of care and Kardex.
Expired and Unlabeled Medications Found in Storage Areas
Penalty
Summary
The facility failed to dispose of expired medications, properly label medications, and keep food items out of the medication refrigerator during observation, interview, and record review of medication storage and labeling practices. In the Rehab Medication Room, a TB vial had a sticker showing it was opened on 7/15/25 with instructions not to use it 30 days past that date, and Vitamin B-12 100 MCG and Docusate 100 MG bottles were both expired in 7/2025. The RN/Nurse Manager/Infection Preventionist stated the TB vial in the Rehab Med Room is used mainly for all residents, and the DON stated nurses were expected to properly date opened medications, discard expired medications, properly label each medication, and keep food items out of the medication refrigerator. In the east west medication room, a bottle of Med Pass was observed in the medication refrigerator along with an undated Tubersol vial. On the East Hall medication cart, an oral inhaler for R9 had no label and was not in its box, though the inhaler had R9's last name written on it and the physician order documented Trelegy Ellipta for COPD. On the rehab unit medication cart, a lispro insulin pen was unlabeled and had an expiration sticker showing 7/17/2025. An LPN stated she did not know who the insulin pen belonged to and that it was expired. The facility policy required medications in the refrigerator to be kept in closed, labeled containers or compartments, separated from foods, and required outdated and unlabeled medications to be removed from stock and disposed of properly.
Failure to Follow Hand Hygiene and PPE Requirements During Resident Care
Penalty
Summary
The facility failed to perform hand hygiene, wear gloves, and use Personal Protective Equipment for 4 of 20 residents reviewed for infection control. On 8/26/25 at 9:06 AM, two CNAs entered R50’s room to transfer the resident to bed and check for incontinence; one CNA performed incontinent care but changed gloves twice during the care without hand hygiene in between. The DON later stated that hands should be washed between glove changes. R50’s record documents a diagnosis of dementia. The facility also failed to follow infection control practices during food handling and wound care. During lunch on 8/25/205 at 11:45 AM, a CNA removed a chocolate chip cookie from a bag with bare hands and placed it beside R104’s plate without sanitizing hands or wearing gloves. For R2, who had diagnoses including type 2 DM, CKD, diabetic foot ulcer, osteomyelitis, bacteremia, and MRSA, the wound nurse performed wound care to the right heel and top of foot while an Enhanced Barrier Precaution sign and PPE were available, but only gloves were worn and no gown or other EBP PPE was used. For R61, who had severe cognitive impairment and required substantial to maximal assistance with toileting and transfers, the wound nurse provided care to a right buttock pressure wound without an EBP sign or PPE at the door and without wearing a gown or other PPE; the resident stated staff never put on gowns when they take care of her.
Failure to Review Urine Results and Complete McGreer Evaluation Before Antibiotics
Penalty
Summary
The facility failed to review urinalysis and urine culture results and complete a McGreer evaluation before notifying the physician and starting antibiotics for 4 of 9 residents reviewed for antibiotic stewardship. For R57, who had dementia and a history of stroke, a nurse note documented that UA results were received, the medical director was notified, and Augmentin 875 mg twice daily for 7 days was ordered; the urine culture later showed gram negative rods with growth of less than 10,000 cfu/ml, and the McGreer evaluation dated the same day documented that UTI criteria were not met. The Infection Preventionist stated that no one reviewed the urine culture and notified the doctor, and that the resident should have been taken off the antibiotic. For R14, who had chronic kidney disease, the urine culture showed mixed genital flora and stated these superficial bacteria were not indicative of a urinary infection, yet cefuroxime axetil 250 mg twice daily was ordered and administered for 14 doses; the McGreer evaluation documented that UTI criteria were not met, and the Infection Preventionist stated the doctor should have been notified and the antibiotic stopped. For R5, who had dementia, the urine culture grew Providencia stuartii at greater than 100,000 cfu/ml, but the McGreer evaluation documented that UTI criteria were not met. For R61, who had a history of stroke, a nurse note documented blood in the urine, the physician was called, and UA/C&S orders were received; the McGreer evaluation again documented that UTI criteria were not met. The Infection Preventionist stated the McGreer evaluation should be completed before the doctor is called and that it was often completed after the fact.
Failure to Provide Dignity During Meals
Penalty
Summary
The facility failed to provide dignity during meals for 2 of 2 residents reviewed for resident rights, R49 and R96. R96’s record showed diagnoses including dementia, dysphasia, phobic anxiety disorders, seizures, type 2 DM, and CHF, and her care plan and MDS documented severe cognitive impairment, a mechanically altered diet with nectar-thick liquids, adaptive feeding equipment, and the need for set-up/clean-up assistance with eating. R49’s record showed diagnoses including major depressive disorder, type 2 DM, CKD, and anemia, and his care plan and MDS documented severe cognitive impairment, a mechanically altered diet, and the need for set-up help only or partial/moderate assistance with eating. During observation, an LPN was seen standing while feeding R96, then moved to feed R49 bites of food while still standing. The LPN then instructed another LPN to stand over by R96 and feed her, and that LPN initially stood while feeding R96 before getting a chair after realizing she was being observed. The DON stated staff should sit down while feeding a resident, perform hand hygiene before and between feeding residents, and not use bare hands to feed a resident a food item. A CNA stated that when assisting residents with eating, staff would sit down, perform hand hygiene, and use utensils rather than hands for items such as bread or rolls.
Failure to Follow Through on Psychotropic Medication Reviews
Penalty
Summary
The facility failed to follow through on consultant pharmacist medication regimen review recommendations for 3 of 5 residents reviewed for chemical restraints. The deficiency involved failure to notify the physician and document responses or medication changes related to antipsychotic, antianxiety, and other psychotropic medications, as well as delayed monitoring and lab follow-up tied to those medications. One resident was admitted with diagnoses including acute respiratory failure, A-fib, CKD, CHF, osteoarthritis, obesity, anemia, generalized anxiety disorder, and major depressive disorder. The resident’s record showed orders for escitalopram, memantine, and trazodone for insomnia. Pharmacy notes dated earlier in the year stated that trazodone was due for hypnotic drug and dose evaluation and later referenced physician recommendation, but the facility was unable to provide the pharmacist’s recommendation, the physician’s response, or any medication change. A second resident was admitted with dementia, generalized anxiety disorder, and schizophrenia and had orders for fluphenazine, hydroxyzine, and memantine. Pharmacy notes requested quarterly abnormal movement monitoring for antipsychotic therapy and recommended lab review, including TSH, HbA1c, CMP, and CBC. The resident’s AIMS was completed several months after the pharmacy recommendation, and the requested labs were not drawn until months later. The facility could not provide the pharmacist’s recommendation or the physician’s response. A third resident had diagnoses including cerebral infarction, hemiplegia, schizophrenia, anxiety disorder, bipolar disorder, dementia, and depression, with orders for lorazepam, mirtazapine, olanzapine, and hydroxyzine. Pharmacy notes requested quarterly abnormal movement monitoring for antipsychotic therapy and specifically questioned the routine use of hydroxyzine, asking that the risks and benefits of continued therapy be reviewed and documented. The resident’s AIMS was not completed until months later, labs were drawn months after the pharmacy recommendation, and the facility was unable to provide the pharmacist’s recommendation, the physician’s response, or any medication change.
Failure to Document Limited Range of Motion in MDS Assessments
Penalty
Summary
The facility failed to document limited range of motion for 2 of 20 residents reviewed for MDS accuracy. One resident with a diagnosis of cerebral palsy had an MDS that documented no limited range of motion, but the resident stated he did not get exercises on his arm or hand and reported limited movement in his left arm and hand. The DON agreed the resident had limited range of motion in both hands, and the LPN/MDS stated the MDS should indicate limited range of motion because it would trigger a care plan for ROM. Observation also showed the resident had curled fingers and contracted fingers in both hands. A second resident admitted with diagnoses including cerebral infarction, hemiplegia, hemiparesis, aphasia, acute kidney failure, type 2 DM, atrial fibrillation, anemia, and obesity had an MDS that failed to document limited ROM despite right-sided hemiplegia/hemiparesis and severe cognitive impairment. The resident stated she could not move her right side and did not receive PT or ROM. During observation, staff assisted her from bed to wheelchair without performing ROM or exercises. Her PT discharge summary stated she would benefit from a restorative program for exercises to maintain strength and ROM, with nursing staff trained to perform PROM and AAROM, but the care plan did not document restorative therapy, including ROM or exercises.
Failure to Develop Care Plans for Residents Needing ROM and Restorative Services
Penalty
Summary
The facility failed to initiate comprehensive care plans for 2 of 20 residents reviewed for care plans. For R23, the admission record documented a diagnosis of Cerebral Palsy, and the MDS documented that the resident was cognitively intact and had no limited range of motion. However, the current electronic care plan did not document any restorative programming or limited range of motion. During interview and observation, R23 stated he did not get exercises on his arm or hand and reported limited movement in his left arm; he was observed with 3 curled fingers in the left hand and 2 contracted fingers in the right hand. The DON agreed that R23 had limited range of motion in both arms, and the LPN/MDS stated the MDS should indicate limited range of motion and that a care plan is generated once the MDS is triggered for that condition. For R61, the admission record documented diagnoses including cerebral infarction, hemiplegia, hemiparesis, aphasia, acute kidney failure, type 2 diabetes mellitus, atrial fibrillation, anemia, and obesity. The care plan failed to document restorative therapy, including ROM or exercises, and the MDS failed to document limited ROM despite hemiplegia/hemiparesis to the right side. The resident stated she had a stroke, could not move her right side, was no longer receiving PT, and no one was working with her or doing ROM. The PT discharge summary documented that the resident would benefit from a restorative program for exercises to maintain strength and ROM of both lower extremities, with CNA/nursing staff to perform PROM to AAROM on the right lower extremity and AROM on the left lower extremity. During the investigation, staff observed assisting with transfers but not performing ROM or exercises, and facility staff stated the restorative program had been discontinued and was not currently set up.
Failure to Provide Feeding Assistance
Penalty
Summary
The facility failed to provide feeding assistance for one resident who was admitted with diagnoses including dementia, vitamin deficiency, and abnormal weight loss. The resident’s MDS documented that she was rarely or never understood, had a memory problem, and required partial/moderate assistance from staff for eating. Her care plan identified her as at increased nutritional risk and stated that she was assisted at meals, offered encouragement/cueing as needed, and given finger foods. A progress note also documented that she was dependent on staff to meet ADLs and remained on hospice care services. During observation, the resident repeatedly struggled to eat independently. She was seen unsuccessfully trying to use utensils, putting empty spoons in her mouth, spilling food and melted sherbert, and using her fingers to pick up food from her plate and from the table. Staff were observed walking away after pouring milk into her cereal or talking briefly with her, without providing additional feeding assistance. The resident’s plate was later removed when it was only about 5-10% eaten and without asking if she was done. Interviews with an LPN, CNA, staffing coordinator, administrator, DON, and regional nurse confirmed that residents who have difficulty eating are expected to be assisted, cued, or prompted.
Failure to Provide ROM for Residents With Limited Mobility
Penalty
Summary
The facility failed to provide range of motion services for 2 residents with limited mobility and contractures. One resident with cerebral palsy and cognitive intactness had no restorative programming or limited ROM documented in the care plan, despite an OT discharge summary that established a functional maintenance/range of motion program for bilateral shoulder flexion and abduction and finger extension. During observation, the resident had curled fingers in both hands and stated he did not receive exercises for his arms or hands. Staff gave conflicting statements about whether ROM was being done, with one CNA describing only informal stretching during daily care and another stating she did ROM on the resident’s fingers when on the floor. The second resident had diagnoses including cerebral infarction, hemiplegia, hemiparesis, aphasia, acute kidney failure, type 2 DM, atrial fibrillation, anemia, and obesity, and the MDS documented severe cognitive impairment and substantial/maximal assistance needs. The care plan did not document restorative therapy or ROM, and the MDS did not document limited ROM despite right-sided hemiplegia/hemiparesis. The resident stated she could not move her right side and was not receiving PT or ROM. The PT discharge summary recommended a restorative program for exercises to maintain strength and ROM of both lower extremities, but during the investigation staff observed the resident being assisted from bed to wheelchair without ROM being performed, and multiple staff members stated the restorative program had not been set up or restarted.
Failure to Follow Through With Pharmacist MRR Recommendations
Penalty
Summary
The facility failed to follow through with the consultant pharmacist’s Medication Regimen Review (MRR) for 3 of 5 residents reviewed for MRRs in a sample of 62. For Resident 1, who was admitted with diagnoses including acute respiratory failure, atrial fibrillation, chronic kidney disease, congestive heart failure, osteoarthritis, obesity, anemia, generalized anxiety disorder, and major depressive disorder, the record showed pharmacy notes related to trazodone that required review and response, but the facility was unable to provide the pharmacist’s recommendation, the physician’s response, or any medication change. Resident 1’s record also showed orders for escitalopram, memantine, and trazodone, and the resident was documented as cognitively intact. For Resident 8, admitted with dementia, generalized anxiety disorder, and schizophrenia and documented as cognitively intact, the pharmacy noted the need for an abnormal movement evaluation for antipsychotic therapy and recommended quarterly monitoring. The resident’s AIMS was completed several months after the pharmacy recommendation. The pharmacy also requested recent TSH, HbA1c, CMP, and CBC labs, but the facility could not provide the pharmacist’s recommendation or physician response, and the labs were not drawn until several months later. For Resident 9, admitted with diagnoses including cerebral infarction, hemiplegia, hemiparesis, schizophrenia, anxiety disorder, bipolar disorder, dementia, and depression, the pharmacy noted the need for quarterly abnormal movement evaluation and raised concerns about hydroxyzine use in the elderly, requesting review of the risks versus benefits and documentation of continued therapy. The facility was unable to provide the pharmacist’s recommendation, the physician’s response, or any medication change for multiple pharmacy notes. The resident’s AIMS was not completed until several months after the pharmacy recommendation, and additional pharmacy requests for CMP, HbA1c, and magnesium labs were not completed until months later.
Failure to Review Culture Results and Clarify Ongoing Antibiotic Use
Penalty
Summary
The facility failed to notify the physician to clarify the continued need for antibiotics for 2 of 7 residents reviewed for medications. For one resident with dementia and a history of stroke, a urinalysis result showed a gram negative rod with growth of less than 10,000 cfu/ml, yet an order for Augmentin 875 mg twice daily for 7 days was entered and the resident received 16 doses from 8/3/25 through 8/11/25. The record documents that the urine culture was received and the POA was notified, but there is no documentation that the culture was reviewed with the physician or that the antibiotic was discontinued after the culture result was available. For another resident with chronic kidney disease, the urine culture showed mixed genital flora and stated that these superficial bacteria were not indicative of a urinary infection, with no further organism identification warranted. Despite this result, a physician order was entered for cefuroxime axetil 250 mg twice daily, and the resident received 14 doses from 8/12/25 through 8/19/25. During interview, the RN/Infection Preventionist stated that the doctor should have been notified and the antibiotic stopped. The facility policy on surveillance for healthcare associated infections did not document an antibiotic and culture review, and the antibiotic stewardship policy set standards for antibiotic prescribing practices and review of antibiotic use data.
Insufficient Resident Room Space in 3-Bed Rooms
Penalty
Summary
The facility failed to provide at least 80 square feet of floor space per resident in eight 3-bed resident rooms, affecting 19 residents identified in the sample. Surveyors observed on 08/28/25 that Rooms 51 through 58 each contained three beds and were licensed and available for three residents per room, but historical measurement data showed that each of these rooms provided only 77 square feet per resident bed. The residents living in these rooms were R3, R22, R24, R25, R27, R34, R36, R45, R51, R66, R71, R72, R76, R84, R89, R92, R95, R98, and R99. During interview on 8/28/2024 at 11:48 AM, the Administrator stated that the facility evaluates compatibility and any behaviors a resident may be having before placing them in a 3-person room, and that all eight of the three-bed resident rooms were Medicare/Medicaid certified.
Failure to Coordinate Oncology Care for Resident with Blood Cancer
Penalty
Summary
The facility failed to coordinate services between the facility and a resident's oncology provider, leading to a deficiency in the quality of care for a resident with a blood cancer diagnosis. The resident, who has been diagnosed with Myeloproliferative Neoplasm, a rare blood cancer, was supposed to have an individualized care plan that included coordination with an oncologist. However, the care plan did not address the resident's blood cancer or the need for oncology consultations. Despite critical lab findings indicating elevated platelet counts, the necessary Jak-2 mutation test was not completed in a timely manner, delaying the resident's treatment. The resident's progress notes indicate multiple instances where critical platelet levels were reported, and the need for a hematologist consultation was emphasized. Despite these critical findings, there was a lack of follow-up and coordination between the facility and the oncology provider. The resident's oncologist's office repeatedly attempted to communicate the importance of the Jak-2 lab test and the subsequent treatment with Hydroxyurea, which is crucial for managing the resident's condition. However, the facility staff failed to complete the lab work and communicate the results to the oncologist, resulting in a significant delay in the resident's treatment. Interviews with facility staff and the oncology provider revealed a breakdown in communication and coordination. The Assistant Director of Nursing was unaware of the situation until late October, despite the oncologist's office making multiple attempts to stress the importance of the lab and treatment. The facility was unable to verify that the lab results were communicated to the prescribing physician's office, highlighting a significant lapse in the coordination of care for the resident.
Failure to Notify Physicians of Critical Lab Results
Penalty
Summary
The facility failed to notify the Oncologist and Attending Physician of a significant lab value for a resident diagnosed with Myeloproliferative, a rare blood cancer. The resident had an increase in platelets, splenomegaly, and weight loss, and was recommended to have a Jak-2 mutation test. The lab was collected on 7/2/2024, but the results were not communicated to the Oncologist or Attending Physician. The Oncology Registered Nurse (V5) stated that the lab was critical for the resident's treatment, as it would determine the dosing of Hydroxyurea, a medication necessary to decrease platelet counts and prevent a stroke. Despite multiple attempts by V5 to educate the facility staff on the importance of the lab and medication, the lab results were not communicated, and the resident had not been seen or treated since June. The Assistant Director of Nursing (V3) was unaware of the situation until contacted by V5 on 10/24/2024. V3 then arranged for the resident to be sent to the hospital for the lab to be drawn. The facility received the lab results on 7/15/2024, but there was no confirmation that the results were sent to or received by the Oncology office. The Administrator (V1) confirmed that there was no verification of communication with the prescribing physician's office. The facility's policy requires prompt notification of abnormal lab results to the physician, which was not followed in this case.
Failure to Provide RN Coverage for 8 Consecutive Hours
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for at least 8 consecutive hours a day for 7 days a week, which has the potential to affect all 106 residents residing at the facility. This deficiency was identified through interviews and record reviews. A Licensed Practical Nurse (LPN) confirmed the shift timings, indicating that the day shift runs from 6 AM to 6 PM and the night shift from 6 PM to 6 AM. However, the facility's staff assignments for August, September, and October 2024 showed that on specific dates, there was no documentation of an RN working for 8 consecutive hours. The facility administrator acknowledged the issue, attributing it to a new scheduler who may not understand that a new day starts at midnight, and stated that they follow federal guidelines for RN coverage.
Infection Control and Medication Handling Deficiencies
Penalty
Summary
The facility failed to adhere to proper hand hygiene and medication handling protocols, as observed with a Licensed Practical Nurse (LPN) who did not perform hand hygiene before donning gloves and after removing them. The LPN was seen preparing and administering medications to residents without sanitizing hands, and in one instance, picked up medications that had fallen onto a medication cart with bare hands before administering them to a resident. The facility's policies on hand washing and glove use were not followed, contributing to potential cross-contamination risks. Additionally, the facility did not have an effective system in place to monitor and track infections. Several residents were prescribed antibiotics for urinary tract infections (UTIs) without meeting the McGreer's Criteria for UTIs, and the infection control log failed to document the organisms responsible for these infections. The Infection Preventionist admitted to not being aware of the organisms present in the facility, except for those on the rehab unit, and relied on monthly reports from the pharmacy to track antibiotic use. The facility's Antibiotic Stewardship Program and Surveillance for Healthcare Associated Infections policies were not effectively implemented. The Infection Preventionist acknowledged that the McGreer's Criteria were completed after antibiotics were prescribed, rather than at the onset of symptoms. The Administrator expected staff to track and monitor all infections, but the current practices did not align with the facility's documented procedures for infection tracking and antibiotic stewardship.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of monitoring and tracking of antibiotic use and infections for four residents. These residents were prescribed antibiotics for urinary tract infections (UTIs) without meeting the McGreer's criteria for such infections. The facility's infection control log did not document the specific organisms causing the UTIs for any of these residents. This indicates a failure in the facility's process to ensure that antibiotics are prescribed based on appropriate clinical criteria and that infections are properly tracked and documented. The Infection Preventionist/RN admitted to not knowing the organisms present in the facility, except for those on the rehab unit, and stated that tracking and trending were only done at the end of the month when the pharmacy provided a list of residents on antibiotics. This lack of timely tracking and documentation of infections and antibiotic use is contrary to the facility's own Antibiotic Stewardship Program, which requires tracking the types and locations of infections and using microbiology culture data to guide antibiotic selection. The Administrator expected staff to track and monitor all infections, but this expectation was not met, leading to the deficiency.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to evaluate, monitor, and prevent a physical altercation between two residents, leading to an incident of abuse. One resident, who was cognitively intact, threw a brown liquid on another resident, who was severely cognitively impaired, during lunch. The incident occurred after the resident who threw the liquid expressed frustration with the other resident's repetitive behavior, which was reportedly bothersome to other residents. Staff did not intervene or redirect the behavior of the resident who was perceived as bothersome, leading to the altercation. Interviews with staff revealed that the resident who threw the liquid was known to be grouchy, especially when desiring a smoke, and had a history of verbal arguments with other residents. The staff acknowledged that more supervision should have been provided to prevent such incidents. The facility's undated Abuse Policy emphasized the commitment to protecting residents from abuse and outlined prevention measures, but these measures were not effectively implemented in this case.
Medication Administration Errors Lead to 8% Error Rate
Penalty
Summary
The facility failed to administer medications as prescribed by the ordering physician for two residents, resulting in a medication error rate of 8%. One resident was given 10 mg of Famotidine instead of the prescribed 20 mg twice a day for gastroesophageal reflux disease. Another resident received four Vitamin D3 capsules of 2000 IU each, instead of the prescribed 25 mcg tablets, leading to a double dose. The Licensed Practical Nurse (LPN) responsible for administering these medications did not realize the errors at the time of administration. The facility's guidelines require that medication and dosage be checked against the Medication Administration Record (MAR) at least three times during the preparation and administration process, which was not adhered to in these instances.
Inadequate Living Space in Resident Rooms
Penalty
Summary
The facility failed to provide the required 80 square feet of floor space per resident in eight three-bed resident rooms, affecting 23 residents. These rooms, numbered 51 to 58, were observed to house three residents each, despite only providing 77 square feet per resident bed according to historical measurement data. All these rooms are Medicaid certified. The deficiency was identified during an observation on October 16, 2024, at 9:00 AM. The facility's administrator acknowledged the situation, stating that they evaluate resident compatibility and behaviors before assigning them to a three-person room.
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What surveyors actually found near you
We read the 62 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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 White Hall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Scott County Nursing Center | 8.5 mi | ★★★★★ | 7 | 0 |
| Jerseyville Manor | 21.2 mi | ★★★★★ | 5 | 0 |
| Grove Health & Rehab Ctr, The | 22.2 mi | ★★★★★ | 18 | 1 |
| Evercare Of Calhoun | 22.3 mi | ★★★★★ | 3 | 0 |
| Jacksonville Skld Nur & Rehab | 22.8 mi | ★★★★★ | 2 | 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.