Inspection visit
Inspection
24 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 24 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews, observations, and record reviews the facility failed to evaluate, monitor, and prevent a physical
altercation from occurring for 1 out of 2 residents, (R86), reviewed for abuse in a sample of 68.
Findings include:
R91 was admitted to the facility on [DATE] with diagnosis of, in part, sequelae of cerebral infarction, anxiety
disorder and depression.
R91's Minimal Data Set (MDS) dated [DATE], documented she was cognitively intact.
R86 was admitted to the facility on [DATE] with diagnosis of, in part, unspecified dementia, unspecified
severity and anxiety disorder.
R86's MDS dated [DATE], documented she was severely cognitively impaired.
On 10/15/2024, at 11:00 AM, R91 threw a brown liquid from her mug on R86 while sitting next to each
other for lunch. R86 was sitting to the left of R91 and was visibly soaked by R91's beverage on her right
arm and chest. R86 asked R91 why she would do that. R91 did not answer R86. R86 got up very quickly,
shook her head in disapproval at R91 and then proceed to leave the cafeteria.
On 10/15/24, at 11:10 AM, R66 stated to R91, so you got R86 to leave. R91 responded stating she wanted
R86 to shut up. R66 stated R86 is frequently bothersome to all the residents, she repeats things over and
over and doesn't stop when you ask her to. R66 stated staff do nothing to intervene or redirect R86 from
upsetting the other residents around her. R66 stated R86 gets on everybody's nerves and people just get
tired of it.
On 10/16/24, at 11:03 AM, R86 was in her room. R86's previous shirt was lying on the bed. The front and
sleeve was stained with a brown liquid. R86 stated that she was not hurt from having tea thrown on her but
that she is very mad.
On 10/15/24, at 11:08 AM, R86 returned to her same spot at the table in new clothes. R91 stated the tea
she threw on R86 was not hot.
On 10/15/24, at 11:11 AM, V2, Director of Nursing (DON), was notified of the incident. R91 and R86 were
then separated from sitting at the same table next to each other.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 10
Event ID:
145519
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
145519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evervella of White Hall
620 West Bridgeport
White Hall, IL 62092
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 0600
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
On 10/17/2024, at 9:40 AM, V16, Certified Nursing Assistant (CNA), stated R91 can frequently be grouchy,
especially if she wants to smoke and even refuses care if she is not in a good mood; you have to be careful
with how you approach her.
On 10/17/2024, at 9:45 AM, V3, Social Services, stated R91 likes to hang out in her room a lot and she
loves to smoke. She will occasionally mumble words under her breath when she is irritated with someone or
something. She has depression and anxiety which she takes medications for and is seeing outside
consultant services for psychiatry.
On 10/17/2024, at 9:55 AM, V17, Registered Nurse (RN), stated R91 likes to smoke, it's usually what she
gets up to do and gets irritated easily. V17 stated R91 has had multiple verbal arguments with the other
residents. V17 is not aware of R91 having any friends at the facility.
On 10/17/2024, at 10:00 AM, V18 (CNA) stated R91 will get up just for her smoke breaks. V18 stated R91
will be really sweet one minute but then talking about how much she hates you the next. V18 stated R91
likes to [NAME] a lot and she doesn't have any friends he is aware of at this time. V18 stated R91 had a
relationship with another resident who left a short time ago.
On 10/21/2024, at 9:50 AM, V1, Administrator, acknowledged more staff supervision on R91 and R86
should be occurring to prevent incidents of abuse.
The facility's Abuse Policy, undated, documented, The facility is committed to protecting the residents from
abuse by anyone. The policy further documented a prevention measure to identify, correct, and intervene in
situations in which abuse, neglect and misappropriation of resident property is more likely to occur.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145519
If continuation sheet
Page 2 of 10
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
145519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evervella of White Hall
620 West Bridgeport
White Hall, IL 62092
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 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
Based on interview and record review the facility failed to provide a Registered Nurse (RN) for a least 8
consecutive hours a day for 7 days a week. This failure has the potential to affect all 106 residents residing
at the facility.
Findings include:
On 10/17/24 at 10:30 AM V19, Licensed Practical Nurse, stated that the day shift for nurses was from 6 AM
to 6 PM and the Night shift runs from 6 PM to 6 AM.
The facility's Staff Assignments, for August 2024, September 2024 and October 2024 were reviewed and
on these dates, 8/22/2024, 8/28/2024, 8/29/2024, 9/1/2024, 9/5/2024, 9/12/2024, 9/18/2024, 9/20/2024,
9/23/2024, 9/26/2024, and 10/3/2024, failed to document that there was a RN working the floor for 8
consecutive hours on these days.
On 10/17/24 at 01:05 PM, V1, Administrator, stated that they have a new scheduler and that she may not
understand that a new day starts at 12 midnight and that she did not know if the facility has a policy but
they follow the federal guidelines for RN coverage.
The facility's Long-term Care facility Application for Medicare and Medicaid, dated 10/15/2024, documented
that there was 106 residents residing in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145519
If continuation sheet
Page 3 of 10
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
145519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evervella of White Hall
620 West Bridgeport
White Hall, IL 62092
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 0759
Ensure medication error rates are not 5 percent or greater.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, observation, and record review, the facility failed to administer medications as prescribed by the
ordering Physician for 2 of 6 residents (R83,R103). This failure resulted in a medication error rate of 8%.
Residents Affected - Few
Findings include:
1. On 10/16/24 at 8:15 AM, V12, Licensed Practical Nurse, (LPN), administered 1 Famotidine 10 milligram
(mg) tablet to R103.
R103's admission Record, print date of 10/21/24, documents that R103 was admitted on [DATE].
R103's Order Summary Report, dated 10/21/24, documents, Famotidine Oral Tablet 20 mg. give 1 tablet by
mouth two times a day for GERD. (gastroesophageal reflux disease). Take 1 tablet PO (by mouth) BID
(twice a day).
2. On 10/16/24 at 8:26 AM, V12 administered 4 Vitamin D3 2000IU (international units) 50 microgram (mcg)
capsules to R83.
R83's admission Record, print date of 10/21/24, documents that R83 was admitted on [DATE].
R83's Order Summary Report, dated 10/21/24, documents, Vitamin D3 Oral Tablet 25 mcg. Give 4 tablet by
mouth one time a day related to Vitamin D deficiency.
On 10/16/24 at 2:30 PM, V12, stated that she did not realize she gave the wrong dose of Famotidine to
R103 or that she used the wrong Vitamin D3 capsules to R83 resulting in giving him a double dose of what
the Physician had ordered.
On 10/16/24 at 4:03 PM, V1, Administrator, stated that medication should be given as the Physician orders.
The Medication Administration - general Guidelines, dated 1/15, documents, 18. Prior to administration, the
medication and dosage, schedule on the residents' MAR /TAR (Medication Administration Record /
Treatment Administration Record) is compared to the medication label. Information on the medication
should be checked against the MAR / TAR at least 3 times during the med (medication) preparation and
administration process.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145519
If continuation sheet
Page 4 of 10
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
145519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evervella of White Hall
620 West Bridgeport
White Hall, IL 62092
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview, observation, and record review, the facility failed to perform hand hygiene, discard of
potentially contaminated medications to prevent cross contamination. The facility also failed to have a
system in place to monitor and track infections in the facility for 6 of 10 (R12, R16, R46, R47, R54 and R83)
residents reviewed for infection control in the sample of 68.
Residents Affected - Some
Findings include:
1. On 10/16/24 at 8:26 AM, V12, Licensed Practical Nurse, (LPN), prepared medication to be administered
to R83. V12 obtained Tylenol 2 tablets, 1 tablet Magnesium Oxide 400 milligram (mg), 4 capsules of Vitamin
D3 50 micrograms, and placed them into a medication cup. V12 donned gloves without hand hygiene,
retrieved the Tylenol and Magnesium Oxide tablets, and placed them into a pill pouch so they could be
crushed. V12 crushed the tablets, mixed them with pudding, added the Vitamin D3 capsules, removed her
gloves. V12 then entered R83's room and administered the medications to R83.
2. On 10/16/24 at 8:39 AM, V12 opened R16's morning medication pass packet which include: Metoprolol
50 milligrams (mg), Losartan 100 mg, and hydrochlorothiazide 25 mg all 3 of the medications fell onto the
top of V12's medication cart. V12 with her bare unsantized hands picked up the medications and placed
them into a medication administration cup. V12 entered R16's room and administered the medications to
R16.
On 10/17/24 at 11:00 AM, V1, Administrator, stated that if medication falls onto the medication cart it should
be discarded and not given to the resident. V1 further stated that staff should perform hand hygiene before
putting gloves on and after removing them. V1 stated that the glove policy does not state hand hygiene
before putting on gloves but it should be done.
The policy hand Washing, dated 9/19, documents, Staff will use proper and washing technique to prevent
the spread of infection.
The policy Personal Protective Equipment Using Gloves, dated 2009, documents, 5. wash hands after
removing gloves.
3. R12's physician order, dated 9/9/2024 documented, Macrobid Oral Capsule 100 MG (Nitrofurantoin
Monohyd Macro) Give 1 capsule by mouth two times a day related to URINARY TRACT INFECTION (UTI),
SITE NOT SPECIFIED (N39.0) for 7 Days
R12's physician order, dated 9/18/2024, documented, Keflex Oral Capsule 500 MG (Cephalexin) Give 1
capsule by mouth three times a day for UTI for 5 Days
R12's physicians order, dated 9/24/2024, documented, Bactrim DS Oral Tablet 800-160 MG
(Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for UTI for 5 Days.
R12's McGreers Criteria, undated, documented, UTI criteria not met, for both antibiotic orders.
R12's face sheet, dated 10/21/2024, documented a diagnosis of UTI.
The facility's infection control log, dated 09/2024, did not document the organism for R12's UTI
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145519
If continuation sheet
Page 5 of 10
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
145519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evervella of White Hall
620 West Bridgeport
White Hall, IL 62092
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 0880
4. R46's Physician order, dated 8/13/2024, documented, Obtain UA with C&S if indicated.
Level of Harm - Minimal harm
or potential for actual harm
R46's Physicians order, dated 8/22/2024, documented, Cephalexin Cap 500 MG Give 1 capsule orally two
times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED (N39.0) until 08/29/2024.
Residents Affected - Some
R46's McGreers Criteria, undated, documented, UTI criteria not met.
The facility's infection control log, dated 09/2024, did not document the organism for R46's UTI.
5. R47's Physicians orders, dated 9/10/2024, documented, Levaquin Oral Tablet 500 MG (Levofloxacin)
Give 1 tablet by mouth in the afternoon related to URINARY TRACT INFECTION, SITE NOT SPECIFIED
(N39.0) for 5 Days
R47's Physicians order, dated 9/22/2024, documented, Ciprofloxacin HCl Tablet 500 MG Give 1 tablet by
mouth two times a day for infection related to URINARY TRACT INFECTION, SITE NOT SPECIFIED
(N39.0) for 7 Days
R47's Physician orders, dated 9/4/2024, documented, CBC bmp UA w/c and s one time only for pain while
urinating for 1 Day.
R47's McGreer's Criteria, undated, documeted, UTI criteria not met.
The facility's infection control log, dated 09/2024, did not document the organism for R47's UTI.
6. R54's Physician order, dated 9/5/2024, documented, UA with C&S one time only for altered mental status
for 1 Day
R54's Physician order, dated 9/6/2024, documented, Macrobid Oral Capsule 100 MG (Nitrofurantoin
Monohyd Macro) Give 1 capsule by mouth two times a day for UTI pending UA results for 7 Days Give 1
cap PO BID X 7 days.
R54's McGreer's Criteria, undated, documented, UTI criteria not met.
The facility's infection control log, dated 09/2024, did not document the organism for R54's UTI.
On 10/21/2024 at 10:35 AM, V14, Infection Preventionist/RN, stated that she took over the infection tracking
in June. She continued to state that she did not know what organisms were in the facility except what was
on the rehab unit because she is the unit manger there. V14 stated that she would track and trend at the
end of the month because that was when pharmacy would send her a list of residents and what antibiotics
they were on but prior to that list coming she did not know what organisms were in the facility. She also
stated that the McGreers criteria was completed after the resident was already placed on an antibiotic and
that this should have been filled out when the resident was starting to have signs and symptoms.
On 10/21/2024 at 12:47 PM, V1, Administrator, stated that she would expect that staff track and monitor all
infections in the facility.
The facility's Antibiotic Stewardship Program, dated 10/2022, documented, Tracking: Process measures:
Track types and location of infections, and where the resident is located in the facility. It
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145519
If continuation sheet
Page 6 of 10
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
145519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evervella of White Hall
620 West Bridgeport
White Hall, IL 62092
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 0880
Level of Harm - Minimal harm
or potential for actual harm
continues, Monitoring use: Facility will collect reports summarizing the antibiotic susceptibility patterns. It
continues, Microbiology culture data will be used to assess and guide future antibiotic selection.
The facility's Surveillance for Healthcare Associated Infections, dated 09/2029, documented, 8. Utilize you
surveillance data to: a. Identify infections quickly. It continues, f. Compare unit by unit data.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145519
If continuation sheet
Page 7 of 10
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
145519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evervella of White Hall
620 West Bridgeport
White Hall, IL 62092
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 0881
Implement a program that monitors antibiotic use.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to have an effective antibiotic stewardship program
to monitor and track antibiotic use and infections in the facility for 4 of 4 (R12, R46, R47 and R54) residents
reviewed for antibiotic stewardship/ Infection control in a sample of 68.
Residents Affected - Some
Findings include:
1 . R12's physician order, dated 9/9/2024 documented, Macrobid Oral Capsule 100 MG (Nitrofurantoin
Monohyd Macro) Give 1 capsule by mouth two times a day related to URINARY TRACT INFECTION (UTI),
SITE NOT SPECIFIED (N39.0) for 7 Days
R12's physician order, dated 9/18/2024, documented, Keflex Oral Capsule 500 MG (Cephalexin) Give 1
capsule by mouth three times a day for UTI for 5 Days
R12's physicians order, dated 9/24/2024, documented, Bactrim DS Oral Tablet 800-160 MG
(Sulfamethoxazole-Trimethoprim) Give 1 tablet by mouth two times a day for UTI for 5 Days.
R12's McGreers Criteria, undated, documented, UTI criteria not met, for both antibiotic orders.
R12's face sheet, dated 10/21/2024, documented a diagnosis of UTI.
The facility's infection control log, dated 09/2024, did not document the organism for R12's UTI
2. R46's Physician order, dated 8/13/2024, documented, Obtain UA (urinalysis) with C&S (culture and
sensitivity) if indicated.
R46's Physicians order, dated 8/22/2024, documented, Cephalexin Cap 500 MG Give 1 capsule orally two
times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED (N39.0) until 08/29/2024.
R46's McGreers Criteria, undated, documents, UTI criteria not met.
The facility's infection control log, dated 09/2024, did not document the organism for R46's UTI.
3. R47's Physicians orders, dated 9/10/2024, documented, Levaquin Oral Tablet 500 MG (Levofloxacin)
Give 1 tablet by mouth in the afternoon related to URINARY TRACT INFECTION, SITE NOT SPECIFIED
(N39.0) for 5 Days
R47's Physicians order, dated 9/22/2024, documented, Ciprofloxacin HCl Tablet 500 MG Give 1 tablet by
mouth two times a day for infection related to URINARY TRACT INFECTION, SITE NOT SPECIFIED
(N39.0) for 7 Days.
R47's Physician orders, dated 9/4/2024, documented, CBC (complete blood count) bmp (basic metabolic
panel) UA w/c and s one time only for pain while urinating for 1 Day.
R47's McGreer's Criteria, undated, documented, UTI criteria not met.
The facility's infection control log, dated 09/2024, did not document the organism for R47's UTI.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145519
If continuation sheet
Page 8 of 10
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
145519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evervella of White Hall
620 West Bridgeport
White Hall, IL 62092
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 0881
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
4. R54's Physician order, dated 9/5/2024, documented, UA with C&S one time only for altered mental status
for 1 Day
R54's Physician order, dated 9/6/2024, documented, Macrobid Oral Capsule 100 MG (Nitrofurantoin
Monohyd Macro) Give 1 capsule by mouth two times a day for UTI pending UA results for 7 Days Give 1
cap PO BID X 7 days.
R54's McGreer's Criteria, undated, documented, UTI criteria not met.
The facility's infection control log, dated 09/2024, did not document the organism for R54's UTI.
On 10/21/2024 at 10:35 AM, V14, Infection Preventionist/RN, stated that she took over the infection tracking
in June. She continued to state that she did not know what organisms were in the facility except what was
on the rehab unit because she is the unit manger there. V14 stated that she would track and trend at the
end of the month because that was when pharmacy would send her a list of residents and what antibiotics
they were on but prior to that list coming she did not know what organisms were in the facility. She also
stated that the McGreers criteria was completed after the resident was already placed on an antibiotic and
that this should have been filled out when the resident was starting to have signs and symptoms.
On 10/21/2024 at 12:47 PM, V1, Administrator, stated that she would expect that staff track and monitor all
infections in the facility.
The facility's Antibiotic Stewardship Program, dated 10/2022, documented, Tracking: Process measures:
Track types and location of infections, and where the resident is located in the facility. It continues,
Monitoring use: Facility will collect reports summarizing the antibiotic susceptibility patterns. It continues,
Microbiology culture data will be used to assess and guide future antibiotic selection.
The facility's Surveillance for Healthcare Associated Infections, dated 09/2029, documented, 8. Utilize you
surveillance data to: a. Identify infections quickly. It continues, f. Compare unit by unit data.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145519
If continuation sheet
Page 9 of 10
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
145519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evervella of White Hall
620 West Bridgeport
White Hall, IL 62092
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 0912
Level of Harm - Potential for
minimal harm
Residents Affected - Some
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
Based on observation, interview, and record review, the facility failed to provide 80 square feet of floor
space per resident in eight, 3-bed resident rooms for 23 of 23 residents (R2, R15, R20, R23, R28, R29,
R33, R41, R44, R49, R52, R57, R60, R63, R74, R77, R79, R81, R87, R96, R98, R101, R365) reviewed for
resident living space in the sample of 68.
Findings include:
On 10/16/2024 at 9:00AM, the 8 three-bed resident rooms, (Rooms 51-58) all had three residents residing
in each of these rooms. Each room was licensed and available for three residents per room. According to
historical measurement data, these eight rooms only provide 77 square feet per resident bed.
The following residents reside in these rooms: R2, R15, R20, R23, R28, R29, R33, R41, R44, R49, R52,
R57, R60, R63, R74, R77, R79, R81, R87, R96, R98, R101, R365.
All eight of these three-bed resident rooms are Medicaid certified.
On 10/17/2024 at 9:00AM V1, Administrator, stated We evaluate the compatibility and any behaviors a
resident may be having, prior to putting them in a 3-person room.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145519
If continuation sheet
Page 10 of 10
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Back to topCitations
24 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- 0004GeneralS&S Fpotential for harm
Develop and maintain an Emergency Preparedness Program (EP).
- 0013GeneralS&S Fpotential for harm
Develop Emergency Preparedness policies and procedures.
- 0029GeneralS&S Fpotential for harm
Develop a communication plan.
- 0036GeneralS&S Fpotential for harm
Establish emergency prep training and testing.
- 0037GeneralS&S Fpotential for harm
Establish staff and initial training requirements.
- 0039GeneralS&S Fpotential for harm
Conduct testing and exercise requirements.
- 0133GeneralS&S Fpotential for harm
Install a two-hour-resistant firewall separation.
- 0341GeneralS&S Fpotential for harm
Install a fire alarm system that can be heard throughout the facility.
- 0345GeneralS&S Fpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F711 - Physician Visits
Provide a written emergency evacuation plan.
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
- 0271GeneralS&S Epotential for harm
Have exits that are accessible at all times.
- 0291GeneralS&S Fpotential for harm
Install emergency lighting that can last at least 1 1/2 hours.
- 0311GeneralS&S Epotential for harm
Have an enclosure around a vertical opening shaft.
- 0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
- 0321GeneralS&S Epotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
FAQ · About this visit
Common questions about this visit
What happened during the October 21, 2024 survey of EverVella of White Hall?
This was a inspection survey of EverVella of White Hall on October 21, 2024. The surveyor cited 24 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at EverVella of White Hall on October 21, 2024?
Yes, 24 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.