Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review, the facility failed to coordinate services between the facility and
resident's oncology provider for one of one resident (R3) reviewed for coordination of services to provide
quality of care in the sample of 8.
Residents Affected - Few
Findings include:
R3's Care Plan, dated 10/10/2024, documents R3 is to have an individualized plan of care while at the
facility. Staff to follow individualized plan of care to meet resident's needs. R3's Care Plan does not address
her blood cancer or her seeing an oncologist, V8.
R3's Report of Consultation, dated 6/24/24, documents Reason for Consultation: increase platelets.
Findings: Increase platelets, splenomegaly, and weight loss. Diagnosis Increase platelets, probably ET
(Essential Thrombocythemia). Recommendations: Add 2-3 cans of Boost or equivalent between meals,
check Jak-2 mutation, continue ASA (aspirin).
Testing.com website, documents the Jak2 Mutation test is used To help diagnose bone marrow disorders
known as myeloproliferative neoplasms (MPNs) in which bone marrow produces too many or one or more
types of blood cells.
R3's Progress Note, 6/24/2024 at 3:51 PM, documents Res returned from (V8's), Oncologist, with findings
of increase platelet counts, lab called with critical findings of 783 platelet count, (V10) MD notified.
R3's Progress Note, dated 6/26/2024 at 8:52 PM, documents (V15, Nurse Practitioner), responded r.t
(related to) R3 platelets for V10 to address at this time either via fax or at facility during his next rounding
date. MUM (memory unit manager) (V16, Memory Unit Manger), aware. F/U (follow up) required in r.t
results for further action required regarding plan of care moving forward.
R3's Progress Note, dated 6/28/2024 at 10:46 AM, documents Spoke with MUM r/t high platelets &
possible Hospice Referral. MUM to address this.
R3's JAK-2 Lab Results, not dated, documents lab collected 7/2/2024 at 5:05 AM. Received 7/3/2024 at
3:50 AM. Reprinted 7/12/2024 10:30 PM. A date of 7/15/204 located at the bottom right corner with no
context given. A stamp Scanned Date/Initials with unrecognizable date and initials. It also documents that
R3 is positive for Jak-2.
R3's Progress Note, dated 8/15/2024 at 11:17 PM, documents MD responded to fax sent regarding inquiry
on if resident is currently seeing a hematologist specialist at this time d/t (due to) elevated H
(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 5
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
10/31/2024
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Platelet count. MD responded with new orders to have resident be referred to see a hematologist specialist
for a consultation regards to lab results at this time. MUM notified r/t consult needing to be scheduled for
specialist to be implemented on behalf of resident's account. F/U needed once appointment has been
scheduled regarding this matter for time and date & w/ whom.
R3's Progress Note, dated 8/20/2024 at 2:55 AM, documents Critical High Platelet level of 1167 called in
from Lab. MD notified. NNO. MD wants res seen by Hematologist soon, questioning when appointment is.
R3's Progress Notes, dated 8/20/2024 at 11:15 AM, documents Writer called (V8's) office,
Oncology-Hematology, to schedule an appointment to be seen regarding the resident's recent critical
platelet levels. Appointment has been scheduled for September 9th at 1:45PM at (City medical clinic) as the
earliest available appointment.
R3's Progress Note, dated 9/15/2024 at 10:43 AM, documents Nurses Note Text: Resident has
appointment with hematology/oncology (V8) on September 27th, 2024, at 1:45 p.m.
R3's Progress Note, dated 9/27/2024 3:17 PM, documents Nurses Note Text: (V8's) office called and
scheduled a follow up appointment for after labs are drawn (they are waiting insurance approval).
Appointment will be October 25th, 2024, at 10:30 a.m. Schedule person for facility notified.
R3's Progress Note, dated 10/22/2024 at 11:20 PM, documents Nurses Note Text: F/U appointment with
(V8) 10/25 @ (at) 1:45pm.
R3's Progress Note, dated 10/24/2024 at 1:57 PM, documents Progress Note Text: rec'd (received) call
from (V8's) office inquiry if resident had [NAME] 2 lab drawn. Stated resident must have the lab drawn prior
to appt. Resident had a scheduled appointment for 10/25. F/U with office and asked would it be possible for
lab to be drawn there. Nurse was unaware since resident resides at nursing home. Advised resident may
have to be sent out to hospital to have drawn since (Lab) or (lab) does not draw this lab. Contacted (local
hospital) lab - Labs do not require an appointment will draw JACK 2 lab and it would be sent out. (V8) office
would like a f/u regarding if and when the lab will be drawn. Appointment for 10/25/24 has been canceled
and need rescheduled.
On 10/29/2024 at approximately 3:00 PM V3, Assistant Director of Nursing (ADON), provided
documentation, dated 6/24/2024, that documents that Res returned from V8, Oncologist/Hematologist, with
report of increase platelets, lab reported platelet count of 783. Please advise.
On 10/29/2024 at 10:58 AM V5, V8's Oncology Registered Nurse, stated that R3 is a patient since August
2023. V5 stated that R3 has Myeloproliferative which is a rare blood cancer. V5 stated that R3 has not been
seen by physician at the oncology office because the ordered lab work has not been completed. V5 stated
that a Jak-2 lab was ordered on 6/24/2024. V5 stated that R3 was seen in the office when the lab was
prescribed, and the order was sent with the resident and paper sent back to facility. V5 stated that the
treatment for R3's diagnosis is Hydroxyurea. For this medication to be ordered and be effective the lab
needs to be completed for dosing. This medication would decrease R3's platelet counts and prevent a
stroke. This lab and medication are imperative. V5 stated that she has made multiple attempts to educate
the staff on the importance of the lab and medication and nothing was done. V5 stated that she spoke the
V3, ADON, on October 24th and stressed the importance of this lab and that R3 has not been seen and
treated since June because the facility has not gotten the lab. V5 stated that they received the results with
platelet count critical at 1410 from the hospital on
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145519
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/31/2024
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
October 25th. V5 stated that the have not received anything from the facility. V5 stated that they have called
and talk with multiple people and nothing. V5 stated that at times they were not able to reach anyone. V5
stated that this lab is critical in R3's treatment.
On 10/29/2024 at 1:08 PM V3, Assistant Director of Nursing, stated that she was not aware of the situation
until she received a call from V5, Oncology RN, on October 24th notifying V3 of the lab not being completed
and that it's critical that this lab be completed. V5 stated at that time she made an appointment and sent R3
to the hospital for the lab to be drawn. V3 stated that today she was able to find a lab drawn. V3 stated that
R3 had labs drawn and had an elevated platelet count. V3 stated that at that time R3 was referred to V8's
office by V10. V3 stated that V8's office is a hematology and Oncology office. V3 stated that R3 was seen
on 6/24/24 and with findings of increase platelets, splenomegaly, and weight loss. V3 stated that orders
were received for boost, check Jak-2 mutation, continue ASA. V3 stated that R3 went to hospital and the
Jak-2 lab was drawn. V3 stated that per the lab it was drawn 7/2/2024 and sent off. V3 stated that it takes
about a week for the lab to be completed and results given. V3 stated that the lab then reported the results
to the hospital 7/12/2024 and the facility received the lab 7/15/2024. V3 stated that there is a stamp on the
lab with date and initials. V3 stated that she was not familiar with the initials. V3 stated that she spoke with
V5 and informed her of this today. V3 stated that she was informed that the Oncology office did not receive
the lab. V3 stated that she was unable to find confirmation that the lab was sent to the office or that it was
received by the oncology office.
On 10/29/2024 at approximately 3:00 PM V1, Administrator, stated that they were not able to find
verification that the lab was communicated with the prescribing physician's office.
On 10/30/2024 at 11:26 AM V5 stated that the facility called the office yesterday (10/29/24) and notified
them that they just became aware that the Jak-2 lab was previously drawn and had not notified them.
On 10/30/2024 at 3:37 PM V17, Oncology Nurse, stated that V10 only sees R3 because he is the house
physician. V17 stated that R3 has been a patient of V8 since 2023. V17 stated that V10 does not handle her
platelets that the results and treatment are handled by V8 not V10. V17 stated that V10 is only seeing R3
because he is the house physician.
The facility's Notification of a Change in Resident's Condition, dated 1/15, documents Procedure: 1.
Guideline for notification of physician/responsible party f. Abnormal lab findings.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145519
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/31/2024
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 0773
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the
results.
Based on interview and record review, the facility failed to ensure the Oncologist and the Attending
Physician were notified of a significant lab value for 1 of 8 residents (R3) reviewed for reporting of
laboratory results in the sample of 8.
Findings include:
R3's Report of Consultation, dated 6/24/24, documents Reason for Consultation: increase platelets.
Findings: Increase platelets, splenomegaly, and weight loss. Diagnosis Increase platelets, probably ET
(Essential Thrombocythemia). Recommendations: Add 2-3 cans of Boost or equivalent between meals,
check Jak-2 mutation, continue ASA (aspirin).
R3's Lab Results, not dated, documents lab collected 7/2/2024 at 5:05 AM. Received 7/3/2024 at 3:50 AM.
Reprinted 7/12/2024 10:30 PM. A date of 7/15/204 located at the bottom right corner with no context given.
A stamp Scanned Date/Initials with unrecognizable date and initials.
R3's Progress Note, dated 10/24/2024 at 1:57 PM, documents Progress Note Text: received call from (V8's,
Oncology Physician) office inquiry if resident had [NAME] 2 lab drawn. Stated resident must have the lab
drawn prior to appt. Resident had a scheduled appointment for 10/25. F/U (follow up) with office and asked
would it be possible for lab to be drawn there. Nurse was unaware since resident resides at nursing home.
Advised resident may have to be sent out to hospital to have drawn since (Lab) or (lab) does not draw this
lab. Contacted (local hospital) lab - Labs do not require an appointment will draw JACK 2 lab and it would
be sent out. (V8) office would like a f/u regarding if and when the lab will be drawn. Appointment for
10/25/24 has been canceled and need rescheduled.
On 10/29/2024 at 10:58 AM V5, Oncology Registered Nurse, stated that R3 is a patient since August 2023.
V5 stated that R3 has Myeloproliferative which a rare blood cancer. V5 stated that R3 has not been seen by
physician because ordered lab work has not been completed. V5 stated that a Jak-2 lab was ordered
6/24/2024. V5 stated that R3 was seen in the office when the lab was prescribed, and the order was sent
with the resident and paper sent back to facility. V5 stated that the treatment for R3's diagnosis is
Hydroxyurea. For this medication to be ordered and be effective the lab needs to be completed for dosing.
This medication would decrease R3's platelet counts and prevent a stroke. This lab and medication are
imperative. V5 stated that she has made multiple attempts to educate the staff on the importance of the lab
and medication and nothing was done. V5 stated that she spoke the V3, ADON, on October 24th and
stressed the importance of this lab and that R3 has not been seen and treated since June because the
facility has not gotten the lab. V5 stated that they received the results with platelet count critical at 1410
from the hospital on October 25th. V5 stated that the have not received anything from the facility. V5 stated
that they have called and talk with multiple people and nothing. V5 stated that at times they were not able to
reach anyone. V5 stated that this lab is critical in R3's treatment.
On 10/29/2024 at 1:08 PM V3, Assistant Director of Nursing, stated that she was not aware of the situation
until she received a call from V5, Oncology RN, on October 24th notifying V3 of the lab not being completed
and that it's critical that this lab be completed. V5 stated at that time she made an appointment and sent R3
to the hospital for the lab to be drawn. V3 stated that today she was able to find a lab drawn. V3 stated that
R3 had labs drawn and had an elevated platelet count. V3 stated that at that time R3 was referred to V8's
office by V10. V3 stated that V8's office is a hematology
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145519
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145519
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/31/2024
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 0773
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
and Oncology office. V3 stated that R3 was seen on 6/24/24 and with findings of increase platelets,
splenomegaly, and weight loss. V3 stated that orders were received for boost, check Jak-2 mutation,
continue ASA. V3 stated that R3 went to hospital and the Jak-2 lab was drawn. V3 stated that per the lab it
was drawn 7/2/2024 and sent off. V3 stated that it takes about a week for the lab to be completed and
results given. V3 stated that the lab then reported the results to the hospital 7/12/2024 and the facility
received the lab 7/15/2024. V3 stated that there is a stamp on the lab with date and initials. V3 stated that
she was not familiar with the initials. V3 stated that she spoke with V5 and informed her of this today. V3
stated that she was informed that the Oncology office did not receive the lab. V3 stated that she was unable
to find confirmation that the lab was sent to the office or that it was received by the oncology office.
On 10/29/2024 at approximately 3:00 PM V1, Administrator, stated that they were not able to find
verification that the lab was communicated with the prescribing physician's office.
On 10/30/2024 at 11:26 AM V5 stated that the facility called the office yesterday and notified them that they
just became aware that the Jak-2 lab was previously drawn and had not notified them.
The facility's Notification of a Change in Resident's Condition, dated 1/15, documents Procedure: 1.
Guideline for notification of physician/responsible party f. Abnormal lab findings.
The facility's Laboratory Tests policy, dated 11/17, documents Procedure: 9. The physician or physician
extender will be promptly notified of abnormal results according to facility policy.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145519
If continuation sheet
Page 5 of 5
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Back to topCitations
2 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.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F773 - The facility must—
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
FAQ · About this visit
Common questions about this visit
What happened during the October 31, 2024 survey of EverVella of White Hall?
This was a inspection survey of EverVella of White Hall on October 31, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at EverVella of White Hall on October 31, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
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
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.