Health inspection·November 21, 2025

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain secure medical records for 1 of 4 (R11) reviewed for privacy / confidentiality of records in the sample of 13.Findings include:R11's Face Sheet, print date of 11/20/25, documents R11 was admitted on [DATE] with diagnosis of Dementia. R11's Minimum Data Set, dated [DATE], documents R11 is severely cognitively impaired. R11's Nurses Note, dated 11/16/25, documents R11 passed away under hospice care. On 11/20/25 at 8:10 AM, V33, Licensed Practical Nurse, (LPN), stated I was present when V34 LPN was upset because the narcotic count sheet for R11 was wrong. V34 went through and figured out that it was a math error not an actual drug divergence. V34 took it to V2, Director of Nurses, and wanted him to fix it. V34 was upset because V2 wouldn't fix it immediately. V2 told her he had to do an investigation into it. V34 told me she took a photo on her phone of the narcotic count sheet, a printed copy of the Medication Administration Record (MAR), and a printed copy of the narcotic count sheet. I did not see her leave the building with them, but I did here the printer going off to print the records. On 11/20/25 at 8:14 AM, V34 LPN, stated R11's morphine narcotic count sheet was off. I brought it up to V2. He wanted me to reach out to the nurse that worked prior to me. I called that nurse and told her she needed to come in and fix her mistake. She had made a math error. The amount of morphine in the bottle was correct it was just the narcotic count sheet was off. V2 told me I needed to write a statement for his investigation that he was doing. I took a photo of the narcotic count sheet on my phone. I wanted it to help me write my statement, so I had all the details. This happened on a Friday, and I told V2 I would bring my statement in on Monday. When I got home, I wrote my statement and then I deleted the photo on my phone. The photo did not have R11's name on it. I did not make any paper copies of R11's record and take them home. On 11/20/25 at 8:34 AM, V1, Administrator, stated she is unable to provide the complete investigation because it is in storage since the facility has new owners. When the new owners came in everything previously was boxed up and hauled away. The previous owners tell me they can locate the record and mail a copy to me. On 11/20/25 at 8:34 AM, V2, Administrator, stated staff should not be taking photos of residents' medical record on their phone or copies of the medical record and taking the record home. On 11/20/25 at 11:00 AM, V38, Director of Clinical Operations, stated no employee should take a picture of medical records on their personal phone.The Final Report - Potential HIPPA (Health Insurance Portability and Accountability), dated 9/29/25, documents, On 9/23/25, (V33) reported to (V2) that on 9/12/25 (v34) was observed to make a phot copy of resident (R11's) narcotic sheet and that (V34) stated, I am going to make a copy of the narc (narcotic) count sheet for that patient and keep it for my records. (V33) reported she also observed her printing and making a copy of the MAR and that (V34) stated to (V33), I am saving that too in case I need proof. It continues, (V34) was notified on 9/23/25 to bring any medical records back to the facility that was allegedly taken. (V34) was interviewed on 9/23/25 and reported that she did not take any paper copies of records from the facility but only took a Residents Affected - Few (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 3 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 11/21/2025 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)