Evervella of White Hall

Inspectors wroteBased on interview and record review the facility failed to provide fluids on the night shift for 2 of 9 residents (R6, and R9) reviewed for hydration in the sample of 9.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review the facility failed to assist 1 of 4 residents (R3) reviewed for feeding assistance in the sample of 13.

Inspectors wroteBased on interview and record review, the facility failed to investigate and provide progressive interventions to prevent falls for one of 10 residents (R34) reviewed for accidents and supervision in the sample of 62. These failures resulted in R34 sustaining a laceration to the face requiring 5 sutures.

Inspectors wroteBased on Interview, Observation, and Record Review, the facility failed to dispose of expired medications, properly label medications, and to keep food items out of the medication refrigerator reviewed for medication storage and labeling in the sample of 62. This failure had the potential to affect all residents in the facility. The Findings Include: 1. On 8/26/25 at 2:45 PM, the Rehab Medication Room was assessed with the following

Inspectors wroteBased on interview, observation, and record review, the facility failed to perform hand hygiene, wear gloves, and wear Personal Protective Equipment for 4 of 20 residents (R2, R50, R61, R104) reviewed for infection control in the sample of 62.

Inspectors wroteBased on interview and record review, the failed review a urinalysis, complete a McGreer evaluation before notifying the doctor and starting antibiotics for 4 of 9 residents (R5, R14, R57, R61) reviewed for antibiotic stewardship in the sample of 62.

Inspectors wroteBased on interviews, observations and record reviews the facility failed to provide dignity during meals for 2 out of 2 residents, (R49, R96); reviewed for resident rights in a sample of 62.

Inspectors wroteBased on Interview, Observation, and Record Review, the facility failed to follow through on Pharmacist's recommendations, including notifying the physician for medication review for possible changes to antipsychotic, and antianxiety medications for 3 of 5 residents (R1, R8, R9) reviewed for chemical restraints in the sample of 62. The Findings Include:1. R1's admission Record, dated 8/27/25, documents R1 was admitted to the facility on [DATE] with Diagnosis of Acute Respiratory Failure, Atrial Fibrillation (A-Fib), Chronic Kidney Disease (CKD), Congestive Heart Failure (CHF), Osteoarthritis, Obesity, Anemia, Generalized Anxiety Disorder, and Major Depressive Disorder. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to document limited range of motion for 2 of 20 residents (R23, R61) reviewed for Minimum Data Set accuracy in the sample of 62.

Inspectors wroteBased on interview, observation, and record review, the facility failed to initiate a Care Plan for 2 of 20 residents (R23, R61) reviewed for Care Plans in the sample of 62.

Inspectors wroteBased on interviews, observation and record reviews the facility failed to provide feeding assistance for 1 out of 1 residents (R34); reviewed for Quality of Life in a sample of 62.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide range of motion for 2 of 2 residents (R23, R61) reviewed for contractures in the sample of 62.

Inspectors wroteBased on Interview, Observation, and Record Review, the facility failed to follow through with the Pharmacist's Medication Regimen Review (MRR), including notifying the physician and obtaining any medication changes as ordered for 3 of 5 residents (R1, R8, R9) reviewed for resident's MRR in the sample of 62. The Findings Include: 1. R1's admission Record, dated 8/27/25, documents R1 was admitted to the facility on [DATE] with Diagnosis of Acute Respiratory Failure, Atrial Fibrillation (A-Fib), Chronic Kidney Disease (CKD), Congestive Heart Failure (CHF), Osteoarthritis, Obesity, Anemia, Generalized Anxiety Disorder, and Major Depressive Disorder. R1's Minimum Data Set (MDS), dated [DATE], documents R1 is cognitively intact. R1's Physician Order (PO), dated 6/30/25, documents Escitalopram Oxalate Oral Tablet 5 MG Give 1 tablet by mouth in the morning related to Major Depressive Disorder. [...]

Inspectors wroteBased on interview and record review, the failed to notify the Physician to clarify the continued need for an antibiotic for 2 of 7 (R14, R57) reviewed for medications in the sample of 62.

Inspectors wroteBased 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 19 of 19 residents (R3, R22, R24, R25, R27, R34, R36, R45, R51, R66, R71, R72, R76, R84, R89, R92, R95, R98, R99) reviewed for resident living space in the sample of 62 . 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 19 of 19 residents (R3, R22, R24, R25, R27, R34, R36, R45, R51, R66, R71, R72, R76, R84, R89, R92, R95, R98, R99) reviewed for resident living space in the sample of 62 .

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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%.

Inspectors wroteBased 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.

Inspectors wroteBased on interview, observation, and record review, the facility failed to prevent resident to resident abuse for 5 of 22 residents (R17, R19, R33, R36, R208) reviewed for abuse in the sample of 58.

Inspectors wroteBased on interview, observation, and record review, the facility failed to place a date on vial when a multi-use medication vial was opened, failed to maintain the medication refrigerator at the proper temperature, and failed to maintain a clean refrigerator and not store food in the medication refrigerator. This failure has the potential to affect 37 residents living in the Memory Unit.

Inspectors wroteBased on interview, observation, and record review, the facility failed to report an allegation of abuse to the Administrator immediately for 2 residents (R18, R36) reviewed for abuse in the sample of 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete injury report, investigate an injury, and implement identified interventions for one of five residents (R20) reviewed for falls in the sample of 58.

Inspectors wroteBased 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 24 of 24 residents (R6, R9, R12, R13, R17, R19, R26, R32, R33, R34, R35, R39, R48, R56, R58, R63, R68, R71, R73, R77, R85, R91, R93, R207) reviewed for resident living space in the sample of 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement broad based testing or contact tracing and implement infection control to prevent the spread of COVID infection. This has the potential to affect all 103 residents at the facility.