Federal inspectors documented the November 16 incident at EverVella of White Hall during a complaint investigation. The resident, identified as R3 in the report, has Parkinson's disease with dyskinesia and severe psychotic symptoms from major depression.
At 7:34 AM, R3 sat before a full breakfast: scrambled eggs, a muffin, fruit loops cereal, juice, water, a Coke can, and both white and chocolate milk. Her left arm and hand shook extremely as she attempted to grab and use her spoon. She couldn't manipulate the utensil.
Eight minutes later, someone pushed her untouched plate aside.
At 7:48 AM, a registered nurse asked R3 why she wasn't eating. "I can't get my silverware," R3 replied. The nurse placed R3's spoon in the cereal bowl and walked away.
R3's food remained untouched. She fidgeted with the Coke can and water glass, touching them and attempting to grab them but unable to drink.
At 7:57 AM, a staff member who serves as both human resources coordinator and certified nursing assistant asked R3 to eat and offered to get her something else. The worker asked if R3 would like a banana, then walked away and returned with one, cutting it in half and placing it on R3's plate.
R3 held the spoon that remained in the cereal bowl, attempting to use it. She held the spoon straight up and down in the bowl, unable to scoop up any cereal. The staff member walked away without helping.
Twelve minutes later, at 8:09 AM, R3 still held the spoon straight up and down in the cereal bowl. Her plate remained untouched. She hadn't managed to get a single bite of cereal.
At 8:13 AM, R3 grabbed the banana half, leaned over her plate, and pushed the banana against the plate. She managed to take two bites.
Eight minutes later, she had a portion of the muffin in her hand and took one bite.
At 8:24 AM, the facility administrator approached and encouraged R3 to eat but offered no physical assistance.
Finally, at 8:25 AM, the registered nurse sat with R3 and provided physical assistance for her to eat the cereal. This occurred 51 minutes after R3 had first sat down for breakfast.
The resident's care plan documents her need for setup and cleanup assistance for dining. Her assessment shows she requires supervision and touch assistance for toileting, partial to moderate help with hygiene, and assistance with position changes and toilet transfers.
During interviews on November 20, both the administrator and the registered nurse acknowledged that staff should assist residents who need help eating. "If someone needs assistance with eating staff should assist them," the administrator told inspectors. The nurse said, "If someone is struggling to eat staff needs to assist the resident."
The facility's Activities of Daily Living policy, dated July 15, states that appropriate care and services will be provided for residents unable to carry out daily activities independently, including dining support and assistance.
Federal inspectors found the facility failed to provide adequate feeding assistance, documenting minimal harm or potential for actual harm. The violation occurred despite clear evidence of R3's physical limitations from Parkinson's disease, which causes the tremors and movement difficulties that prevented her from feeding herself.
The inspection was conducted in response to a complaint. R3 was one of four residents reviewed for feeding assistance in a sample of 13 residents examined during the investigation.
The 47-minute period during which R3 struggled to eat while staff provided minimal intervention illustrates the gap between the facility's stated policies and actual care delivery. Despite multiple staff interactions with R3 during breakfast, meaningful assistance came only after she had spent nearly an hour attempting to feed herself with severely limited success.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evervella of White Hall from 2025-11-21 including all violations, facility responses, and corrective action plans.