Evercare of Breese

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly transfer 4 of 4 (R33, R34, R16, R51) residents reviewed for falls in the sample of 39. This failure resulted in R16 and R34 sustaining fractures.

Inspectors wroteBased on observation, interview, record review, and the facility failed to obtain necessary rehabilitation services for 2 (R40, R76) of 2 residents reviewed in the sample of 39. This failure resulted in R40 and R76 having a decline in function.

Inspectors wroteBased on interview and record review, the Facility failed to ensure sufficient staffing to promote resident safety and highest practical well-being. This has the potential to affect all 80 residents living in the Facility.

Inspectors wroteBased on interview and record review, the Facility failed to ensure call lights were answered in a timely fashion for 5 of 5 residents (R51, R79, R86, R73, R76) reviewed for resident rights in the sample of 39.

Inspectors wroteBased on interview and record review the facility failed to ensure 4 of 4 (R34, R43, R67, R71)) residents reviewed for immunizations in the sample of 38, received the education addressing the benefits and risks and/or had the opportunity to receive Center for Disease Control, CDC recommended immunizations. Findings Include:Review of R34's Face Sheet documents an admission date of 10/13/2023 and documents a birthdate of 3/14/1930. Diagnosis include Brachial Plexus Disorders, Aneurysm of the Ascending Aorta, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease. Review of R43's Face Sheet documents an admission date of 6/2/2024 and birthdate of 3/14/1930. Diagnosis includes Cerebral Infarction, Peripheral Vascular Disease, Chronic Kidney Disease, Hypertension. Review of R67's Face sheet documents an admission date of 6/5/2024 with a birthdate of 11/25/1935. [...]

Inspectors wroteBased on interview and record review, the Facility failed to provide Covid-19 vaccine education and offer Covid-19 vaccination to 5 of 5 residents (R34, R49, R50, R67, R71) reviewed for immunization in the sample of 39.

Inspectors wroteBased on interview and record reviews, the facility failed to revise resident's care plans with progressive interventions for 2 of 8 (R2, R22) residents investigated for falls in a sample of 39.

Inspectors wroteBased on observation, interview, and record review, the facility failed to investigate, recognize, isolate, track/trend and treat a scabies outbreak per current standards of practice for 5 of 5 residents (R1, R2, R6, R7, and R10) in a sample of 13 reviewed for infection control. Applying the reasonable person concept, a reasonable person would have extreme discomfort due to itching and psychosocial distress issues due to anxiety, embarrassment, shame, or even isolation. This failure has the potential to affect all 69 residents residing in the facility. Findings Include:1. R1's Face Sheet, print date of 09/30/25, documented R1 has diagnoses of but not limited to Dementia, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, and transient cerebral ischemic attack. [...]

Inspectors wroteBased on interview and record review the facility failed to follow the privacy policy for 1 (R5) of 3 residents reviewed for privacy in the sample of 3.

Inspectors wroteBased on interview and record review, the facility failed to prescribe physician ordered medications upon admission for 2 (R1 and R3) of 3 residents reviewed for pharmacy services in a sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's rooms are maintained at comfortable temperature for 2 out of 3 residents (R1 and R2) reviewed for homelike and comfortable environment in a sample of 4. Findings Include: 1. R2's Face Sheet, print date of 07/07/25, documented he has diagnoses of but not limited to Chronic obstructive pulmonary disease, obstructive sleep apnea, and Ischemic Cardiomyopathy. R2's Minimum Data Set (MDS), dated [DATE], documented he is cognitively intact with a Brief Interview for Mental Status (BIMS) of 15 out of 15 and he is dependent on staff or requires substantial/maximal assistance with his activities of daily living (ADLs). On 07/02/25 at 1:40 PM, R2 was lying in bed with just a sheet on the lower half of his body. He did not have on any clothing on the upper half of his body. [...]

Inspectors wroteBased on interview and record review the facility failed to properly transfer and use appropriate assistive devices for transfers for 1 of 3 (R2) resident investigated for falls. This failure resulted in R2 sustaining a left knee periprosthetic fracture of the tibial component.

Inspectors wroteBased on observation, interview and record review the facility failed to monitor and treat a suspected deep tissue injury (SDTI) for 1 of 4 (R7) reviewed for pressure ulcers in the sample of 25. This failure resulted in R7 documented as having an SDTI reported as first being observed on 8/20/2024 to the right toe(s) with no skin monitoring or treatments implemented until 10/8/2024. At that time gangrene was present, requiring hospitalization with right second toe amputation on 10/19/2024. Subsequently R7 required additional amputation to her right lower extremity, above the right knee on 11/30/2024. [...]

Inspectors wroteBased on interview and record review the facility failed to insure the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. This failure has the possibility to affect all 77 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision, implement new care plan fall prevention/interventions, and assure current interventions were in place for 2 of 3 residents (R2 and R3) reviewed for falls in a sample of 3. This failure resulted in R2 having an unwitnessed fall and sustaining a fractured hip that required surgery to repair.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their infection control policy and procedure for 1 of 3 residents (R18) who was on contact isolation precautions for Clostridium difficile (C-diff).

Inspectors wroteBased on interview and record review the facility failed to provide pain management for one of three residents (R2) reviewed for pain management in the sample of six. This failure resulted in R2 having to endure increased untreated pain for a prolonged period of time Findings Include: R2's Minimum Data Set, dated [DATE], documented that R2 is cognitively intact. R2's Pain Care Plan, dated 8/8/23, documented, (R2) has complaint of pain at times related to Osteoarthritis. The nursing (staff) monitors his pain each shift and prn (as needed). He (R2) is offered pain medications as per medical doctor orders. On 1/30/24 at 11:30 AM, R2 stated, I hurt a lot. I have to take pain medicine R2's Physicians Order Sheet (POS), dated 12/29/23, documented that R2 was admitted to hospice with a diagnosis of Colon Cancer. [...]