Evercare Of Breese

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include: R5's Undated Face Sheet documents he was initially admitted to the facility on [DATE]. R5's Quarterly Minimum Data Set (MDS) dated [DATE] documents he is alert. On 9-17-2025 10:35 AM V10, Former LPN stated she received a text message on her personal cell phone on 9/6/2025 which included V1 Administrator, V3 ADON and V24 RNC and it had R5's first and last name and documented detailed health information regarding R5 which she felt was not appropriate to communicate via cell phone text message because it is not secure or encrypted and it's a HIPPA/privacy violation. V10 stated the text message was initiated by V3. V10 stated she responded to the text message immediately, Please delete my name and do not message me again. Probably shouldn't put HIPAA information with an employee you banned from your facility. An undated text message sent at 12:21 PM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. R1's Undated Face Sheet documents she was initially admitted to the facility on [DATE] with diagnosis including anxiety disorder, major depressive disorder, bipolar disorder and panic disorder. R1 was covered by Med A benefits. R1's Hospital Discharge Paperwork, dated 8/7/2025, documents continue these medications which included Austedo XR 24 milligrams (mg) take 48 mg by mouth daily for treatment of depression and Vraylar 3 mg 1 capsule by mouth daily for treatment of depression. R1's Physician's Summary Report, dated 8/7/2025 documented do not send on Austedo XR 24 milligrams (mg) 2 tablets by mouth a day for treatment of depression and Vraylar 3 mg give 1 capsule by mouth once a day for treatment of depression. R1's Medication Administration Record (MAR), dated 8/2025, documents no Austedo 48…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. He had a small osculating fan sitting on his over the bed table blowing directly on him. The room was warm and stuffy. R2's room did not have any air…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include: Facility Assessment Tool undated documents under staff RN minimum of 12 hours per day. Facility's January 2025 Nursing Schedule documents that the facility did not have an RN (Registered Nurse) working on 01/01/25, 01/02/25, 01/04/25, 01/05/25, 01/15/25, 01/16/25, 01/17/25, 01/18/25, 01/19/25, and 01/24/25. On 01/29/25 at 12:50 PM, V2, DON (Director of Nursing) stated that in January, the facility did not have an RN working every day. She stated that the facility did hire a new RN that started January 22nd. On 01/31/25 at 9:58 AM, V1, Administrator supplied a paper that stated (Facility Name) staffs Nurses and CNAs to State and Federal requirements and resident needs. Resident Census and Conditions of Residents dated 01/28/25 documents a census of 77 residents residing in the facility.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings include: R18's Face Sheet, with a print date of 07/17/24, documented R18 has a diagnosis of but not limited to enterocolitis due to clostridium difficile. R18's Minimum Data Set (MDS), dated [DATE], documented R18 is cognitively intact with a Brief Interview for Mental Status (BIMS) of 14 out of 15, and requires assistance with his activities of daily living (ADL). R18's Progress Notes, dated 7/2/2024 at 5:41 PM, documented R18 was admitted to the local hospital with pneumonia and C-diff. On 07/17/24 at 11:02 AM, V21, Certified Occupational Therapy Assistant (COTA) was in R18's room on the north end of the 100-hall doing therapy with him using exercise bands. V21 was observed not wearing a gown or gloves. She also was observed to have an over the bed table with her computer,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to provide complete incontinence care for 4 of 6 residents (R1, R4, R6, R7) reviewed for incontinent care in a sample of 19. Findings include: 1. R6's Care Plan, dated 4/18/22, documents (R6) has an ADL (activity of daily living) deficit related to weakness, removal of R (right) hip, no weight bearing and confusion due to dx (diagnosis) of Dementia. (R6) is unable to communicate her needs to staff. It continues Toileting: (R6) is incontinent of B&B (bowel and bladder). Ensure (R6) is clean and dry by checking on her every 2-3 hours and prn (as needed) when she is hollering out or restless. (R6) is resistive when receiving peri care from staff. It also documents (R6) is always incontinent of bowel and bladder. Staff check (R6) at least every 2 hours. Provide peri care when needed and change. With last revision date 11/29/21. It continues Clean peri-area with each incontinence episode. INCONTINENT: Check every 2-3 hours and prn for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure call lights were within residents' reach and easily accessible for 2 of 5 residents (R13, R28) reviewed for accommodation of needs in a sample of 19. Findings include: 1. R13's Face Sheet, with a print date of 11/17/22, documents R13 has diagnoses of Parkinson's Disease, and Multiple Fractures of Pelvis with Stable Disruption of Pelvic Ring, Initial Encounter for Closed Fracture. R13's Minimum Data Set (MDS), dated [DATE], documents R13 is moderately cognitively impaired, and requires extensive assistance, 2 plus person physical assist with bed mobility, dressing, toilet use, and personal hygiene. She also requires 2 plus person physical assist with transfer. R13's Care Plan, with an admission date of 08/05/22, documents The resident has an Activities of Daily Living (ADL) self-care performance deficit. It further documents TOILET USE: The resident is able to: extensive assistance of two staff members. TRANSFER: The resident is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review the Facility failed to ensure hand hygiene was performed prior to and during a Peripherally Inserted Central Catheter (PICC) dressing change as well as while providing incontinent care to prevent the spread of infection for 3 of 12 residents (R18, R6, R34) reviewed for infection control in the sample of 19. Findings include: 1. R18's Physician's Orders dated 11/10/2022 documents, Change PICC dressing weekly on Mondays and PRN (as needed) if it becomes loose, soiled or moist. On 11/15/2022 at 11:06 AM, V12, Registered Nurse (RN) picked up a bag of medication from the medication storage area and entered R18's room to administer R18's Intravenous (IV) medication. R18 was observed with a PICC line located in R18's left arm. The transparent dressing was soiled with blood underneath. V12 stated she is going to change R18's dressing. Without the benefit of hand hygiene, V12 applied nonsterile gloves and proceeding to pick up a plastic bag from the bottom of the trash can. V12 then began removing R18's PICC line dressing. V12 touched the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.