Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evercare Of Breese during CMS and state inspections, most recent first.
A scabies outbreak was not properly investigated or controlled, as multiple residents developed persistent rashes and itching over several months without timely diagnostic testing, isolation, or systematic tracking. Staff concerns were not addressed, and infection control protocols were not followed until a staff member was diagnosed with scabies, leading to delayed treatment for all affected individuals.
A resident's protected health information, including their name and detailed medical status, was shared via unsecured text message by an ADON to several staff, including a former LPN who should not have received the information. The message included sensitive details about the resident's confusion, treatment, and risk of sepsis, violating the facility's privacy policy and HIPAA regulations.
Two residents did not receive physician-ordered medications upon admission due to facility staff writing unauthorized notes on medication lists instructing the pharmacy not to send certain high-cost medications. The pharmacist did not fill these prescriptions or complete the required high-cost medication forms, and no alternative medications were provided. Administrative and clinical leaders were unaware of this practice, and the nurse practitioner confirmed that staff did not have the authority to withhold prescribed medications.
Two residents with significant medical conditions experienced uncomfortably high room temperatures due to non-functioning air conditioning and lack of vents in their rooms. Staff and residents reported the environment as hot and stuffy, with only hallway vents available and minimal interventions provided. Temperature logs confirmed elevated room temperatures, and grievances were filed requesting air conditioners.
A resident with a history of knee replacement and mobility impairments was not transferred using the required sit-to-stand device, as specified in her care plan and therapy recommendations. Instead, a CNA assisted her with a gait belt and one-person assist, leading to a fall and a periprosthetic fracture of the left knee. Staff interviews and documentation confirmed that the proper transfer protocol was not followed, resulting in injury.
A resident with multiple comorbidities, including diabetes and osteomyelitis, developed a suspected deep tissue injury on the right toe that was not assessed or treated by the facility until it worsened into gangrene, resulting in toe and subsequent above-the-knee amputations. Despite documentation of the injury, the facility failed to conduct timely skin assessments and implement necessary interventions, leading to severe outcomes.
The facility did not maintain the required RN coverage of at least 8 consecutive hours a day, 7 days a week, affecting 77 residents. The January 2025 Nursing Schedule revealed multiple days without an RN on duty, despite the facility's claim of meeting staffing requirements. The DON acknowledged the staffing gaps, although a new RN was hired mid-month.
The facility failed to provide adequate supervision and implement effective fall prevention measures for two residents, resulting in significant incidents. One resident, with dementia and osteoporosis, experienced an unwitnessed fall leading to a fractured hip requiring surgery. Despite being a high fall risk, interventions like alarms were not effectively monitored. Another resident, also a high fall risk, lacked consistent use of fall prevention devices, leading to multiple falls. The facility's policies on safety and fall prevention were not adequately followed, contributing to these incidents.
A resident with Clostridium difficile (C-diff) was not properly managed according to the facility's infection control policy. A Certified Occupational Therapy Assistant (COTA) failed to wear the required personal protective equipment (PPE) while providing therapy and moved unsanitized equipment through the facility. Interviews with staff confirmed the expectation of PPE use and isolation for residents with C-diff, highlighting a breach in protocol.
Failure to Investigate and Control Scabies Outbreak
Penalty
Summary
The facility failed to properly investigate, recognize, isolate, track, trend, and treat a scabies outbreak according to current standards of practice for five residents in a sample of thirteen reviewed for infection control. Multiple residents developed rashes over a period of months, with documentation in CNA shower sheets, skin checks, and progress notes indicating the presence and spread of rashes, itching, and scratching. Despite these ongoing symptoms, there was a lack of timely and coordinated investigation into the cause of the rashes, and no consistent use of diagnostic skin scrapings to confirm scabies in residents, even as the outbreak spread among both residents and staff. Residents affected had significant medical histories, including dementia, Parkinson's disease, hemiplegia, diabetes, and other chronic conditions, and many were dependent on staff for activities of daily living. The documentation shows that rashes were noted repeatedly on various body parts, and anti-pruritic medications and topical creams were ordered and applied. However, the facility did not implement appropriate isolation or infection control measures in a timely manner, and there was no systematic tracking or trending of the outbreak in the infection control log. Staff interviews revealed that concerns about scabies were raised for months, but administration attributed the rashes to other causes, such as laundry soap, and did not act on staff reports or implement recommended infection control practices. The facility's infection prevention and control program required the recording and surveillance of suspected infections, but there was no documentation of monitoring or tracking the affected residents' rashes. The outbreak was only recognized after a staff member was diagnosed with scabies by a dermatologist, at which point the facility treated all residents and staff. Prior to this, there was no evidence of isolation, systematic investigation, or notification of public health authorities as required by guidelines. The failure to follow established protocols for early detection, confirmation, and containment of scabies resulted in ongoing transmission among residents and staff.
Unsecured Text Message Breaches Resident Privacy
Penalty
Summary
The facility failed to follow its privacy policy regarding the handling of protected health information (PHI) for one resident. An Assistant Director of Nursing (ADON) sent a text message from her personal cell phone to a group that included the facility Administrator, Regional Nurse Consultant, and inadvertently, a former LPN who was no longer employed at the facility. The text message contained the resident's first and last name along with detailed medical information, including the resident's confusion, recent removal of a midline, ongoing treatment for EBSL in urine, and concerns about potential sepsis. The text message was not encrypted or secure, and the facility's policy prohibits the transmission of PHI via unsecured text messaging. Multiple staff, including the former LPN and the Regional Nurse Consultant, recognized the privacy violation and identified the use of unsecured text messaging as a breach of HIPAA regulations. The ADON acknowledged that she sent the message in error, including the wrong recipient, and admitted awareness that such communication was not permitted. The facility's HIPAA policy, dated 6/1/2025, clearly states that all staff are prohibited from sharing PHI through unsecure means and that violations may result in disciplinary action. There was no documentation in the resident's nursing notes regarding the transmission of this information via text message.
Failure to Administer Physician-Ordered Medications Due to Unauthorized Staff Instructions
Penalty
Summary
The facility failed to ensure that physician-ordered medications were prescribed and administered upon admission for two residents. One resident with multiple mental health diagnoses, including anxiety disorder, major depressive disorder, bipolar disorder, and panic disorder, was admitted with orders for Austedo XR and Vraylar to treat depression. Despite these orders, the medications were not administered, as indicated by the Medication Administration Record and confirmed by the pharmacist, who received the medication list with a handwritten note stating 'do not send.' Another resident with diabetes mellitus and diabetic polyneuropathy was admitted with a prescription for Ozempic to manage diabetes. The hospital discharge summary included a handwritten note stating 'Not while at facility,' and the medication was not administered during the resident's stay. The pharmacist did not fill the prescription due to this note and did not complete a high-cost medication form, as is the facility's protocol for medications exceeding a $200 threshold. No alternative diabetes medication was prescribed or administered to this resident during their stay. Interviews with facility staff, pharmacy staff, and the nurse practitioner revealed that facility staff had written unauthorized notes on medication lists sent to the pharmacy, instructing not to send certain medications. The nurse practitioner and administrative staff were unaware of these actions and stated that facility staff do not have the authority to alter or withhold physician-ordered medications. The facility did not have a formal policy addressing this practice, and the pharmacy did not question or report the handwritten instructions, resulting in residents not receiving prescribed medications.
Failure to Maintain Comfortable Room Temperatures for Residents
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment by not ensuring that resident rooms were kept at a comfortable temperature for two out of three residents reviewed. Both residents had significant medical conditions, including chronic obstructive pulmonary disease, obstructive sleep apnea, ischemic cardiomyopathy, chronic embolism, thrombosis, urinary tract infection, and bone disorder. Observations revealed that one resident was lying in bed with minimal clothing and using a small fan due to the lack of air conditioning vents in the room, which was described as warm and stuffy. The resident reported that the room became excessively hot, especially when the door was closed, and that staff and residents were sweating due to the heat. The resident also stated that temperature checks in the room were not performed until after the surveyor's visit, and the temperature was measured at 79 degrees during the surveyor's presence. Another resident reported difficulty sleeping due to the heat when the air conditioner was not functioning, stating that a nurse eventually provided a fan to help. Staff interviews confirmed that the air conditioning had not been working for several days, and that only hallway vents were present, with no vents in the resident rooms. Staff described the environment as miserable for both residents and workers, and noted that management's response was limited to advising the closing of blinds and turning off lights. Maintenance staff were aware of the issue, and a regional maintenance director commented on the extreme heat in the building. Temperature logs showed that room temperatures for the affected residents ranged from 74 to 79 degrees over several days, with no temperature documentation prior to the surveyor's intervention. A facility grievance documented that residents had requested air conditioners in their rooms. The facility's policy on extreme temperatures stated the purpose of assuring resident comfort and safety during periods of extreme heat, but the actions taken were insufficient to maintain a comfortable environment as required.
Failure to Use Proper Transfer Device Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of left knee replacement, mobility issues, and recent fractures was not transferred using the appropriate assistive device as required by her care plan and therapy recommendations. The resident was assessed as dependent for transfers and required a sit-to-stand device for safe movement. However, on the day of the incident, a CNA assisted the resident to the bathroom using only a gait belt and one-person assist, rather than the prescribed sit-to-stand device. During this transfer, the resident's leg gave out, and she was lowered to the ground, resulting in pain and subsequent diagnosis of a left knee periprosthetic fracture of the tibial component. Interviews with facility staff confirmed that the resident was supposed to be transferred with a sit-to-stand device, and the improper transfer method directly led to the injury. The facility's policy requires that residents be handled and transferred safely according to individualized assessments, but this protocol was not followed in this instance. Documentation in the resident's medical record and care plan indicated her high risk for falls and need for substantial assistance, yet the transfer was not performed according to these requirements.
Failure to Monitor and Treat Pressure Ulcer Leads to Amputation
Penalty
Summary
The facility failed to monitor and treat a suspected deep tissue injury (SDTI) on a resident's right toe, which was first observed on August 20, 2024. Despite documentation of the area of concern, no assessment or treatment was implemented until October 8, 2024, when the resident was hospitalized with gangrene and osteomyelitis, leading to the amputation of the right second toe on October 19, 2024. The situation worsened, resulting in an above-the-knee amputation on November 30, 2024. The resident, who had a history of cerebral infarction, chronic obstructive pulmonary disease, type II diabetes mellitus, morbid obesity, and osteomyelitis, was at risk for pressure ulcers as indicated by a Braden Scale assessment. However, the facility did not conduct updated Braden Scales or weekly skin assessments as required. The resident's care plan and physician's orders were not adequately followed, as there was no documentation of treatment for the right toe despite multiple reports of skin concerns from staff and dialysis personnel. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's condition. The Assistant Director of Nursing (ADON) and other staff members were unaware of the right toe wound until it had significantly worsened. The facility's policy on pressure injury prevention and management was not adhered to, as the resident's clinical condition and risk factors were not properly evaluated, and necessary interventions were not implemented in a timely manner.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, which is a requirement for the care of the 77 residents residing in the facility. The Facility Assessment Tool, which was undated, indicated a minimum of 12 hours per day for RN staffing. However, the facility's January 2025 Nursing Schedule showed that there were several days in January when no RN was on duty, specifically on 01/01, 01/02, 01/04, 01/05, 01/15, 01/16, 01/17, 01/18, 01/19, and 01/24. The Director of Nursing (DON) confirmed that there were days in January without RN coverage, although a new RN was hired and started on January 22nd. Despite the facility's claim of staffing to meet state and federal requirements, the absence of an RN on these days represents a failure to comply with regulatory standards.
Inadequate Supervision and Fall Prevention in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision and implement effective fall prevention interventions for two residents, resulting in significant incidents. Resident R2, who was admitted with diagnoses including dementia and osteoporosis, experienced an unwitnessed fall that led to a fractured hip requiring surgical repair. Despite being identified as a high fall risk with a Morse Fall Scale score of 80, interventions such as bed and chair alarms were not effectively monitored or adjusted following her initial fall. On the day of her second fall, R2 was left unsupervised at the nurse's station, and her alarm went unanswered, leading to her fall and subsequent injury. Resident R3, who was also identified as a high fall risk with a Morse Fall Scale score of 55, did not have the necessary fall prevention measures consistently in place. Observations revealed that R3 was often without a wheelchair alarm or cushion, despite having a history of multiple falls. The care plan for R3 included interventions such as a sensor alarm and dycem cushion, but these were not consistently implemented, as confirmed by R3 and staff interviews. The facility's policies on resident safety and fall prevention were not adequately followed, as evidenced by the lack of consistent supervision and failure to ensure that fall prevention devices were in place. Staff interviews indicated a lack of communication and awareness regarding the placement of residents at risk for falls, contributing to the incidents. The facility's failure to adhere to its own policies and procedures resulted in preventable accidents and injuries for the residents involved.
Infection Control Breach for Resident with C-diff
Penalty
Summary
The facility failed to adhere to its infection control policy and procedures for a resident diagnosed with Clostridium difficile (C-diff), who was on contact isolation precautions. The resident, who was cognitively intact and required assistance with activities of daily living, was observed receiving therapy from a Certified Occupational Therapy Assistant (COTA) who did not wear the required personal protective equipment (PPE), such as a gown and gloves, while in the resident's room. Additionally, the COTA brought a table with various items into the room and later moved it through the facility without sanitizing it, contrary to the facility's infection control protocols. Interviews with facility staff, including a Licensed Practical Nurse (LPN), a Certified Nurse's Assistant (CNA), the Director of Nursing (DON), and the Infection Control Preventionist (ICP), confirmed that the expected protocol for residents with C-diff includes isolation and the use of PPE by staff. The facility's policy, revised in 2004, outlines the necessity of wearing appropriate PPE and maintaining clean techniques to prevent the transmission of C-diff. Despite these guidelines, the observed actions of the COTA demonstrated a failure to comply with the established infection control practices, potentially compromising the safety and health of other residents and staff.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Breese
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviston Countryside Manor | 4.4 mi | ★★★★★ | 9 | 0 |
| Carlyle Healthcare & Sr Living | 8.4 mi | ★★★★★ | 1 | 0 |
| Clinton Manor Living Center | 10.9 mi | ★★★★★ | 0 | 0 |
| Highland Health Care Center | 11.6 mi | ★★★★★ | 3 | 1 |
| Cedar Ridge Health & Rehab Ctr | 15.8 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.