Evercare of Breese

In the surveyor’s words

From the most serious findings on record at Evercare of Breese, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Jan 31, 2025

  Based 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. […]

• Actual harm, isolatedF689Apr 17, 2026

  Based 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. Findings include: 1. R34's face sheet documents an admission date of 10/13/2023. Diagnosis includes Brachial Plexus Disorders, Aneurysm of the Ascending Aorta, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease. R34's Minimum Data Set, MDS, dated [DATE] documents R34 is severely cognitively impaired. R34's MDS dated [DATE] documents R34 requires substantial/maximum assistance for mobility and transfers. R34's care plan updated 4/14/2026 Risk for Falls. Falls documented on 4/1/2026 and 4/13/2026. […]

• Actual harm, isolatedF825Apr 17, 2026

  Based 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. Findings include:R40's face sheet documents admission date of 8/13/2024. Diagnosis includes Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Pulmonary Fibrosis, Acute and Chronic Respiratory Failure. R40's Minimum Data Set, MDS, dated [DATE] documents R40 has moderate cognitive disabilities. R40 requires partial/moderate assistance with mobility and transfers. R40 requires supervision/touching assistance with walking 10 feet. […]

• Actual harm, isolatedF880Oct 16, 2025

  Based 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. […]

• Actual harm, isolatedF689May 20, 2025

  Based 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. Findings include: R2's EMR (Electronic Medical Record) undated documents that the resident was readmitted to the facility on [DATE]. R2's EMR dated 2/9/22 documents a diagnosis of other abnormalities of gait and mobility. R2's EMR dated 11/5/24 documents a diagnosis of difficulty in walking, not elsewhere classified. R2's EMR dated 8/14/24 documents a diagnosis of unspecified fracture of left fibula, subsequent encounter for closed fracture with routine healing. […]