Health inspection·February 2, 2024

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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 Residents Affected - Few 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. R2's POS, dated 1/18/24, documented, Morphine Sulfate 20 mg (milligrams)/ML (Milliliters) by mouth in the morning every Monday, Wednesday, and Friday prior to Dialysis. R2's POS, dated 1/2/24, documented, Tramadol 50 mg 1 tablet every 4 hours when needed for pain. R2 POS, dated 1/8/24, documented, Morphine sulfate 20 mg/ml give 0.25 ml by mouth every one hour as needed for pain. R2's Nurses Note, dated 1/24/23 at 1:21 AM, documented, Received call from night nurse that evening shift agency nurse must have took med cart (medicine cart) keys home with her. Call placed to (Agency) representative and (Facility's) Pharmacy, message left for both to call this writer back. Call placed to administrator and updated on situation. R2's Nurses Note, dated 1/24/23 at 08:49 AM, documented, Call placed to (Facility's) Pharmacy, request to receive extra set of keys to lock box on each med cart for back up. Faxed over ID information on each lock box, pharmacy will send out keys. R2's Nurses Note, dated 1/24/23 at 9:52 AM, documented, Call placed to agency nurse that worked evening shift prior, to check once she gets home for keys. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 145410 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145410 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Evercare of Breese 1155 North First Street Breese, IL 62230 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)