Health inspection·October 16, 2025

F 0880 Level of Harm - Actual harm Residents Affected - Few documented R1 has no new skin issues identified.On 09/29/25 at 1:25 PM, R1 had redness and little red spots to both of her arms.On 09/29/25 at 1:25 PM, R1 said she had a rash on her arms, and it was itching. She was seen by the Nurse Practitioner (NP) V12 and was treated for the rash. 2. R2's Face Sheet, print date of 09/30/25, documented R2 has diagnoses of but not limited to Parkinson's disease without dyskinesia, Type II diabetes mellitus (DM) with diabetic polyneuropathy, and dementia. R2's MDS, dated [DATE], documented R2 is severely cognitively impaired with a BIMS of 04 out of 15 and unable to be interviewed. She requires substantial/maximal assistance with her ADLs. R2's Care Plan, dated 08/30/24, documented date initiated on 09/29/25, the resident has a rash r/t possible scabies and will be treated as such. Goal: The resident will have no complications from rash through the review date, the resident will have no s/sx of infection of the rash through the review date, and the resident's rash will heal by review date. Interventions include but not limited to Avoid scratching and keep hands and body parts from excessive moisture, give anti-pruritic medication as ordered by MD. Monitor/document side effects and effectiveness, and monitor skin rashes for increased spread or signs of infection.R2's Physician's Orders, dated 07/01/25, documented skin checks-perform upon admission and weekly thereafter, every day shift every Thursday for facility protocol, complete skin assessment under assessment tab.R2's Physician's Orders, dated 09/11/25, documented Triamcinolone Acetonide External Cream 0.1% (topical) Apply to trunk and extremities topically every day and night shift related to Allergy status to unspecified drugs, medicaments ad biological substances discontinue (D/C) when rash is gone.R2's Physician's Orders, dated 09/24/25, documented Elimite External Cream 5% (Permethrin) Apply to whole body neck to toes topically at bedtime for skin care until 09/25/25 13:59 (1:59 PM) and remove per schedulR2's Facility Nursing Home CNA shower sheet, for August 2025 and September 2025 were reviewed and documented the following skin issues:On 08/10/25, rash to left abdomen and left back areas. Reported by V10, CNA. On 08/21/25, discoloration to bilateral tops of hands.On 08/25/25, rash to front chest area.On 08/28/25, rash to front upper chest and back upper chest. In the comments/follow up section by the nurse it documented: Red rash across chest and upper back.On 09/01/25, rash to chest and upper back area.On 09/04/25, rash to chest and upper back area.On 09/08/25, discoloration to bilateral hands.On 09/11/25, rash to chest, back, and front of legs. On 09/15/25, rash to chest area.On 09/18/25, rash to chest, upper back, and abdomen areas.On 09/22/25, rash to front and back areas.On 09/25/25, in the comment section it documented scratching everywhere on upper body. On 09/29/25, rash/spots chest area. R2's Skin Checks, for August 2025 and September 2025 were reviewed and documented the following skin issues:On 09/11/25 at 12:41 PM, New skin issue: Rash, in-house acquired. Skin notes: Rash continues to body. Continuing Triamcinolone Acetonide External Cream 0.1% to trunk and extremities topically every morning and at bedtime. On 09/18/25 at 2:43 PM, Needs Review: Rash, in-house acquired. Skin issues notes: rash remains, treatment (tx) in place.R2's Progress Notes, were reviewed and documented the following:On 09/04/25 at 10:16 AM, documented Skin Check, No new skin issues.On 09/11/25 at 12:41 PM, documented Skin Check, Skin: Skin warm and dry, skin color within normal limits (WNL) and turgor is normal. On 09/17/25 at 11:16 PM, documented Type: Skin/wound note, late entry Note Text: Notified nurse practitioner (NP) about recommendations for rash to try Triamcinolone 0.1% and Cetaphil or Eucerin over the counter (OTC) twice a day (BID). On 09/18/25 at 2:43 PM, documented Skin Check Skin: Skin warm and dry, skin color within normal limits (WNL) and turgor is normal. Skin Issues: Skin issue has not been evaluated. Location: Generalized. Issue type: Rash. Rash continues to body. Continuing Triamcinolone Acetonide External Cream 0.1% to trunk and extremities topically every morning and at bedtime.On 09/24/25 at 10:01 PM, documented Note Text: Triamcinolone Acetonide External Cream 0.1% Apply to trunk and extremities topically (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145410 If continuation sheet Page 2 of 8 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 10/16/2025 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)

F 0880 Level of Harm - Actual harm Residents Affected - Few every day and night shift related to allergy status to unspecified drugs, medicaments and biological substances. Discontinue (D/C) when rash is gone, other cream applied.On 09/25/25 at 10:24 AM, documented Note Text: Resident had a skin check done on 09-24 due to a small outbreak of scabies in the facility. Resident does have a small rash and will be treated, and all lines will be washed, family was notified and is fine with the treatment. 3. R6's Face Sheet, print date of 09/30/25, documented R6 has diagnoses of but not limited to Parkinson's disease with dyskinesia, vascular dementia, and cerebral infarction due to embolism of basilar artery.R6's MDS, dated [DATE], documented R6 is severely cognitively impaired with a BIMS of 07 out of 15 and he requires substantial/maximal assistance or is dependent on staff for most of his ADLs. R6's Care Plan, admission date of 01/07/25, documented the resident (R6) has a rash related to possible scabies and will be treated as such (Date Initiated: 09/30/25). Goal: Resident will have no complications from rash through the review date, the resident will have no s/sx of infection of the rash through the review date, and the resident's rash will heal by review date. Interventions include but not limited to: Give anti-pruritic medication as ordered by MD, monitor skin rashes for increased spread or signs of infection, and seek medical attention if skin becomes bloody or infected. R6's Physician's Orders, dated 01/07/2025, documented Free of signs and symptoms of communicable diseases. R6's Physician's Orders, dated 07/07/25, documented Skin Checks-Perform upon admission and weekly thereafter, every day shift every Wednesday for facility protocol complete skin assessment under assessment tab. R6's Physician's Orders, dated 09/17/25, documented Apply to rash areas Triamcinolone cream and mix with Cetaphil/Eucerin cream (OTC) BID every day and night shift for skin care. R6's Physician's Orders, dated 09/24/25, documented Elimite External Cream 5% (Permethrin) Apply to whole body neck to toes topically at bedtime for skin care until 09/25/25 1:59 PM and remove per schedule.R6's Facility Nursing Home CNA shower sheet, for August 2025 and September 2025 were reviewed and documented the following skin issues:On 08/09/25, Rash to chest area.On 08/13/25, Communication section: Red bumps all over body/mostly on left (Lt.) upper arm.On 08/23/25, Rash to front/back areas. Anti-itch cream applied.On 08/27/25, Rash to front and back areas and scratches to his front area.On 08/30/25, Rash to Right (Rt.) and Lt. upper chest/arm, left lower arm, Rt. upper back and Rt. lower back.On 09/03/25, Rash to front and back areas.On 09/06/25, Rash to front/back area and left back of leg.On 09/10/25, Rash to front/back area, left back of leg, and scratches to leg.On 09/17/25, Rash to front upper chest, arms, upper legs, abdomen, and scratches to Rt. upper back and left calf area.On 09/20/25, Rash front/back, upper and lower torso, bilateral lower extremities, and scratches to Rt. shoulder and Lt. lower leg. On 09/24/25, Rash entire front, Rt. shoulder scratches, and scratches to Lt. lower leg. On 09/27/25, Rash to his Rt. and Lt. arms, chest, abdomen, bilateral legs and feet, and his back.R6's Skin Check, dated 08/09/25 2:53 PM, documented Skin Issues Note Rash noted to upper chest, physician notified, awaiting response.R6's Skin Check, dated 08/13/25 at 10:58 AM, documented Skin Issues Note Resident is breaking out with red rash, has scratches on left upper arm from itching. New order of Benadryl ointment to begin upon arrival.R6's Skin Check 08/27/25 at 6:06 PM, documented R6 had no skin issues.No September 2025 Skin checks for R6 were provided after requested on 09/30/25 and 10/16/2025.R6's Progress Notes, were reviewed and documented the following skin issues:On 09/17/25 at 11:16 AM, documented Type: Skin/Wound Note Late Entry, Note Text: Notified NP about recommendations for rash to try Triamcinolone 0.1% and Cetaphil or Eucerin OTC BID, Orders entered. On 09/24/25 at 1:34 PM, documented Type: Skin Check. Skin warm and dry, skin color WNL and turgor is normal. No new skin issues identified. Skin issues: New skin issues. Location: Generalized. Issue type: Rash. Wound acquired in-house. Skin issue note: scattered rash to back/torso. TMC (Triamcinolone)/Cetaphil/Eucerin cream mix. On 09/25/25 at 9:53 AM, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145410 If continuation sheet Page 3 of 8 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 10/16/2025 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)

F 0880 Level of Harm - Actual harm Residents Affected - Few documented Resident had a skin check done on 09-24 due to a small outbreak of scabies in the facility. Resident does have a small rash and will be treated, and all lines will be washed, family was notified and is fine with the treatment. 4. R7's Face Sheet, print date of 09/30/35, documented R7 has diagnoses of but not limited to Multiple sclerosis, need for assistance with personal care, dementia, and hypertension (HTN).R7's MDS, dated [DATE], documented R7 is severely cognitively impaired with a BIMS of 05 out of 15 and she requires substantial/maximal assistance with most of her ADLs.R7's Care Plan, admission date of 05/10/24, documented the resident (R6) has a rash related to possible scabies and will be treated as such (Date Initiated: 09/30/25). Goal: Resident will have no complications from rash through the review date, the resident will have no s/sx of infection of the rash through the review date, and the resident's rash will heal by review date. Interventions include but not limited to: Give anti-pruritic medication as ordered by MD, monitor skin rashes for increased spread or signs of infection, and seek medical attention if skin becomes bloody or infected.R7's Physician's Orders, dated 09/02/25, documented Free of signs and symptoms of communicable diseases, Skin Checks-Perform upon admission and weekly thereafter, every day shift every Thursday for facility protocol complete skin assessment under assessment tab, and Benadryl itch stopping external cream 1-0.1% (Diphenhydramine-Zinc Acetate) Apply to Pruritus areas typically every 12 hours as needed for itching.R7's Physician's Orders, dated 09/11/25, documented Monitor rash to chest, back, and BIL (bilateral) front and back of legs until healed every shift for skin care.R7's Physician's Orders, dated 09/17/25, documented Apply to rash areas Triamcinolone cream mixed with Cetaphil/Eucerin cream BID every day and night shift for skin care.R7's Physician's Orders, dated 09/24/25, documented Elimite External Cream 5% (Permethrin) Apply to whole body neck to toes topically at bedtime for skin care until 09/25/25 1:59 PM and remove per schedule.R7's Facility Nursing Home CNA shower sheet, for August 2025 and September 2025 were reviewed and documented the following skin issues:On 08/04/25, Rash with scratches to whole front upper torso, rash to both upper legs, and rash to entire back area.On 08/07/25, Red rash to entire torso (front/back) and both upper (thigh) legs.On 08/11/25, Rash to upper torso front and back.On 08/14/25, Rash to upper torso and bilateral upper legs.On 08/18/25, Rash to upper chest, abdomen, bilateral arms, bilateral thighs, and scratches to bilateral legs.On 08/21/25, Rash to upper torso and both upper legs.On 08/25/25, Rash to upper torso and bilateral upper legs.On 08/28/25, Rash to upper torso.On 09/04/25, Rash to torso front and back and both legs front and back.On 09/08/25, Rash to entire body.On 09/11/25, Rash to entire body. (Orders placed to monitor rash every (Q) shift.)On 09/15/25, 09/18/25, and 09/22/25, Rash to entire body.On 09/26/25, Rash to abdomen, back and both legs.R7's Skin Checks, documented the following skin issues:On 08/18/25 at 10:00 AM, documented new skin issue: Generalized rash and to apply as needed (PRN) cream. On 08/25/25 at 9:51 AM, documented evaluation generalized rash.On 09/02/25 at 2:29 PM, documented skin issue needs reviewed, generalized rash.On 09/11/25 at 12:36 PM, documented evaluated, generalized rash is stable.On 09/18/25 at 2:41 PM, documented needs reviewed generalized rash. R7's Progress Notes, were reviewed and documented the following:On 09/02/25 at 2:49 PM, documented Skin Check generalized rash. On 09/11/25 at 12:36 PM, documented Skin Issues: Skin issue has been evaluated. Generalized rash.On 09/17/25 at 11:15 AM, documented Late Entry Note Text: Notified NP about recommendations for rash to try Triamcinolone 0/1% and Cetaphil or Eucerin OTC BID. Orders entered. On 09/18/25 at 2:41 PM, documented Skin Check Skin Issues Note: sporadic rash noted to body, tx in place.On 09/25/25 at 9:30 AM, documented Resident had a skin check done on 09-24 due to a small outbreak of scabies in the facility. Resident does have a small rash and will be treated, and all lines will be washed, family was notified and is fine with the treatment. 5. R10's Face Sheet, print date of 09/30/25, documented R10 has (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145410 If continuation sheet Page 4 of 8 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 10/16/2025 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)

F 0880 Level of Harm - Actual harm Residents Affected - Few diagnoses of but not limited to hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left dominant side, type II DM, epilepsy, and HTN.R10's MDS, dated [DATE], documented R10 is cognitively intact with a BIMS of 14 out of 15 and she requires substantial/maximal assistance or is dependent on staff for help with her ADLs.R10's Care Plan, admission date of 04/03/25, documented the resident (R10) has a rash related to possible scabies and will be treated as such (Date Initiated: 09/30/25). Goal: Resident will have no complications from rash through the review date, the resident will have no s/sx of infection of the rash through the review date, and the resident's rash will heal by review date. Interventions include but not limited to: Give anti-pruritic medication as ordered by MD, monitor skin rashes for increased spread or signs of infection, and seek medical attention if skin becomes bloody or infected.R10's Physician's Orders, dated 04/03/25, documented Free of signs and symptoms of communicable diseases.R10's Physician's Orders, dated 07/01/25, documented Skin Checks-Perform upon admission and weekly thereafter, every evening shift every Thursday for facility protocol complete skin assessment under assessment tab. R10's Physician's Orders, dated 08/07/25, documented Benadryl Allergy oral capsule give 12.5 milligrams (mg) by mouth every 8 hours as needed for itching, hives.R10's Physician's Orders, dated 08/08/25, documented Silicone Cream to back of both legs BID every day and evening shift for dry areas.R10's Physician's Orders, dated 09/21/25, documented Clobetasol Propionate Cream 0.05% apply to affected areas topically every day and evening shift for skin.R10's Physician's Orders, dated 09/24/25 at 5:16 PM, documented Elimite External Cream 5 % (Permethrin) Apply to whole body neck to toes topically at bedtime for skin care until 09/25/2025 1:59 PM and remove per schedule.R10's Facility Nursing Home CNA shower sheet, for August 2025 and September 2025 were reviewed and documented the following skin issues:On 08/04/25, Rash to back of right lower leg.On 08/21/25, Rash to back of both lower extremities. Comments: Cream to legs.On 09/01/25, Rash to back of bilateral upper legs.On 09/11/25, Rash to right side, abdomen, and back areas.On 09/15/25, Scratches to right arm, both lower legs, and neck.On 09/18/25, documented treatment applied.On 09/25/25, Rash to upper chest, right abdomen, upper back, and left buttock. R10's Skin Checks, for August 2025 and September 2025 were reviewed and documented the following skin issues:On 08/07/25 at 4:33 PM, Skin issues: Needs review rash to left lateral calf and right lateral calf. They were in-house acquired, and the onset date is unknown. On 08/14/25 at 9:24 PM, There were no documented skin issues noted.On 08/14/25 at 4:33 AM, Skin issues: New issue rash noted to the left lateral calf and the right lateral calf. It was in-house acquired, and the onset date is unknown.On 09/12/25 at 4:37 PM, Skin issues: Reviewed Rash to left lateral calf and right lateral calf with an onset date of unknown. New skin issues of a rash to R10's Rt. outer wrist.On 09/25/25 at 4:52 PM, Skin issues: Evaluated rash to R10's left lateral calf and right lateral calf done showing improvement. R10's Progress Notes, were reviewed and documented the following:On 09/12/25 at 4:37 PM, documented Skin issue #001 Left lateral calf has a rash and #002 Right lateral calf has a rash. It is unknow how long it (rash) has been present.On 09/16/25 at 1:46 PM, documented Late Entry Note Text: Spoke with NP for local wound management regarding areas on multiple patients. NP suggested Medrol dose pack and Clobetasol 0.5% mixed with Cetaphil lotion BID. Suggestion sent to MD for orders. On 09/18/25 at 9:53 PM, documented Skin check showed R10 had a new skin issue, rash to right outer wrist. On 09/25/25 at 10:31 AM, documented Resident had a skin check done on 09-24 due to a small outbreak of scabies in the facility. Resident does have a small rash and will be treated, and all lines will be washed, family was notified and is fine with the treatment.On 09/25/25 at 4:52 PM, documented Rash to R10's left, and right lateral calf is showing improvement. On 09/30/25 at 1:25 PM, R10 said she got the rash about six weeks ago or so. She said she had it on both of her sides, stomach, and the back (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145410 If continuation sheet Page 5 of 8 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 10/16/2025 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)

F 0880 Level of Harm - Actual harm Residents Affected - Few of her legs. R10 stated they had the NP (V11) from the local wound management come in and look at her rash and V11 said didn't know what kind of rash R10 had but said it looked like all the other rashes in the building. R10 said they didn't do any kind of skin scraping to see what kind of rash she had but they treated her last Thursday with a special cream, and they put it on from her hairline down to her feet. R10 said the itching stopped after that until just recently and it started itching again. R10 said the worst the itching has been on a scale of 0-10 with 10 being the worst has been a 7 and that was about two or three weeks into the rash. R10 stated more and more people on the east side was getting the rash. R10 said in the beginning they didn't really get a treatment for the rash they were just putting some silicone cream on it, and they ordered her Benadryl but she would only use it at night because it made her sleep. R10 said someone came around today and talked with her and she told them about the itching again and they were going to see if she could get another treatment with the special cream.On 09/30/25 at 1:25 PM, R10 has a raised red area on her right side going around to her back and on her abdomen. The facility's Infection Control Log for the months of August 2025 and September 2025 were reviewed and there was no documentation R1's, R2's, R6's, R7's, and R10's rash was being monitored or tracked. On 09/30/25 at 12:20 PM, V9 Assistant Director of Nursing (ADON)/Infection Control Preventionist (ICP)/Wound Nurse brought this surveyor a sheet of paper labeled Rash timeline it documented the following: First Rash EE Hall- R6 08/09/25 provider notified, and cream ordered.EE Hall- R7 08/18/25 cream ordered 08/18/25.NE Hall- R10 Benadryl ordered 08/23/25 and cream on the 25th. NE Hall- R11 cream ordered Medrol pack.EE Hall- R2 09/11/25 cream ordered.EE Hall- R12 09/18/25 cream ordered 09/19/25.EE Hall- R13 09/19/25 Benadryl ordered 09/23/25 and Medrol pack.SE Hall- R1 09/24/25 during sweep.On 09/29/25 at 1:42 PM, V5, Licensed Practical Nurse (LPN) stated they have had a few residents who had a rash, and they did the scraping and then the facility treated them for scabies. V5 said they were seen by V7, NP. V5 said they then treated everyone on the wing for them.On 09/30/25 at 8:01 AM, V9, ADON/ICP/Wound Nurse stated R5 was the first one to get the rash. She said at first, they didn't know what it was. They sent R5 to the dermatologist multiple times and they said it was dermatitis. V9 said other residents started to get rashes and none of the rashes looked alike so they had V11, Wound NP look at the rash and she ordered different creams and stuff. V9 said she heard staff had rashes and a few of the residents also. She said V10, CNA told her she had the rash since June or July, but she said another nurse told her V10 said it was since May. V9 said V10 was covered with the rash. She said V11 got V10 into a friend of hers who is a dermatologist and they did a scraping, and it was positive for scabies. V9 said when they found out V10 had scabies they treated the whole building for it and then the ones who had the rash will get a second treatment tomorrow (10/01/25). V9 was asked if she had any tracking/trending of when all of this started, she said not yet but she has been working on it because she knew this was going to happen.On 09/30/25 at 8:53 AM, V10, CNA said back in June she had noticed a rash on her stomach, and she said she didn't think much of it. She thought it was a heat rash because she had gotten a rash like that the summer before, and it went away. V10 said then in late July or early August she noticed the rash had spread to her chest, arms, and thighs. V10 said she didn't report to the office when she had first noticed her rash, but she did report about some of the residents having a rash. V10 said her and some of the other workers talked amongst themselves about them having a rash. V10 said they would all report it and put it on the shower sheets when they noticed any resident who had a rash. V10 said she thinks they contacted a doctor, and they ordered some type of cream. She said she isn't aware of them doing any kind of scraping on any of the residents at that time. V10 said they did not put any of the residents on any type of isolation or anything like that. V10 said V11, NP got her into (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145410 If continuation sheet Page 6 of 8 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 10/16/2025 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)

F 0880 Level of Harm - Actual harm Residents Affected - Few a Dermatologist that was her friend, and they did a scraping, and it was positive for scabies. She said there were residents who had a rash before she developed the rash on her stomach. She said she doesn't have any kids at home they are all grown and no grandchildren. V11 said she comes to work and goes home and doesn't do much of anything else. She said it's just her and her husband at home and he still doesn't have any type of rash.09/30/25 at 10:24 AM, Follow up interview with V10, CNA. V10 said she remembers reporting R2, R5, R6, and R7, all had rashes. V10 stated she went to the doctor on 09/24/25 and can't return to work until 10/02/25. She said they are making her stay off for a week. She said while she was still at work, they did not put anyone in isolation but after that she doesn't know what they did.On 09/30/25 at 10:55 AM, V15, CNA said the staff have been telling administration for months that some of the residents have scabies, but they just tell the staff that's not what it is. She said they were trying to tell everyone it was from the laundry soap, but they all knew it wasn't. V15 said she isn't aware any scrapings being done on any of the residents. V15 said she feels like the staff got this from the residents and she doesn't think any of the staff brought it in. V15 said she knows she pointed it out to nurses on the resident's shower day and that was a couple of months ago. V15 said prior to the treatment no one was placed on any type of isolation. On 09/30/25 at 11:10 AM, V16, Regional Nurse Consultant stated she doesn't believe any of the residents had a skin scraping done. She said she knows they treated everyone out of abundance of caution they just treated everyone.The facility's Infection Prevention and Control Program, reviewed date of 9/5/25, documented Purpose To comply with a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement. It further documented Guidelines 6. The program provides for the recording of each suspected infection and surveillance activities as they relate to individual resident infections. A log is maintained o suspected and actual infections on a day-to-day basis. It also documented 19. Communicable disease outbreaks and infections that meet criteria for reporting will be reported to the Local and State Health Department. Investigation and/or outbreak line listing report will be completed as recommended.A document titled Scabies, dated 07/28/22 and found at Scabies - Symptoms and causes - Mayo Clinic documented Scabies is an itchy rash caused by a tiny burrowing mite called Sarcoptes scabiei. In the area where the mite burrows intense itching usually occurs and the need to scratch may be stronger at night. Scabies is contagious and can be spread quickly through close person-to-person contact in a family, school, or even nursing home. Symptoms of scabies include itching, often worse at night, and thin, wavy tunnels made up of tiny blisters or bumps on the skin.The Center for Disease Control (CD) information, dated 12/18/2023, documented Public Health Strategies for Scabies Outbreaks in Institutional Settings has a few key points. Scabies outbreaks have occurred in patients, visitors, and staff in institutional settings. When the characteristic symptoms of itching and rash are absent, it is easy to misdiagnose scabies, which can lead to outbreaks and often scabies is not recognized until it begins to appear among staff. Scabies can spread easily under crowded conditions where close body and skin contact is frequent and scabies outbreaks more commonly occur in the following settings such as nursing homes, extended care facilities, and childcare facilities. Early detection, treatment, and implementation of appropriate isolation and infection control practices are essential in preventing scabies outbreaks. Institutions should maintain a high index of suspicion that undiagnosed skin rashes and conditions may be scabies, even if characteristic signs or symptoms of scabies are absent (e.g. no itching). When there is concern for scabies in a person, skin scrapings should be obtained and examined carefully by a person who is trained and experienced in identifying scabies mites. Appropriate (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145410 If continuation sheet Page 7 of 8 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 10/16/2025 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)

F 0880 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete isolation and infection control practices (e.g., gloves, gowns, avoidance of direct skin-to-skin contact, etc.) should be used when providing hands-on care to patients/residents who might have scabies. Epidemiologic and clinical information about patients/residents with confirmed and suspected scabies should be collected and used for systematic review to facilitate early identification of and response to potential outbreaks.The facility should have an active program for early detection of infested patients/residents and staff. Maintain a high index of suspicion that scabies may be the cause of undiagnosed skin rash; evaluate and confirm suspected cases by obtaining skin scrapings. If there are multiple cases, notify the local health department of the outbreak; determine if there is evidence of an increase in scabies cases in the community; notify other institutions to or from which infected or exposed patients/residents may have transferred.Consult with an experienced dermatologist for assistance in differentiating between skin rashes and scabies. Ensure a trained and experienced staff member can obtain and examine skin scrapings to identify scabies mites.The facility should maintain records with patient/resident name, age, sex, room number, roommate(s) name(s), skin scraping status and result(s), and name(s) of all staff who provided hands-on care to the patient/resident before implementation of infection control measures: symptoms can take up to 2 months to appear in exposed persons and staff.MedRxiv.org document Impact of Scabies on Quality of Life and recent advances in management: A systematic Review, posted 11/26/2024, documented Scabies remains a significant global health issue, particularly in resource-limited settings. Despite its prevalence and impact on individuals and communities, scabies often receive inadequate attention in healthcare settings and research agendas. Scabies affects individuals of all ages and socioeconomic backgrounds, with a higher prevalence observed in overcrowded areas. The burden of scabies extends beyond physical discomfort, impacting quality of life, mental health, and economic productivity. Thus, it is imperative to diagnose scabies early and initiate treatment as soon as possible. The facility midnight census report 09/28/2025, dated 09/29/25 at 11:50 AM, documented there were 69 residents currently residing in the facility. Event ID: Facility ID: 145410 If continuation sheet Page 8 of 8