Evercare of Breese: Scabies Outbreak Violations - IL
The October 16 complaint inspection, which covered all 69 residents then living at the facility, cited the home under the infection control tag at the highest level of harm short of immediate jeopardy: actual harm, affecting a few residents. That designation means inspectors concluded real injury occurred, not a theoretical risk.
Scabies is caused by a microscopic mite that burrows into skin, triggering intense itching and a rash that can be difficult to distinguish from other skin conditions. In a nursing home, where residents share staff, common areas, and sometimes rooms, a single undetected case can move through a population quickly. The mite spreads through direct skin contact, and symptoms can take up to two months to appear in someone who has been exposed, meaning a person can be infectious long before anyone realizes they are sick.
That delay is exactly what makes an early detection program so important, and exactly what inspectors found missing at Evercare of Breese.
The inspection report cited the facility's failure to maintain an active program for identifying infested residents and staff. The standard for that kind of program is specific: when a resident has an undiagnosed skin rash, staff should treat scabies as a possible cause and confirm or rule it out by obtaining skin scrapings. Inspectors noted the facility lacked a trained staff member capable of obtaining and examining those scrapings to identify scabies mites. Without that capacity, the facility was dependent on outside confirmation, adding time to a process where time is the enemy.
The report also cited failures in record-keeping. When a scabies case is identified, a facility is supposed to maintain records that track the resident's name, age, sex, room number, the names of any roommates, the status and results of skin scraping tests, and the names of every staff member who provided hands-on care before infection control measures were put in place. That list exists for one reason: to find everyone who might have been exposed before anyone knew there was a problem. At Evercare of Breese, inspectors found that documentation was not being maintained as required.
The report also addressed what the facility should have done once multiple cases appeared. Notification of the local health department is required when an outbreak is confirmed. Facilities are also supposed to reach out to any other institutions that received or sent residents who may have been infected or exposed, because a resident discharged to a hospital or transferred to another nursing home can carry the mite with them. There is no indication in the inspection record that those notifications occurred.
Infection control for scabies requires more than treatment. Staff providing hands-on care to a resident with confirmed or suspected scabies are supposed to use gloves, gowns, and avoid direct skin-to-skin contact. The inspection report cited failures in those protective practices as well.
The facility's midnight census report from September 28, 2025, recorded 69 residents in the building. The inspection took place roughly two and a half weeks later. How many of those 69 residents were exposed during the period when the outbreak went uncontrolled, and how many staff carried the mite home, is not stated in the inspection record.
Scabies in a nursing home is not merely uncomfortable. The itching is severe, often worse at night, and for elderly residents with dementia or limited ability to communicate, the distress it causes can be significant and prolonged. A 2024 research review cited in the inspection report described scabies as a condition that extends beyond physical discomfort, affecting mental health and quality of life. In a population already living with chronic illness, reduced mobility, and compromised immune systems, that burden lands harder.
The inspection was filed as a complaint, meaning someone, a resident, a family member, or a staff member, contacted regulators before inspectors arrived. Whatever they reported was serious enough to trigger a site visit. What inspectors found when they got there was a facility that had allowed an outbreak to develop without the systems in place to catch it, contain it, or fully account for who had been harmed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evercare of Breese from 2025-10-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 25, 2026 · Our methodology
EVERCARE OF BREESE in BREESE, IL was cited for violations during a health inspection on October 16, 2025.
That designation means inspectors concluded real injury occurred, not a theoretical risk.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.