Evercare Of Breese

F 0583 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

wrong person in the group which included V10, Former LPN, after V10 replied with no to message her anymore she realized she text messaged the wrong person and stopped any further text messages regarding Resident R5 and his medical care. V3 stated sending the text message to V10 was an accident and she knew better than to text message a resident's name and medical information but it was a weekend and she needed guidance on how to proceed with caring for Resident R5. V3 stated V1 inserviced her on 9/8/2025 regarding not text messaging resident's names and medical information because it's not secure or encrypted and stated she won't text message resident information again. The Facility's HIPPA Policy and Procedure, dated 6/1/2025, documents this policy applies to all employees with access to personal health information (PHI.)

This includes all administrative, clinical and support staff. Definition: PHI: any information recorded in any form, that relates to health, provision of health care that can be linked to an individual. Staff members will receive training on HIPAA policies and procedures, with additional training provided as rules and regulations evolve. This training includes but is not limited to privacy practices, security measures and breach notification procedures. Violations of this policy may result in disciplinary action.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/18/2025

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

depression is very expensive and costs $6,000.00 for a 14-day supply and Vraylar 3 mg for depression is also expensive as it cost $700.00 for a 14-day supply. V11 stated these medications for Resident R1 and Resident R3 were not filled from the pharmacy because staff handwrote a note on the medication list that stated, do not send or not while at facility. V11 stated she was the billing director, and she didn't know who documented not to send the medication on the resident's medication lists that were sent to the pharmacy. On 9/16/2025 at 10:00 AM V23, Nurse Practitioner stated she wasn't aware the facility wrote on Resident R1's and Resident R3's admission medication list that was sent to pharmacy with a handwritten note not to fill medications. V23 stated the facility staff don't have the authority to not fill physician prescribed medications and it most definitely should not be occurring. V23 stated Resident R1 has multiple mental health diagnoses including major depressive disorder and abruptly stopping any of those medications including Austedo and Vraylar to treat her major depressive disorder could cause her to downward spiral into a deep depression and ultimately, she could be so depressed she commits suicide. V23 stated Resident R3 had a diagnosis of diabetes and that's what the injectable medication, Ozempic 1 mg was prescribed to treat. V23 stated Resident R3 wasn't prescribed any other medication to treat diabetes while at the facility and she wasn't aware facility staff put a handwritten note on Resident R3's medication list sent to the pharmacy documented, Not while at the facility. V23 stated she should have known staff were making that decision to not treat Resident R3's diabetes because she would have at least ordered staff to check Resident R3's blood sugar a few times a day and if it was high she would've prescribed sliding scale insulin. V23 stated she knows why the facility isn't filling all the resident's medications, it's because residents on Med A have the facility is responsible for paying for their medications and the facility is always harping her to prescribe lower cost medications and she can't sometimes. On 9/17/2025 at 11:00 AM V1 Administrator, V3 Assistant Director of Nurses and V24 Regional Nurse Consultant stated they were not aware of facility staff writing on resident medication lists that are sent to pharmacy with handwritten notes documenting do not send or not while at the facility. V1 stated pharmacy staff should've questioned that because they know facility staff do not have the authority to document a note like that and not to send the medication or notify her or V2, Interim Director of Nurse of what's going on so they can look into it. V1 stated the facility has a $200 per medication threshold and the pharmacy knows that so when there is a high cost medication the pharmacy emails her a high cost form that documents the current prescribed medication and an alternative lower cost medication and she forwards these forms to the provider, the provider ultimately decides what medication is to be prescribed and the facility will pay for it if the resident is

on Med A. No staff stated they were aware of staff documenting handwritten notes on residents' medications lists and sending it to the pharmacy. On 9/18/2025 at 11:44 AM V1, Administrator responded to

an email and stated, We do not have a formal policy, we request pharmacy provides alternatives and recommendations regarding medications over $200 that must still be approved by the resident physician.

No one goes without medications, if there is no alternative to a high cost medication or the physician declines an alternative/generic, the medication is still provided to the resident.An Undated Physician's Orders Entering and Processing Policy, documents to provide general guidelines when receiving, entering, and confirming physician or prescriber's orders. (a prescriber is noted as physician, nurse practitioner, and

a physician's assistant.) Fax or call the orders to the appropriate pharmacy as needed. If pharmacy is integrated with EHR (Electronic Health Record), orders will be automatically transmitted. Notify the resident's physician (if not the prescribing physician), for verification if applicable.

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