Cycle 1
Health 2025-01-31 · Fire 2025-01-31
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Breese, IL
Evercare Of Breese
2-star overall rating with 3-star inspections with $117,659 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1155 North First Street, Breese, IL
(618) 526-4521
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1982-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.28
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.01
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.05
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.73
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.24
CMS adjusted RN staffing hours
Adjusted total hours
2.55
CMS adjusted total nurse staffing hours
Case-mix index
1.61
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
13,109
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
8.31
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.51
Performance 20.27% · Measure score 2.51 · Achievement 2.51 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 8.96% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
0.82
Baseline 23.33% · Performance 60.35% · Measure score 0.82 · Achievement 0.82 · Improvement 0
Adjusted total nurse staffing
0
Baseline 4.05 hours · Performance 2.85 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.2% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 13.13% · Lower 95% interval 7.72% |
| Discharge to community | 45.58% |
50.57%
5 pts worse
|
No Different than the National Rate · Eligible stays 85 · Observed rate 38.82% · Lower 95% interval 37.56% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 63 · Denominator 63 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 63 |
| Discharge self-care score | 52.5% |
53.69%
1.2 pts worse
|
Numerator 21 · Denominator 40 |
| Discharge mobility score | 35% |
50.94%
15.9 pts worse
|
Numerator 14 · Denominator 40 |
| Pressure ulcers or injuries, new or worsened | 1.59% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 63 · Adjusted rate 1.69% |
| Healthcare-associated infections requiring hospitalization | 8.96% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 98 · Observed rate 12.24% · Lower 95% interval 6.06% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 86 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 55% |
56.45%
1.5 pts worse
|
Numerator 22 · Denominator 40 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 53.85% |
96.28%
42.4 pts worse
|
Numerator 14 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 40.48% |
25.2%
15.3 pts better
|
Numerator 17 · Denominator 42 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
2.0
0.4 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.4 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
2.3
0.1 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.9 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.9% |
89.6%
1.7 pts worse
|
93.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 56.6% · Q2 94.9% · Q3 100.0% · Q4 94.4% · 4Q avg 87.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.4% |
91.6%
7.2 pts worse
|
95.5%
11.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.8% |
50.3%
30.5 pts better
|
11.4%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 9.6% · Q3 25.0% · Q4 28.3% · 4Q avg 19.8% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
6.5%
6.5 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.7% |
18.5%
4.2 pts worse
|
19.6%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 25.0% · Q3 20.3% · Q4 22.4% · 4Q avg 22.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.8% |
22.8%
1 pts worse
|
16.7%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 24.4% · Q3 26.9% · Q4 19.6% · 4Q avg 23.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 31.1% |
17.2%
13.9 pts worse
|
16.3%
14.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 47.0% · Q3 27.5% · Q4 26.3% · 4Q avg 31.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 36.4% |
15.0%
21.4 pts worse
|
14.9%
21.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.1% · Q2 47.2% · Q3 29.6% · Q4 22.2% · 4Q avg 36.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
1.1%
1.7 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 6.3% · Q3 0.0% · Q4 0.0% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.7%
0.5 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.4% |
21.3%
5.1 pts worse
|
19.8%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 47.0% · Q3 22.0% · Q4 17.1% · 4Q avg 26.4% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.2%
1.1 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 2.6% · Q3 3.7% · Q4 3.0% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 67.0% |
68.8%
1.8 pts worse
|
81.7%
14.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 80.0% · Q3 92.0% · Q4 62.7% · 4Q avg 67.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.1% |
14.0%
7.1 pts worse
|
12.0%
9.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 21.2% · Expected 11.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
2.3%
1.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.5% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.5% |
63.0%
16.5 pts better
|
79.7%
0.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.1% |
26.2%
1.9 pts worse
|
23.9%
4.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.1% · Observed 30.3% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-22 · Fire 2023-12-22
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2022-11-17 · Fire 2022-11-17
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-31
E25 · Emergency Preparedness Deficiencies
Fire Safety
Create arrangements with other facilities to receive patients.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-31
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-02-28
F · Potential for more than minimal harm
2025-01-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-19
F · Potential for more than minimal harm
2025-01-31
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-31
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-31
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2025-02-28
E · Potential for more than minimal harm
2025-01-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-28
E · Potential for more than minimal harm
2023-12-22
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-12-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-01-12
F · Potential for more than minimal harm
2022-11-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-01
Inspection history
Recent health citations
G · Actual harm
2025-10-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-25
D · Potential for more than minimal harm
2025-09-18
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-09-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-07-07
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-07-10
G · Actual harm
2025-05-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-13
J · Immediate jeopardy
2025-01-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-17
F · Potential for more than minimal harm
2025-01-31
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-02-17
G · Actual harm
2024-10-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-05
D · Potential for more than minimal harm
2024-07-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-19
G · Actual harm
2024-02-02
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-02-03
E · Potential for more than minimal harm
2022-11-17
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-17
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-12-30
D · Potential for more than minimal harm
2022-11-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-12-30
Penalties and ownership
What sits behind the stars
$19,135
2025-05-20
Fine
Fine · fine $19,135
Fine
$0
2025-05-20
Payment Denial
Payment Denial · denial start 2025-06-11 · 2 days
2 day denial
$87,877
2025-01-31
Fine
Fine · fine $87,877
Fine
$10,647
2024-10-16
Fine
Fine · fine $10,647
Fine
Ownership
Halloran, Mark
5% Or Greater Direct Ownership Interest · Individual
Macaluso, Steven
5% Or Greater Direct Ownership Interest · Individual
Halloran, Mark
Corporate Director · Individual
Halloran, Mark
Corporate Officer · Individual
Halloran, Mark
W-2 Managing Employee · Individual
Macaluso, Steven
Corporate Director · Individual
Macaluso, Steven
Corporate Officer · Individual
Macaluso, Steven
W-2 Managing Employee · Individual
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#3
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