Evercare of Lebanon: Elopement Immediate Jeopardy - IL
Federal inspectors classified the failure as immediate jeopardy, the most serious category of nursing home violation, meaning the deficiency had already caused or was likely to cause serious injury or death to a resident. The finding was documented during a complaint inspection completed October 14, 2025.
The resident identified in the inspection report only as R2 was cognitively impaired and, by the facility's own definition, incapable of protecting themselves from harm. That is precisely the kind of resident an elopement prevention system is designed to protect. Evercare of Lebanon did not have one working.
Elopement, as the inspection report defines it, is when a cognitively impaired resident who cannot protect themselves successfully leaves a facility unsupervised and unnoticed and may enter into harm's way. The word "unnoticed" is doing heavy work in that definition. It means staff did not see R2 leave. It means no alarm stopped them. It means whatever systems existed on September 25, 2025, failed completely.
The facility did not dispute any of this.
What happened after the elopement tells its own story about how unprepared the facility was. Within 24 hours, Evercare of Lebanon moved R2 to a room closer to the nurse's station and placed them on one-to-one supervision, meaning a staff member assigned to that resident alone, with a re-evaluation ordered after 72 hours. A psychiatric medication review was requested. The administrator and the director of nursing were personally in-serviced by the company's vice president of clinical services. The administrator then turned around and in-serviced the entire interdisciplinary team. Current staff were in-serviced on elopement policy and procedure. All residents in the building had elopement risk assessments completed. The facility's elopement binder was updated. Policy and procedure documents were revised. Every staff member in the building was in-serviced on elopement and staffing by September 26. Daily audits were implemented and scheduled to run for four weeks.
All of that happened in one day.
That timeline is not a story of a facility responding quickly to an emergency. It is a story of a facility that had been operating without functional elopement safeguards for long enough that a single incident required a complete rebuild of the system from the ground up, completed in under 24 hours because inspectors were watching.
The immediate jeopardy was initiated on September 25, 2025, the day of the elopement. It was removed on September 26, after the facility completed its emergency corrective actions. The complaint inspection itself concluded on October 14, nearly three weeks later.
Wandering, the inspection report notes, is different from elopement. Wandering is a cognitively impaired resident moving through the facility aimlessly, without clear purpose, without regard to their own safety, but still inside. Elopement is when they get out. The distinction matters because facilities are supposed to assess which residents are at risk for each, document that risk, and put systems in place accordingly. The inspection record makes clear that at Evercare of Lebanon, R2's elopement risk had not been adequately addressed before September 25.
The root cause analysis the facility completed identified the deficiency plainly: failed to prevent elopement.
That analysis was initiated on September 25 and completed on September 26. A root cause analysis conducted in one day, under immediate jeopardy status, while simultaneously retraining every staff member and revising every relevant policy, raises its own questions about how thorough the underlying investigation could have been.
What the inspection record does not say is also significant. It does not say where R2 went after leaving the facility. It does not say how long they were outside, or unsupervised, or both. It does not say whether R2 was found on the facility grounds or somewhere else. It does not say whether R2 was injured. The inspection report as filed with the Centers for Medicare and Medicaid Services does not answer any of those questions.
What it does say is that R2 is cognitively impaired, that cognitively impaired residents who elope "may enter into harm's way," and that R2 eloped.
Evercare of Lebanon is located at 1201 North Alton in Lebanon, Illinois, a small city in St. Clair County in the southwestern part of the state. The facility's CMS provider number is 145897.
The corrective actions the facility took were extensive enough that federal inspectors agreed to remove the immediate jeopardy finding within 24 hours. R2 was moved closer to staff. One-to-one supervision was assigned. A psychiatric medication review was requested, suggesting that medication may have been a factor in R2's behavior, or that it was considered as a tool for managing that behavior going forward. The elopement binder, a document that should have contained current risk assessments for every resident who poses an elopement risk, was updated because it had not been current before.
The daily audits the facility committed to, four weeks of them, would check whether elopement risk assessments were being completed within 72 hours of each new admission. That 72-hour window matters because the period immediately after admission is when a resident's risk is least understood and the facility's defenses are most likely to have gaps. The audit commitment suggests that gap had existed before September 25, not just for R2 but potentially for other residents as well.
The vice president of clinical services traveling to the facility to personally in-service the administrator and director of nursing is not a routine corrective action. It is what happens when a company's leadership concludes that the people responsible for running the building did not understand what was required of them, or had not been enforcing it.
R2 remains a resident at the facility, moved now to a room closer to the nurse's station, with staff assigned to watch them, in a building where every employee has been retrained and every policy has been rewritten. Whether that is enough is a question the daily audits are supposed to answer.
The inspection report does not say what R2 experienced on September 25, between the moment they left the building and the moment someone realized they were gone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evercare of Lebanon from 2025-10-14 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: August 4, 2026 · Our methodology
EVERCARE OF LEBANON in LEBANON, IL was cited for immediate jeopardy violations during a health inspection on October 14, 2025.
The finding was documented during a complaint inspection completed October 14, 2025.
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.