Evercare Of Lebanon
EVERCARE OF LEBANON in LEBANON, IL — inspection on October 14, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of policy and procedure were completed to reflect current practice.
All staff have been in-serviced on elopement, and procedures on steps to take if a resident is at risk.
All facility staff will were in-serviced by 9/26/25 for elopement and staffing. A QA tool was implemented along with Daily audits of the 24-hour report for wandering/elopement risks.
Daily audit for elopement risk assessments completed within 72 hours of admission.
Audits to continue daily for 4 weeks to ensure that elopement risk is documented.
Root Cause Analysis completed for elopement: Deficiency: Failed to prevent elopement.
Initiated 9/25/25, Completed on 9/26/2025.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/14/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Evercare of Lebanon
1201 North Alton Lebanon, IL 62254
SUMMARY STATEMENT OF DEFICIENCIES
Based on observation, interview, and record review, the facility failed to have an adequate number of staff available to care for the residents when reviewed for staffing.
This failure has the potential to affect all 76 residents residing in the building.
Findings Include:The facility's Final Report to the state surveying agency, dated 10/3/25, documents R2 eloped from the facility on 9/25/25 at 7:45 PM from the male locked memory care unit, on which he resided. On 10/7/25 at 5:05 AM, there were two CNAs (Certified Nursing Assistant), one on the male locked memory care unit, one on the female locked memory care unit, and one nurse that was working both the male and female locked memory care units. V28 (Licensed Practical Nurse/LPN), was observed in the beauty shop with the lights off, leaned back in a chair, sleeping. V28 was working on the 100 hallway with two CNAs.On 10/7/2025 at 5:20 PM, V19 (LPN) stated, I was working the night (R2) got out of the facility. I was on the women's unit and earlier that day the exit door on the woman's side (200 hall) was sticking which would cause the alarm to go off.
That evening, I went to shut off the alarm and realized the alarm was still going on and that is when I realized it was coming from the men's (300 hall). I ran down to the other hall.
You have to enter a code to go from the women's side to the male side and vice versa. I was not working the hall (V23 LPN) had a split hall that night and she was passing out medications on the 100 hall. At that time, I did not realize there was only one CNA working. I guess the other CNA was on break so there was only 1 CNA on that hall that night (R2) eloped.On 10/8/25 at 5:22 AM, V23 (LPN) stated she was working the night R2 eloped from the facility, she was working the 100-hall split (1/2 of the 100 hallway and the male memory care unit), when she was notified that R2 was gone. V23 stated this was over a week ago and couldn't recall the exact date or time but it could have been after supper. V23 stated they did a head count and R2 was missing. On 10/8/25 at 5:39 AM, V28 (LPN) stated he has worked the midnight shift for over 20 years and had never had trouble with it until he was in a car accident recently. V28 stated sometimes he just needs to sit back, relax, and waits for his name to be called when he is needed.
On 10/8/25 at 6:37 AM, V1 (Administrator) stated she has not had any recent concerns brought to her attention regarding staff sleeping on the job. V1 stated she will often come into the facility between 2:00 AM and 5:00 AM, to talk with the night shift staff and hasn't observed anyone sleeping. On 10/8/2025 at 11:00 AM, V20 (CNA) stated, I was working a split 100 hall and men's hall. My nurse was passing out medications, and the other CNA was out on lunch break. I was the only one working on that hall when (R2) exited the building. I was in another room with another resident getting them ready for bed. I have hearing issues, and I heard an alarm, but we had been having issues with the door from the women's side to the male's side and the door was sticking and when I heard the alarm, I thought it was just that door not realizing it was the back door.
Then I found out later when they did a head count that (R2) was missing. No, I did not stop when I heard the alarm and check.The Staffing Policy, undated, documents it is the policy of the facility to provide sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident.
Nurse staffing shall be based upon resident evaluation by the Administrator and Director of Nursing as specified by the (state surveying agency).
The Resident Census, dated 10/7/25, documents there are 76 residents residing in the facility.
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