Evercare Of Lebanon

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

implement risk reduction strategies for those identified as an elopement risk, and institute measure for resident identification at the time of admission Elopement is the ability of a cognitively impaired resident who is not capable of protecting himself or herself from harm, to successfully leave the facility unsupervised and unnoticed who may enter into harm's way. Wandering refers to a cognitively impaired resident's ability to move about insive (inside?) the facility aimlessly, but often without clear purpose and without regard to one's personal safety. The Immediate Jeopardy and deficiency practice that began on 9/25/2025 was corrected/removed on 9/26/2025 after the facility took the following actions to correct the noncompliance prior to the start of current survey: Facility failed to ensure residents were supervised to prevent elopement.

Actions Taken: Resident R2 was moved to a room closer to the nurse's station, placed on 1:1 with re-evaluation after 72 hours, elopement risk re-evaluated, and psych medication review requested. Administrator and Director of Nursing were in-serviced by the VP of Clinical Services. Administrator in-serviced the IDT (Intradisciplinary Team). Current staff were in-serviced on elopement policy and procedure. All residents that reside in the facility will have an elopement risk assessment completed. Elopement Binder was updated based on those risk assessments. 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.

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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

10/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Evercare of Lebanon

1201 North Alton Lebanon, IL 62254

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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

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 Resident 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 (Resident 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 (Resident R2) eloped.On 10/8/25 at 5:22 AM, V23 (LPN) stated

she was working the night Resident 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 Resident 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 Resident 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 (Resident 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 (Resident 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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