Inspection·December 11, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide residents with incontinence briefs, pads, and diapers that promote residents' dignity for 4 of 4 residents (R1, R2, R13, R14) reviewed for resident needed supplies, in the sample of 15. The findings include: 1. R2's Face Sheet, dated 7/24/23, documents R2 was admitted to the facility on [DATE]. R2's Medical Record, documents R2's Diagnosis include chronic kidney disease (CKD), Hypertension (HTN), Hypothyroidism, Obesity, Osteoporosis, and Pulmonary Embolism. R2's Care Plan, dated 7/24/23, documents R2 has alteration in bladder elimination related to incontinence, wears adult briefs. It continues R2 has risk factors that require monitoring and intervention to reduce potential for self-injury related to falls. Risk factors include use of assistive device, need for assistance with ADL (activities of daily living) completion. Interventions: Review quarterly and PRN (as needed) resident's ADL, mobility, cognitive, behavior and overall medical status. IDT (Interdisciplinary team) review of changes and needs with resident and/or responsible party (when choose to attend) during care plan. Review quarterly and as needed during daily care and services of resident's plan for safety. It continues R2 has impaired physical mobility. Interventions: 9/29/23 (after fall) Continue to educate resident on proper use of assistive device (wheeled walker), 10/10/23 (after fall) restorative walking program. R2's Minimum Data Set (MDS), dated [DATE], documents R2 is cognitively intact and requires substantial/maximum assistance for most of her ADLs. R2 is occasionally incontinent of urine and always continent of bowels. On 12/5/23 at 12:55 PM, R2 stated The biggest problem here is the lack of supplies. Usually, the last two weeks of the month, they run out of (Incontinence Briefs) and diapers. I wear a pad inside my (Incontinence Brief) because I'm on Lasix and have accidents, and I must buy my own because they don't supply them for me. When they run out of (Incontinence Briefs), they want to put me in diapers which I refuse to do, so they will use a smaller size (Incontinence Brief), and it is uncomfortable to wear, and cuts into my legs. I am the Resident Council Vice-President and during the meetings, we always talk about our issues. I think what happens is when a new resident moves in, the staff use other residents supplies for the new resident, and that is why we are always short of supplies. V5 (R2's Niece) documented via letter to Illinois Department of Public Health (IDPH), dated (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 145897 Printed: 05/15/2026 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 145897 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/11/2023 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)