Inspection visit

InspectionFebruary 27, 2024

EVERCARE OF LEBANONCMS #14589711 citations on this visit

11 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 11 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prevent resident to resident abuse for 7 of 8 residents (R23, R37, R41, R42, R44, R45, R49) reviewed for abuse in the sample of 38. This failure resulted in harm based upon the reasonable person concept, as R23, R41, R42, R44, R45, and R49 would have experienced psychosocial harm including fear, anger, and humiliation as a result of physical abuse, since a reasonable person would not want to be physically abused in their home. Findings includes: 1. During the survey from 2/20 through 2/27/24, R44 was residing on the memory care unit. R44's Minimum Data Set (MDS) dated [DATE] documents that R44 is severely cognitively impaired. R44's Resident to Resident Investigation entitled Investigation of possible Neglect/Abuse form, dated 3/4/23, documents R44 was convinced that R42 is his wife. The Investigation documented that both reside on the dementia unit. The Investigation documented R44 became agitated at R42 grabbed her wrist and then slapped her. The Untitled Follow up to the initial report documents R44 and R42 reside on our memory care unit. The Follow-up report documented R44 was convinced that R42 was his wife, and he wanted her to leave with him. The report documented R44 grabbed her wrist, and when she refused to go, R44 slapped her in the face. The report documented the nurse assessed R42, and she had no bruising or injuries to face or wrist. The report documented In conclusion the QA (Quality Assurance) team implemented a new intervention that the residents are to remain apart. R42's MDS dated [DATE] documents R42 is moderately cognitively impaired. R42's Behavioral Care Plan dated 1/1/24 documents Resident will have a stable, safe environment with routine scheduling of activities. The Care Plan document to Monitor for signs and symptoms of fatigue or agitation. R44's Incident investigation form dated 4/19/23 documents a resident-to-resident altercation occurred on 4/18/23. The form documented CNA (Certified Nursing Assistant) heard a slap. (R44) states (R42) slapped him, R44 slapped back. Must keep residents apart. Must have staff in the common area. Immediately separated. V23's (CNA) written statement dated 4/18/23 documented I heard (R44) and (R42) arguing. She was calling him names because he bumped into her walker. I went to break them up and before I got in there, I heard a slap and seen (R44) standing over (R42). (R44) stated that she hit him, so he hit her (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 12 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 02/27/2024 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 0600 back. Level of Harm - Actual harm The follow up to the initial report, dated 4/19/23 documented In conclusion, the QA team implemented a new intervention that the residents are to remain apart from each other and staff must be present in common areas at all times. Residents Affected - Few 2. R44's follow-up report, dated 5/8/23, regarding the incident on 5/3/23, documents I was reported by the nurse and staff that (R44) wandered into (R45) room. She (R45) then yelled at him (R44) to get out. Staff heard altercation and ran to the room. Upon entrance both residents were hitting each other and yelling. Staff immediately separated them. Upon assessment the nurse noted scratches on both resident's arms. After redirection no further incidents occurred. R44's Nurse's Note, dated 5/3/23 documented Was notified by staff that he heard resident yelling. (R44) wanted resident out of her room. CNA separated residents (and) notified me. Skin assessment done. The Note documented 3 x 1.5 purple bruise L (left) forearm, 1.5 x 1 purple bruise to L forearm, 4.5x3.5 purple bruise L forearm, 2 x .5 purple bruise top left hand, 1.5 x 1 purple bruise to left hand and 2 x 1 purple bruise top of left hand. R45's Nurse's Note, dated 5/3/23, documented Was notified by staff that he heard yelling for (R44) to get out of her room. CNA separated residents and notified the nurse skin assessment done. Resident has 1.x .2 scratch to top of left hand, 1.5 x .5 bruise to left hand (and) 2 x 2 bruise to top of left hand. R45's MDS dated [DATE] documents R45 is severely cognitively impaired. R45 Behavioral Care Plan dated 2/17/24 documents R45 has behavioral disturbances and cognitive deficits. R45's Care Plan Intervention documents Remove resident from situations that are causing anxiety and observe for cues of agitation. 3. R44's Initial Report, dated 7/7/23, regarding incident date 7/6/23 documents There was a resident-to-resident altercation between (R44) and (R41). The report documented Both residents showing aggressive behaviors. (R44) had his hands around (R41) neck, and (R41) scratched (R44). R44's Quality Care Reporting Form, dated 7/6/24, documents scratches to hand, arm, face. R41's A.I.M for Wellness form, dated 7/6/23, documented Was called to TV room when heard screaming. When I got in, I witnessed the other resident hovering over resident with hand on neck. Residents were separated calmed down. The report documented there was redness on R41's neck. R41's MDS dated [DATE] documents R41 is severely impaired for daily decision making. R41's Behavior Care Plan dated 12/2/23 documents residents have behavioral disturbances and cognitive deficits. R41's Goal is resident will have stable, safe environment with routine scheduling of activities to decrease. The Care Plan goal documents Interventions: remove resident from situations that are causing anxiety and observe for cues of agitation. 4. R44's Incident Investigation Form dated 1/28/24 at 3:00 PM documents V25's (CNA) Interview as I was standing in the doorway of the sitting room on the Dementia Unit. (R44) walked by and was heading to the couch to sit by (R23). (R23) then moved the walker next to her in (R44's) way so he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145897 If continuation sheet Page 2 of 12 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 02/27/2024 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 0600 Level of Harm - Actual harm Residents Affected - Few couldn't sit down. (R23) stated b**** f*** you. He tried to move the walker out of the way, but she moved it back in front of him. (R44) then threw the walker and placed his left hand on (R23) throat. I immediately stepped in between them and pulled his hand off her throat. He then tried to slap her, while I was pulling him away stated I'm gonna get ya I took (R44) to the dining room to redirect him and immediately notified the nurse. R44's Psychiatry Note dated 1/29/24 documents Chief Complaint: Patient stated I'm fine. Per staff the patient attempted to strangle another resident. He has a documented history of Major Depressive Disorder, General Anxiety Disorder, and Dementia with behaviors. He denies feeling depressed or hopeless. Physicals and verbal aggression. R44's medications are Depakote 500mg (milligrams) QD (every day), Escitalopram 15mg QD Ativan 1 mg at 6:00 PM. R23's MDS dated [DATE] documents R23 is severely cognitively impaired. R23's Behavioral Care Plan dated 2/15/24 documents Resident will have a stable, safe environment with routine scheduling of activities to decrease behaviors. On 2/22/24 at 3:05 PM V23 (CNA), stated, Sometimes he (R44) is sweet and helpful with other resident's other days he is easily agitated. We try to redirect and get him away from other residents. We sometimes get him a new staff and that helps get him away from other residents. He has 15-minute monitoring and also behavior charting. On 2/23/24 at 9:35 AM V14 (CNA) stated, He (R44) has behaviors, but his behaviors are more spread out now. He can be a handful. 5. R49's Face Sheet documents R49 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and dementia. R49's MDS dated [DATE] documented R49 was severely cognitively impaired and required supervision with ambulation. R49's Care Plan starting 7/26/23 documents, Impaired cognition as related to Alzheimer's/Dementia. R49's Care Plan does not address abuse. R37's Face Sheet documents R37 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, unsteadiness on feet, and other lack of coordination. R37's MDS dated [DATE] documented R37 walked with supervision. R37's cognition was not evaluated. R37's Care Plan starting 10/19/22 documents, Resident may display ineffective coping or overt behaviors due to PTSD (Post-Traumatic Stress Disorder) diagnosis. R37's Care Plan does not address abuse. The Facility's Initial Report sent to the state agency on 9/22/23 at 7:10 PM documents R37 and R49 were involved in a resident-to-resident altercation. The Report documented there were no injuries, the residents' physicians and families were notified, and an investigation was initiated. V13's (Activities Director) Witness Statement dated 9/22/23 at 7:30 PM documents, In the doorway of nurses station on (Memory) unit, at 7:00 PM, (R37) was walking down the hallway from his room without his walker, so I walked to his room and got it for him. He was agitated and yelled this is your fault. (R37) then started walking with walker, and aggressively jerking his walker around. (R37) was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145897 If continuation sheet Page 3 of 12 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 02/27/2024 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 0600 Level of Harm - Actual harm Residents Affected - Few screaming about his wife. (R49) then walked from the dining room and put his hand on (R37)'s shoulder and said, Hey bud calm down. (R37) yelled I [sic] not going to f******* calm down. (R49) then put both of his hands on (R37)'s chest pushing him down. (R37) landed on his buttocks. On 2/21/24 at 12:23 PM, V13 (Activities Director) stated she witnessed the incident between R49 and R37. V13 stated, Basically, (R37) was agitated and yelling and cussing at me, trying to leave (the locked unit). I was trying to calm him down. We had called his wife and tried other things to calm him down. He was standing by the nursing station when (R49) came up and said, 'Hey, [NAME] .Calm down, Bud. It's not that serious.' (R37) reacted by yelling and screaming and continuing to cuss. (R49) pushed him, trying to be protective of me, I think. I think (R37) was blaming me for his wife not coming down here. (R37)'s butt hit the ground, but he did not hit his head. He didn't express pain but was still irate. I stood in between them blocking them (from each other) until another staff member came to help me separate them. (R49) went to the TV room, and (R37) refused to get up. The Facility's Final Report sent to the state agency on 10/31/23 substantiated the abuse, documenting, Investigation revealed (R49) did push (R37) down onto his buttocks. On 2/23/24 at 10:40 AM, V1 (Administrator) stated she expects the Facility to follow its abuse policy. The Facility's Abuse Prevention Program Policy revised 11/28/2016 documents, This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined below. This facility therefore prohibits mistreatment, exploitation, neglect or abuse of its residents, and has attempted to establish a resident sensitive and resident secure environment. This facility is committed to protecting our residents from abuse by anyone including but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individual. Abuse is the willful injection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. An adverse event is an untoward, undesirable, and usually unanticipated event that causes death or serious injury, or the risk thereof. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145897 If continuation sheet Page 4 of 12 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 02/27/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure progressive fall interventions were in place for 2 of 11 residents (R26, R35) reviewed for falls in the sample of 38. Findings include: 1.R35's Face Sheet documents R35 was admitted to the facility on [DATE] with diagnoses including cerebral infarction and traumatic brain injury. R35's Minimum Data Set (MDS) dated [DATE] documented R35 was severely cognitively impaired, ambulated with wheelchair, and was dependent with oral hygiene, toileting, bathing, dressing, personal hygiene, and transfer. R35's Care Plan starting 3/14/23 documents, Resident has risk factors that require monitoring and intervention to reduce potential for self-injury r/t (related to) fall. R35's Fall Risk Assessments dated 9/11/23 and 1/12/24 both documented R35 was at high risk for falls. The Facility's Fall Log dated 2/22/24 documents R35 had falls on 3/15/23, 3/19/23, 4/3/23, 4/20/23, 8/30/23, 9/1/23, 9/11/23, and 1/12/24. R35's Care Plan intervention for her 1/12/24 fall documents, Keep in staff visual when out of bed. On 2/21/24 at 8:40 AM, R35 was sleeping in her specialty chair inside her room. The door was open, but no staff were on the hallway within sight of R35. On 2/22/24 at 8:15 AM, R35 was sitting in her specialty chair in the TV (Television) Room with other residents. There were no other staff in the room or within sight of R35. 2.R26's Face Sheet documents R26 was admitted to the facility on [DATE] with diagnoses including unspecified dementia with behavioral disturbance, unsteadiness on feet, and need for assistance with personal care. R26's MDS dated [DATE] documented R26 was severely cognitively impaired, ambulated with wheelchair, and was dependent in toileting, bathing, lower body dressing, personal hygiene and transfer. R26's Care Plan starting 1/30/20 documents, Resident has risk factors that require monitoring and intervention to reduce potential for self-injury r/t fall. R26's Fall Risk Assessments dated 2/27/23 and 9/11/23 both documented R26 was at high risk for falls. The Facility's Fall Log dated 2/22/24 documents R26 had falls on 2/27/23 and 9/11/23. R26's Care Plan Intervention for the 9/11/23 fall documents, Resident to lay down after meals. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145897 If continuation sheet Page 5 of 12 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 02/27/2024 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 2/21/24 at 8:35 AM, R26 was sitting in her specialty chair in the TV Room watching television. V8 (Certified Nursing Assistant/CNA), stated sometimes R26 goes to bed after meals, and sometimes she watches television. V8 stated they watch R26's body language, and if she does not appear to be tired after lunch, they bring her in the TV Room to watch television. On 2/21/24 at 12:43 PM, R26 was sitting in her specialty chair inside her room after lunch service. R26 was awake and rubbing her hands together. On 2/22/24 at 8:15 AM, R26 was sitting in the TV Room with other residents after breakfast service. On 2/21/24 at 12:05 PM, V1 (Administrator) stated all fall interventions should be documented in the resident care plan. On 2/23/24 at 10:40 AM, V1 (Administrator) stated she expects staff to follow the Facility fall policy and ensure progressive interventions are in place. The Facility's Fall Prevention Policy revised 11/10/18 documents, Policy: To provide for resident safety and to minimize injuries related to falls; decrease falls and still honor each resident's wishes/desires for maximum independence and mobility. All staff must observe residents for safety. Immediately after any resident fall the unit nurse will assess the resident and provide any care or treatment needed for the resident. A fall huddle will be conducted with staff on duty to help identify circumstances of the event and appropriate interventions. The unit nurse will place documentation of the circumstances of a fall in the nurse's notes or on an AIM for Wellness form along with any new intervention deemed to be appropriate at the time. The unit nurse will also place any new intervention on the CNA assignment worksheet. All falls will be discussed in the Morning Quality Assurance meeting and any new interventions will be written on the care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145897 If continuation sheet Page 6 of 12 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 02/27/2024 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 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, and record review, the facility failed to provide a Registered Nurse (RN) for a least 8 consecutive hours a day 7 days a week. This failure has the potential to affect all 64 residents residing at the facility. Findings include: The facility working schedule for February 2024 shows V2 (Director of Nursing/DON) was the only RN scheduled on 2/1/2024, 2/2/2024, 2/5/2024, 2/6/2024, 2/7/2024, 2/8/2024, 2/9/2024, 2/12/2024, 2/13/2024, 2/14/2024, 2/15/2024, 2/16/2024, 2/19/2024, 2/20/2024, 2/21/2024, and 2/22/2024. On 2/21/2024 V2 (DON) was observed working in the facility as a floor nurse. On 2/22/2024 at 3:10PM V12 (Licensed Practical Nurse/LPN) stated During the week we have the Director of Nursing as our RN coverage. On the weekends we have an RN that comes in. On 2/23/2024 at 8:40AM V2 stated I work the floor whenever there is a call off. We also use agency to fill in. On 2/23/2024 at 9:00AM V8 (Certified Nursing Assistant/CNA) stated There is an RN that usually works the weekends and (V2) is here during the week. Facility undated staffing policy states It is the policy of [NAME] Healthcare 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 wellbeing of each resident. Nurse staffing shall be based upon resident evaluation by the Administration and Director of Nursing as specified by the (state agency). The facility's Long-Term Care Facility Application for Medicare and Medicaid, CMS 671, dated 2/22/24, documented that 64 residents reside in the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145897 If continuation sheet Page 7 of 12 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 02/27/2024 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 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow physician prescribed therapeutic diet orders for 1 of 1 resident (R5) reviewed for therapeutic diets in the sample of 38. Findings include: R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including dementia, chronic systolic (congestive) heart failure, and end stage renal disease. The Face Sheet documents R5 goes to dialysis three days per week. R5's Minimum Data Set (MDS) dated [DATE] documented R5 was severely cognitively impaired. R5's Care Plan reviewed 11/9/22 documents, Potential risk for altered nutritional status and/or weight loss related diagnosis renal failure, goes to dialysis 3x/week. The Care Plan intervention documents Provide diet as ordered. See POS (Physician Order Summary) for current diet order. R5's Physician Orders for 2/1/24 through 2/29/24 documents diet as, cottage cheese at breakfast and lunch, no OJ (orange juice)/bananas/baked potato/tomato products, mechanical soft/pureed meats, double protein port (portions). R5's Diet Card for lunch documents Renal, Mechanical (Soft) Diet with no potatoes, orange juice, banana, or tomato. On 2/20/24 at 12:35 PM, V3 (Dietary Manager) took a baked potato out of the oven, removed the skin, chopped the potato, and placed it on R5's plate. On 2/20/24 at 12:43 PM, V3 pointed to a binder and stated, We follow the menu. Oh, it does say corn (instead of potatoes). Well, she can't have corn because she is a mechanical, but we usually never give her potatoes. I think my thought process was it would be more acceptable and softer without the skin. On 2/23/24 at 10:40 AM, V1 (Administrator) stated she expects staff to follow therapeutic diet orders. The Facility's Therapeutic & Mechanically Altered Diets Policy revised 10/20 documents, It is the policy of (Facility Company) that therapeutic and mechanically altered diets are ordered by the physician and planned by the dietitian. A physician's order is written for all diets including therapeutic and mechanically altered diets. The facility prepares and serves all therapeutic and mechanically altered diets as planned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145897 If continuation sheet Page 8 of 12 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 02/27/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure the dish machine sanitizes dishes, and failed to store, prepare, and distribute food in a manner that prevents potential contamination. This has the potential to affect all 64 residents living in the facility. Findings include: 1. On 2/20/24 at 8:00 AM, there was a flexible hose attached to the back of the ice machine that was covered in a black, patchy substance. The hose was resting directly on floor where any drainage would run directly onto the kitchen floor. 2. On 2/20/24 at 8:03 AM, V4 (Cook) stated she tested the dish machine before breakfast but could not remember where she placed the test strips. On 2/20/24 at 8:05 AM, V4 located the dish machine test strips and placed one strip into the machine mid-cycle. The chemical sanitizing dish machine utilized quaternary sanitizer. V4 stated I'm trying to get it (to change colors). V4 tested three different strips which all resulted in a yellow color. V4 stated the test strip should result in a green color to indicate correct level of sanitizer. V3 (Dietary Manager) stated she would change out the sanitizing solution. 3. On 2/20/24 at 8:07 AM, in the walk-in refrigerator there was a 48-ounce container of commercially manufactured potato salad with a brown liquid inside. The container was not dated, and the label did not reflect the substance inside. There was a 32-ounce container of commercially manufactured chicken salad that was partly consumed but had not been dated upon opening. There was a box of 10 individual yogurts with a Best By date of 2/2/24. There was a box of 11 individual yogurts with a Best By date of 2/11/24. The yogurt boxes were soft, and there were ice crystals on the fans overhead. There was a tub containing a white substance that was covered with plastic wrap and was not labeled or dated. There was a box of bacon that had been opened, but was not resealed, leaving the contents inside open to air. The box of bacon had not been dated upon opening. There were 5 pitchers of brown liquid that were not labeled or dated. On 2/20/24 at 8:13 AM, in the walk-in freezer there was a plastic bag of frozen omelets that was not labeled or dated. There were three plastic bags of frozen potato cakes that were removed from the original box but were not dated or labeled. On 2/20/24 at 8:17 AM, V3 stated the container with the white substance in the walk-in refrigerator was fettucine alfredo, and the label on the container had just rubbed off. She stated the dish was from three days ago and will throw it out. On 2/20/24 at 8:20 AM, V3 stated the chicken salad and potato salad are not for resident consumption, and one of the staff members likely put it in there. On 2/21/24 at 12:26 PM, V1(Administrator) stated she expects staff to follow the Facility's food service policies. The Facility's Storage Policy revised 10/20 documents, It is the policy of (Facility Company) that food shall be stored on shelves in areas that provide the best preservation. Food shall be stored at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145897 If continuation sheet Page 9 of 12 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 02/27/2024 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 0812 Level of Harm - Minimal harm or potential for actual harm the proper temperature and for appropriate lengths of time to protect quality of food and food cost. The Policy documents All items will be dated upon receipt. Individual cans or bags shall each be dated to ensure that stock is rotated properly. The Policy documents Store leftovers in covered, labeled and dated containers under refrigeration or frozen. The Policy documents When using only part of a product, the remaining product should be in the original package or airtight contained [sic] and labeled and dated. Residents Affected - Many The Facility's Long-Term Care Facility Application for Medicare and Medicaid form, CMS-671 dated 2/20/24, documents there are 64 residents living in the Facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145897 If continuation sheet Page 10 of 12 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 02/27/2024 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 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide ordered specialized rehabilitative services for 4 of 4 residents (R29, R52, R111, R161) reviewed for specialized rehabilitative services in the sample of 38. Residents Affected - Some Findings include: 1. On 2/20/24 at 10:34 AM, R111 stated she was unhappy because she came to this facility from the hospital for physical therapy and has yet to have any therapy or even meet with a therapist. R111's Face Sheet documents R111 was admitted to the facility on [DATE]. R111's Social Service admission Assessment documents R111 had a fall at home and was being admitted for therapy rehab. R111's Physician Order dated 2/19/24 documents, PT/OT/ST (Physical Therapy/Occupational Therapy/Speech Therapy) eval (evaluation) when available. R111's Baseline Care Plan dated 2/14/24 documented R111 was alert to time, self, and place, and made her own decisions. It documents R111 used wheelchair and walker for ambulation and was dependent with one person assistance for bed mobility, locomotion, bathing, hygiene, toileting, transfer, and dressing. On 2/22/2024 at 10:35 AM, V1 (Administrator) stated We do not have a therapy program at this time. We have a new program beginning next week. On 2/22/2024 at 10:50 AM V21 (Contracted Physical Therapist) stated The therapy company I work for has severed its contract with the Facility due to nonpayment. The last day of the contract was 2/17/2024, and the last time I was in Facility was 2/16/2024. On 2/22/24 at 2:49 PM, V1 (Administrator) stated, I can't get it (new therapy contract), because they are in the middle of doing it. When asked if the contract was still being settled, V1 stated, I would say that. Yes. 2.R29's Face Sheet documents R29 was admitted to the facility on [DATE] with diagnoses including acute kidney failure, depression, anxiety, hypokalemia (low potassium), and tachycardia (rapid heartbeat). R29's undated Physician Order documents Yes to PT and OT. On 2/23/24 at 10:40 AM, V1 (Administrator) stated sometimes orders are written out in detail, but other times the prescriber just circles Yes or No to the therapies. R29's MDS dated [DATE] documented R29 was moderately cognitively impaired, ambulated with wheelchair and/or scooter, and required substantial assistance with transfer. 3.R52's Face Sheet documents R52 was admitted to the facility on [DATE] with diagnoses including (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145897 If continuation sheet Page 11 of 12 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 02/27/2024 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 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some hypertension, chronic obstructive pulmonary disease, hyperlipidemia, type 2 diabetes mellitus, neuropathy, aphasia, obstructive sleep apnea, and arthritis. R52's Physician Order dated 1/29/24 documents, PT and OT to evaluate and tx (treat). R52's MDS dated [DATE] documented R52 was severely cognitively impaired, ambulated with wheelchair, and was dependent with toileting, bathing, and transfer. 4.R161's Face Sheet documents R161 was admitted to the facility on [DATE] with diagnoses including schizophrenia and gangrene to finger on right hand. R161's undated physician order documents Yes to PT and OT. R161's MDS dated [DATE] documented R161 was moderately cognitively impaired and required substantial assistance with eating, oral hygiene, toileting, bathing, dressing, and personal hygiene. The Facility's List of residents who had been receiving therapy in the Facility was provided and included R29, R52, and R161. During the survey from 2/20/24 through 2/23/24, no residents were observed participating in Physical Therapy, Occupational Therapy, or Speech Therapy. On 2/23/24 at 10:40 AM, V1 (Administrator) stated they were given a five-day notice that the therapy company would no longer be providing services to the Facility. She stated the Facility does not have a policy regarding specialized therapy services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145897 If continuation sheet Page 12 of 12

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Citations

11 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0600SeriousS&S Gactual harm
F600 - Freedom from Abuse, Neglect, and Exploitation
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
0689GeneralS&S Epotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0812GeneralS&S Fpotential for harm
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
0825GeneralS&S Epotential for harm
F825 - Specialized rehabilitative services
Provide or get specialized rehabilitative services as required for a resident.
0727GeneralS&S Fpotential for harm
F727 - Except when waived under paragraph (f) or (g) of this section, the
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.
0808GeneralS&S Dpotential for harm
F808 - Therapeutic Diets
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
0324GeneralS&S Epotential for harm
Provide properly protected cooking facilities.
0355GeneralS&S Fpotential for harm
Properly select, install, inspect, or maintain portable fire extinguishes.
0372GeneralS&S Epotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
0712GeneralS&S Fpotential for harm
F712 - Frequency of physician visits
Have simulated fire drills held at unexpected times.
0923GeneralS&S Epotential for harm
F923 - Have adequate outside ventilation by means of windows, or mechanical
Have proper medical gas storage and administration areas.

FAQ · About this visit

Common questions about this visit

What happened during the February 27, 2024 survey of EVERCARE OF LEBANON?

This was a inspection survey of EVERCARE OF LEBANON on February 27, 2024. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at EVERCARE OF LEBANON on February 27, 2024?

Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect b..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Inspection·February 27, 2024