Evercare of Lebanon

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate pressure relief to prevent new pressure ulcers from developing and prevent declines in existing pressure ulcers in 1 of 1 resident (R8), reviewed for Treatment/Services to Prevent/Heal Pressure Ulcers in the sample of 37. These failures led to R8 developing a new pressure ulcer and a decline in current pressure ulcers. Findings Include: R8's Face Sheet, undated, documents R8 has the following diagnoses, in part: Cerebrovascular Disease, Traumatic Brain Injury, Vascular Dementia, Epilepsy, Hypertension, Hypothyroidism, Hyperlipidemia, Stage 3 Pressure Ulcer to the Sacrum (Coccyx), and Stage 2 Pressure Ulcer to the Left Hip. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure sexual abuse allegations were reported for 1 of 4 residents (R3) reviewed for abuse. This failure occurred when R2, who had known sexually inappropriate behaviors, went into R3's room and was observed with his hands in R3's briefs and staff did not report the incident. A reasonable person would likely suffer serious psychosocial harm, such as emotional distress or trauma and fear for safety as a result of sexual abuse.

Inspectors wroteBased on interview and record review the facility failed to ensure 2 of 4 residents (R3 and R5) were protected from resident-to-resident abuse. This failure resulted in R3, who was nonverbal under end-of-life care, being the victim of sexual abuse by another resident (R2) with known inappropriate sexual behaviors. A reasonable person would likely suffer serious psychosocial harm, such as emotional distress or trauma and fear for safety as a result of sexual abuse. Findings Include:1. R3's Face Sheet, admission date of 03/13/16, documents R3 has diagnoses of but not limited to unspecified dementia, malignant neoplasm of upper-outer quadrant of unspecified female breast, major depressive disorder, recurrent, in partial remission, and hypertension (HTN). [...]

Inspectors wroteBased on interview and record review the Facility failed to ensure misappropriation of medication did not occur for 2 of 3 residents (R6 and R7) reviewed for missing medication in the sample of 8. This past non-compliance occurred from 10/8/2025 to 10/29/2025.

Inspectors wroteBased on observation, interview and record review the Facility was unable to account for narcotic medication (alprazolam) for 2 of 3 residents (R6 and R7) reviewed for missing narcotic medication in the sample of 8. This past non-compliance occurred from 10/8/2025 to 10/29/2025.

Inspectors wroteBased on observation, interview and record review the Facility failed to ensure residents did not exit through an exit door and were being supervised to prevent any potential elopements for 1 of 3 residents (R2) reviewed for elopement in the sample of 6. This failure resulted in R2 pushing the exit alarm and exiting the facility around 7:45 PM with no staff intervention on 9/25/2025 from a secured memory unit and leaving the facility when it was pitch dark and he was later found at 10:00 PM (two hours and 15 minutes later) and returned to the facility. This past compliance occurred from 9/25/2025 to 9/26/2025.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents did not exit through an exit door and were being supervised to prevent any potential elopements for 1 of 6 residents reviewed for elopement in the sample of 15. This failure resulted in R2 pushing the exit alarm and exiting the facility around 3AM on 6/19/2025 from a secured memory unit into pitch darkness and was found wandering around by a civilian driving in his car two subdivisions over (one block east and one block north) from the facility. This past non-compliance occurred on 6/19/2025.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the required Registered Nurse (RN) coverage services for eight consecutive hours a day for seven days a week. This has the potential to affect all 75 residents living in the facility.

Inspectors wroteBased on interviews and record reviews the facility failed to provide Register Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week. This has the potential to affect all 54 residents residing in the facility reviewed for RN coverage in a sample of 39.

Inspectors wroteBased on observation, interview, and record review, the facility failed to operationalize the facility's Legionella Policy and Procedure and perform hand hygiene to prevent the spread of infections (R5). This has the potential to affect all 54 residents.

Inspectors wroteBased on interviews, observations, and record reviews the facility failed to feed residents in a dignified manner for 4 out of 4 residents (R11, R14, R17, R34) reviewed for dignity in a sample of 39.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement progressive care plan interventions and ensure interventions were followed to prevent falls for 4 of 6 residents (R5, R10, R30, and R31) reviewed for falls in a sample of 39.

Inspectors wroteBased on observation, interview, and record review, the facility failed to date medications containers that had been opened, and to ensure proper medication storage was maintained during medication administration for 4 of 4 residents (R6, R32, R49, R105) reviewed for medication labeling and storage in the sample of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide incontinent care per standards of practice for 3 of 5 residents (R5, R11, R26) reviewed for incontinent care in a sample of 39.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen tubing was dated as well as provide humidified water per their policy for 3 of 3 residents (R5, R12, R31) reviewed for oxygen administration, in the sample 39.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain equipment in safe condition regarding lint buildup and failed to follow the Facility Policy. This has the potential to affect all 54 residents in the facility.

Inspectors wroteBased on interview and record review, the Facility failed to document the discharge in the medical record and communicate necessary information for receiving facility for 1 of 3 residents (R2) reviewed for discharge in the sample of 5.

Inspectors wroteBased on interview and record review, the Facility failed to follow discharge requirements for 1 of 3 residents (R2) reviewed for discharge in the sample of 5.

Inspectors wroteBased on interview and record review, the Facility failed to allow a resident to return to the Facility following hospitalization in 1 of 3 residents (R2) reviewed for transfer/discharge in the sample of 5.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 49 residents living in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was stored, labeled, and prepared in a manner which prevents potential contamination. This has the potential to affect all 49 residents living in the facility.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the Facility failed to complete quarterly Resident Assessments/Minimum Data Sets (MDS) in a timely fashion for 4 of 5 residents (R1, R2, R8, R10) reviewed for quarterly MDS in the sample of 14.

Inspectors wroteBased on interview and record review, the Facility failed to revise care plans as needed for 3 of 5 residents (R1, R8, R10) reviewed for Care Plans in the sample of 14.

Inspectors wroteBased on interview, and record review, the facility failed to prevent resident to resident sexual abuse for 2 of 3 residents (R2 and R3) reviewed for abuse in a sample of 7. This failure resulted in harm as a reasonable person would not engage in sexual encounters without the decisional capacity to do so.

Inspectors wroteBased on observation, interview and record review, the facility failed to use the services of a Registered Nurse for at least 8 consecutive hours a day, 7 days a week. This failure has the potential to affect all 50 residents living in the facility.