Evercare of Lebanon

In the surveyor’s words

From the most serious findings on record at Evercare of Lebanon, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Feb 25, 2022

  Based on observation, interview and record review the facility failed to implement infection control procedures to prevent the spread of COVID-19 as evidenced by: failing to isolate COVID-19 positive resident from other residents whose COVID-19 status is unknown; failing to identify COVID-19 related symptoms and utilize testing strategies to determine the extent of outbreak; failing to implement required isolation procedures; failing to ensure all staff wear required personal protective equipment; failing to ensure staff conducted required screening and do not work with possible COVID-19 symptoms; and failing to encourage residents to wear source control and socially distance. […]

• Immediate jeopardy, isolatedF609Apr 16, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689Oct 14, 2025

  Based 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. Findings include: The Immediate Jeopardy began on 9/25/2025 when R2 eloped from the facility and there was no staff available to redirect R2. […]

• Immediate jeopardy, isolatedF689Jul 10, 2025

  Based 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.Findings include: The Immediate Jeopardy began on 6/19/2025 when R2 eloped from the facility at around 3AM in the morning in the pitch darkness and R2 was found on the side of the road by a civilian. […]

• Actual harm, isolatedF686Apr 30, 2026

  Based 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.R8's Minimum Data Set, dated [DATE], documents R8 has severe cognitive… […]