Evercare of Lebanon: Staffing Failures Led to Elopement - IL
The elopement came to light not because anyone saw R2 leave, but because staff did a head count and he was gone.
The sequence of failures that allowed it to happen unspooled over several staff interviews conducted by inspectors in early October. V19, a licensed practical nurse who was working the women's unit the night R2 got out, told inspectors that a door on the women's side had been sticking and triggering false alarms earlier that day. When she heard an alarm that evening, she went to silence what she assumed was the same door, and only then realized the sound was coming from the men's hall. She ran. To get from the women's side to the men's side, she said, you have to enter a code. By the time she got there, R2 was already gone.
V20, the CNA who was the only staff member physically present on R2's hall when he left, said she heard the alarm too. "I thought it was just that door not realizing it was the back door," she told inspectors. She did not stop to check. She has hearing issues, she said, and she was in a room with another resident. The other CNA assigned to the hall was on a lunch break. V23, the LPN who had been assigned to cover both the 100-hall split and the male memory care unit that night, told inspectors she couldn't recall the exact date or time of the elopement. It was over a week ago, she said.
That was the staffing picture on the night a memory care resident walked out of a locked unit: one nurse splitting her attention across multiple hallways, one CNA on break, one CNA alone in a room with another resident, and an alarm that two separate staff members heard and dismissed.
Inspectors returned to the facility for an early-morning visit on October 7. At 5:05 AM, they found two CNAs covering the entire locked memory care wing, one on the male unit and one on the female unit, with a single nurse working both. Then they found V28.
V28, an LPN, was in the beauty shop with the lights off, leaned back in a chair, asleep.
When inspectors spoke with him the following morning, V28 said he had worked the midnight shift for more than 20 years and had never had trouble with it until a recent car accident. "Sometimes he just needs to sit back, relax, and waits for his name to be called when he is needed," inspectors wrote, summarizing his account.
The administrator, V1, told inspectors on October 8 that no one had recently brought concerns about staff sleeping on the job to her attention. She said she comes into the facility herself between 2:00 AM and 5:00 AM to check on night staff and had never seen anyone sleeping. Inspectors had found V28 asleep at 5:05 AM.
The facility's own staffing policy states that sufficient nursing staff must be provided on each shift to attain or maintain the highest practical well-being of each resident. On the night R2 walked out of a locked unit, there was one CNA on his hall, and she was in another room, and she heard the alarm, and she kept going.
Inspectors cited the facility for failing to maintain adequate staffing, noting the deficiency had the potential to affect all 76 residents in the building.
Where R2 was found, and what condition he was in when staff located him, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evercare of Lebanon from 2025-10-14 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
EVERCARE OF LEBANON in LEBANON, IL was cited for violations during a health inspection on October 14, 2025.
The elopement came to light not because anyone saw R2 leave, but because staff did a head count and he was gone.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.