Federal inspectors documented the sleeping incident at Evercare of Lebanon during an October inspection triggered by the September 25 elopement of a male resident from the facility's locked memory care unit at 7:45 PM.
On October 7 at 5:05 AM, inspectors observed Licensed Practical Nurse V28 in the beauty shop with the lights off, leaned back in a chair, sleeping. V28 was assigned to work the 100 hallway with two nursing assistants that night.
The same staffing pattern had been in place the night the resident escaped. Only one certified nursing assistant was working the male memory care unit when the patient walked out, while the other aide was on break.
V28 told inspectors he had worked the midnight shift for over 20 years without problems 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 documented him saying.
The elopement unfolded during a shift where nurses were splitting responsibilities across multiple units. LPN V19 was working the women's unit when she heard an alarm going off. She initially thought it was a malfunctioning door between the women's and men's sides that had been sticking earlier that day.
"That evening, I went to shut off the alarm and realized the alarm was still going on and that is when I realized it was coming from the men's hall," V19 told inspectors. "I ran down to the other hall. You have to enter a code to go from the women's side to the male side and vice versa."
V19 said she didn't realize there was only one nursing assistant working the men's unit. "I guess the other CNA was on break so there was only 1 CNA on that hall that night the resident eloped."
The sole nursing assistant on duty, V20, was in another resident's room when the patient escaped. V20 told inspectors she has hearing issues and heard an alarm but thought it was the malfunctioning door between units.
"When I heard the alarm, I thought it was just that door not realizing it was the back door," V20 said. "Then I found out later when they did a head count that the resident was missing. No, I did not stop when I heard the alarm and check."
LPN V23 was working a split assignment covering half of the 100 hallway and the entire male memory care unit while passing medications. She told inspectors the incident happened over a week before her interview and "couldn't recall the exact date or time but it could have been after supper."
Administrator V1 told inspectors she had not received recent concerns about staff sleeping on duty. She claimed to frequently visit the facility between 2:00 AM and 5:00 AM to speak with night shift staff and had not observed anyone sleeping.
The facility's undated staffing policy requires "sufficient licensed and unlicensed nursing staff on each shift of the day to attain or maintain the highest practical physical, mental, and psychosocial well-being of each resident."
Federal regulations require nursing homes to provide adequate staffing every day to meet residents' needs and have a licensed nurse supervising each shift. The facility houses 76 residents according to census records from the inspection date.
The staffing failures affected the facility's ability to monitor residents in the locked memory care unit, which houses patients with dementia and other cognitive impairments who require constant supervision to prevent wandering.
Inspectors cited the facility for failing to maintain adequate staffing levels, noting the violations had the potential to affect all 76 residents. The elopement and sleeping incident highlighted how understaffing during night shifts can compromise resident safety in facilities serving vulnerable populations.
The inspection report does not indicate whether the escaped resident was found or what injuries, if any, resulted from the incident.
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.