Evercare of Lebanon: Narcotic Pills Vanished From Residents - IL
Nobody was.
The missing narcotics came to light in a sequence that a licensed practical nurse described in detail to inspectors on November 21, 2025. The nurse, identified in inspection records as V8 LPN, said she had called the pharmacy to reorder medication for a resident identified as R7, only to be told by the pharmacist that two cards totaling 60 pills had already been sent out. Thirty of those pills should still have been on hand. They weren't.
"The pharmacy told me that they sent out two cards, 60 pills, so he should have 30 more pills, and it was too early," V8 told inspectors. She went and found another nurse working the floor to report the problem. A count was done. Then a second shortage turned up. A resident identified as R6 was also missing her medication.
"I guess they did a count and R6 was missing her medication too," V8 said. "I am not sure if they were able to find out who took the meds. I don't know if anyone was fired. I was not drug tested."
A second staff member, identified in the report as V17, told inspectors she had been working the front hall when the medication arrived from the pharmacy. She was the one who signed for it. She remembered two cards rubber-banded together. She took the delivery back to an agency nurse, identified as V18 LPN, who was working the dementia unit. Shortly after, the Director of Nursing called V17 to ask whether she had counted the medication when she received it.
She had said yes.
"They said V18 was fired because they suspected she was the one taking the drugs," V17 told inspectors. "I was not asked to drug test, after they found out some drugs were missing."
The inspection report does not say what medications were taken, what doses were involved beyond the 30-pill gap in R7's supply, or whether either resident experienced any consequences from going without their controlled substances. The period of noncompliance was documented as running from October 8 through October 29, 2025, three weeks during which the shortage apparently went undetected.
What the facility's own narcotic counting policy required during those three weeks was explicit and detailed. The policy, revised as recently as November 1, 2025, just days after the noncompliance period ended, spelled out that staff should always participate in counting controlled substances at the beginning and end of every shift. It stated that staff should never say "go ahead without me and I'll sign later." It warned that signing for medications without directly observing them could implicate a staff member if those medications later went missing.
The policy also required nurses to inspect the physical integrity of every medication card, checking whether pills had been punched out of sequence, whether the card itself had been tampered with, whether the pills themselves looked correct. It required a partner for every count, a verbal confirmation, a signature with time and date, and the return of keys to the appropriate person after every single count.
Whether any of those steps were followed consistently during October is not addressed in the inspection report. What the report does establish is that 30 pills were gone before anyone noticed, and that the mechanism for catching the loss was not the counting process but a pharmacist flagging a reorder as premature.
The facility told inspectors what it had done after the fact. All staff and residents were interviewed. Staff were given in-service training covering medication handling, controlled substance disposal, narcotic count verification, and abuse. Residents were assessed for behavioral changes. The Director of Nursing began conducting daily audits of narcotics. The Social Services Director started daily psychosocial check-ins with residents.
The inspection report does not say whether the missing medications were ever accounted for, whether law enforcement was contacted, or what became of the agency nurse who was fired. It does not say whether R7 or R6 were told their medications had gone missing, or whether their families were notified. It does not say whether either resident went without doses during the three weeks the shortage went undetected, or whether substitute medications were provided.
R7 was running low on a controlled substance and called the pharmacy to reorder. That call is what exposed the loss. Without it, the inspection report gives no indication of when, or whether, the missing pills would have been discovered.
The violation was cited at a level of harm described as minimal harm or potential for actual harm, affecting few residents. That classification sits alongside a factual record in which a dementia unit lost a month's worth of controlled medications for at least one resident, a second resident's supply also came up short, an agency nurse was terminated on suspicion, and the staff who touched the medications walked away without drug testing.
The facility's revised narcotic counting policy was dated November 1, 2025. The noncompliance period ended October 29. The policy was updated two days after the problem it was designed to prevent had already occurred.
R7 needed his medication. The pharmacy said it had already been sent.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evercare of Lebanon from 2025-11-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
EVERCARE OF LEBANON in LEBANON, IL was cited for violations during a health inspection on November 21, 2025.
The missing narcotics came to light in a sequence that a licensed practical nurse described in detail to inspectors on November 21, 2025.
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.