F0755

D

Failure to Accurately Account for and Document Controlled Substances

Freeport, Illinois Survey Completed on 02-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain accurate receipt, documentation, administration, and reconciliation of controlled substances for multiple residents. For one resident with extensive medical conditions including COPD, major depressive disorder, alcohol abuse, diabetes, traumatic lower leg amputation, and malnutrition, the pharmacy manifest showed two cards of Oxycontin 5 mg (30 tablets each) were delivered, but one card and its corresponding controlled drug receipt/record/disposition form were missing. The President of Operations confirmed that card one and sheet two for this Oxycontin order could not be located and acknowledged that extra medications from the cart had been stored in a medication cupboard that was not included in shift-change narcotic counts. For the same resident, controlled drug forms for Oxycodone 5 mg tablets showed numerous doses subtracted as given on specific dates and times, but these administrations were not documented on the resident’s MAR.

For a second resident receiving hydromorphone HCL 4 mg tablets, the November controlled drug receipt/record/disposition form indicated two cards of 30 tablets each were delivered, but only one card’s form was present. On that form, six doses were signed out as administered on specific dates and times, yet these doses were not documented on the November MAR. Additional hydromorphone deliveries in December and January were documented on manifests, but the facility lacked controlled drug receipt/record/disposition forms for several of the cards delivered, and for some periods there were hydromorphone doses signed out on the controlled drug forms that were not recorded on the MAR. The President of Operations stated that pharmacy did not reconcile narcotics beyond current medications, that clinical managers such as the DON were expected to perform random monthly audits comparing manifests, narcotic sheets, and MARs, and that no records of such audits were available.

For a third resident admitted with multiple diagnoses including a stage 4 sacral pressure ulcer, the December MAR showed an order for Morphine Sulfate ER 15 mg twice daily that was discontinued and later replaced with Morphine Sulfate ER 30 mg three times daily. The controlled drug receipt/record/disposition form for Morphine Sulfate ER 15 mg documented 30 tablets dispensed, and on one date a nurse signed out two tablets at 9:00 AM, noted an increase from 15 mg to 30 mg, and then crossed out the entire line as an error, leaving the count at 20, followed by signing out one tablet at 7:00 AM and ultimately destroying the card with 19 tablets. The 30 mg morphine controlled drug sheet showed an additional tablet signed out at 9:00 AM the same day. The President of Operations stated that controlled medications should not be signed out after discontinuation. Additionally, the manifest showed two cards (60 tablets total) of Hydrocodone/APAP 5-325 mg delivered for this resident, but the facility could not provide any controlled drug receipt records documenting receipt or destruction of these tablets.