Misappropriation of Controlled Pain Medication Due to Inadequate Delivery and Storage Controls
Summary
The deficiency involves the facility’s failure to fully implement its own policies for the delivery, receipt, and secure storage of controlled medications, resulting in the misappropriation of 120 hydrocodone-acetaminophen tablets prescribed for Resident #51. Resident #51 was originally admitted on 8/6/2024 with diagnoses including colon cancer and had a physician’s order for hydrocodone-acetaminophen 10-325 mg, one tablet three times daily. A Minimum Data Set dated 10/24/2025 documented a BIMS score of 9/15, indicating severe cognitive impairment. On 9/19/2025, during a routine medication pass, nursing staff discovered that the resident’s scheduled narcotic pain medication was missing when they attempted to obtain it from the StatSafe and were informed by the pharmacy that the facility should already have 120 tablets on hand. The facility’s internal investigation determined that the hydrocodone tablets for Resident #51 had not been administered, destroyed, or documented as wasted and were unaccounted for. Review of proof-of-use sheets, shift counts, and chain of custody records showed no documentation explaining the disposition of the medication. A nurse was identified as potentially involved in the missing medication based on the chain of custody review, and that nurse was no longer employed at the facility as of 9/14/2025. The incident was reported as misappropriation of 120 narcotic pain medications for Resident #51. Interviews and observations revealed that, at the time of the incident, pharmacy medications, including controlled substances, were delivered to the facility in regular cardboard boxes sealed with standard packaging tape, without locks or tamper-evident features. Nurses reported that these boxes were often left unattended in the front office among other facility and resident packages, and a nurse would have to search through multiple boxes to locate the pharmacy shipment. A single nurse would open the box, check inventory, and fill the medication cart with routine medications, and later call another nurse to sign off on the narcotic inventory sheet, even though the box itself could be easily opened and re-taped, including from the bottom. Staff interviews indicated that there was no clear, written procedure in the facility’s Pharmacy Services or Medication Storage policies describing who was responsible for receiving delivered medications, checking the box for tampering, or ensuring secure handling upon delivery. Policy review confirmed that, although the policies addressed storage and reconciliation of controlled substances, they did not address the actual delivery process or current courier methods, contributing to the conditions under which the controlled medications for Resident #51 were misappropriated. Additional staff interviews further supported that the delivery process lacked defined safeguards. RN B and RN C both described that pharmacy boxes arrived via UPS or FedEx, were not locked, and could be opened and re-taped without detection. They acknowledged that, even after the missing narcotic incident, pharmacy boxes sometimes continued to be retrieved from the front office among other packages, and there was uncertainty about who was responsible for inspecting boxes for signs of tampering. Observation of a pharmacy-labeled box delivered by UPS showed it to be a standard cardboard box with packaging tape and no locking or tamper-proof features. The Assistant DON confirmed that the facility’s policies did not specify the current procedures for receiving medications, did not address how medications were delivered, and did not identify who was responsible for checking in delivered medications or inspecting for tampering, which were key process gaps associated with the misappropriation of Resident #51’s controlled medication supply.
Penalty
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Medication labeling and storage deficiencies were observed during med pass and cart/room checks. An LPN prepared hydrocodone-acetaminophen for a resident from blister packs whose labels did not match the EMR orders, another cart contained a loose pill in an unlabeled state, and a rehab unit med room had a controlled-medication lock box that was not affixed to the refrigerator. The DON and Administrator stated labels should match orders, carts should not contain loose pills, and controlled meds should be securely locked.
Unattended RT Medication Cart Left Unlocked: RT Medication/Treatment Cart A was observed unlocked and unattended in the 200 Hall with the keys hanging from the opened lock while no staff or residents were within eyesight. RT F stated she had stepped away briefly to check on a resident and acknowledged she should have locked the cart. Medications and supplies were visible in the cart, and RT F said she did not know when she was last trained on keeping the cart locked when unattended. The DON and ADM stated staff were expected to keep carts locked when not with them.
Unlabeled medication cups and supplies were left unattended at the bedside of two residents. A CNA stated cream was left in one resident’s room and later applied, while another resident had a clear cup with a spoon and cream on the nightstand. Staff confirmed neither resident had an order to self-administer medications, and an LPN and the DON stated the residents did not have self-administration orders. The facility policy required medications and biologicals to be stored in locked compartments.
Medications in two med carts and one med room were found without opened-on dates, including eyedrops, creams, gels, ointments, and an insulin pen. RN-A and RN-B stated these items should be dated when opened, and the DON confirmed staff were expected to affix and complete date-opened stickers for these medications. Facility policy required containers or vials to be dated when the original seal was broken.
Missing Medication Refrigerator Temperature Monitoring: The facility failed to monitor temperatures in 3 of 3 medication refrigerators. Temperature logs for Station 1, Station 2, and Station 3 showed multiple missing daily entries, and the Administrator confirmed staff were expected to check the refrigerators daily but there was no back-up temperature monitoring system on the days with blank temperatures.
Expired and discontinued medications were left available in multiple medication carts, including Pantoprazole, ABH Gel syringes, and Propranolol. The DON, an LPN, and a medication aide stated the medications should have been removed from the carts and placed in the return-to-pharmacy bin, but they remained on the 100-hall cart and both 200-hall carts.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and labeled in accordance with accepted professional principles. During a medication pass observation, an LVN prepared to give Resident #51 hydrocodone-acetaminophen from the 700/800 hall nurse cart using a blister pack labeled Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet by mouth every 6 hours as needed, while the EMR order for that medication was Hydrocodone-Acetaminophen 10-300 mg, give 1 tablet by mouth every 6 hours as needed. The LVN stated the EMR order did not match the blister pack label and that the order would need to be clarified with the prescriber. A second medication pass observation showed another LVN preparing to administer hydrocodone-acetaminophen from the 800 hall medication aide cart to Resident #51 from a blister pack labeled Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet by mouth every 6 hours as needed, while the EMR order for that medication was Hydrocodone-Acetaminophen 10-325 mg, give 1 tablet by mouth twice daily. The LVN stated the PRN-labeled blister pack should not have been in the medication aide cart and that the cart should have contained a blister pack with routine dosing for the resident. The DON stated the prescription labels on blister packs needed to match the EMR orders and that staff were expected to follow physician orders and clarify orders when needed. On another observation, a loose pill was found in the third drawer of the 500/600 hall nurse cart, and RN B stated loose pills should not be in medication carts because they are unlabeled and could be taken or consumed without knowing what they are. In the rehabilitation unit medication room, the lock box for controlled medications was observed not affixed to the refrigerator. RN G stated the box should be affixed so it could not be removed, and the DON and Administrator both stated lock boxes for controlled medications should be affixed to the refrigerator. Resident #51 had diagnoses including depression, anxiety, seizures, and diabetic neuropathy, with a BIMS score of 14 and opioid use documented in the MDS.
Unattended RT Medication Cart Left Unlocked
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles for 1 of 2 RT carts reviewed. During an observation on 06/11/26 at 8:44 AM, RT Medication/Treatment Cart A was seen in the 200 Hall unlocked and unattended, with the keys hanging from the opened lock. No staff or residents were within eyesight of the cart at that time. During an observation and interview at 8:46 AM, RT F stated she had gone into a resident's room quickly to see what he needed and acknowledged she should have locked her cart when she stepped away from it. RT F opened the top drawer, and medications and supplies were observed in the cart. RT F stated she did not know when she was last trained to keep her cart locked when unattended and did not know of a potential negative outcome to residents. The DON and ADM later stated they expected staff to keep carts locked when not with them and that keys should be kept in their pocket or on their person. The facility policy stated medication carts and supplies are to be locked or attended by authorized persons.
Unlabeled Medications Left at Bedside
Penalty
Summary
The facility failed to follow standards for medication storage for 2 of 6 halls reviewed for unattended medication. During observation, a clear medication cup containing cream was found at the bedside of Resident #86, and the cup was not labeled. Two normal saline flush syringes were also observed on top of the resident’s nightstand. In interviews, the resident’s representative stated staff came in and applied the cream when they changed the resident, and a CNA stated the wound care nurse gave her the cream that morning, she left it in the resident’s room, and later applied it. An LPN stated she was not aware of any cream or normal saline flushes and had not done any of it. A similar observation was made at the bedside of Resident #38, where a clear medication cup with a spoon and cream was left on the nightstand. The resident stated staff apply the cream when they change him. A CNA confirmed the cup with the spoon was at the bedside and said it was cream to apply when the resident was changed, but it should not have been left there. An LPN stated the resident did not have an order to self-administer medication, and the DON later stated that Residents #86 and #38 did not have orders to self-administer medications. The facility policy titled Medication Labeling and Storage stated that medications and biologicals are stored in locked compartments under proper controls and only authorized personnel have access to keys.
Medications Missing Opened-On Dates
Penalty
Summary
The facility failed to ensure medications were appropriately labeled with an opened-on date in 2 of 2 medication carts and 1 of 1 medication rooms reviewed for medication labeling and storage. During observation and interview, the North medication cart contained multiple medications without opened-on dates, including Nizoral shampoo, Victosa insulin pen, Diclofenec Sod Top Gel, Biofreeze gel 4%, Hydrocortison cream 1%, Nystatin cream, Hemorrhoidal ointment, Calmoseptine ointment, Diclofenca Sod Top Gel 1%, and Triamcinolone Acetonide Cream. RN-A stated that all eyedrops, creams, gels, and similar medications in tubes should be dated as soon as they are opened, and that nurses and TMAs should check for an opened-on date when using these medications. The medication room also contained opened medications without opened-on dates, including Sustane eye drops, Ketoconazole cream 2%, Bacitracin ointment, Hydrocortisone cream 2.5%, and Dorzolamide Hydrochloride and Timolol Maleate Ophthalmic Solution 2%. In the East wing medication cart, Hydrocortisone Cream 1% and Diclofenac Sodium Gel 1% were also missing opened-on dates. RN-B stated that if a medication was missing the opened-on date it should not be used because it could be expired and the resident would not get the actual prescribed dose. The DON stated all medications should have an opened-on date clearly affixed and that staff should place an opened-on sticker and fill it out each time a new bottle of eyedrops, creams, gels, or similar medications was opened. Facility policy stated that when the original seal is broken, the container or vial will be dated and the nurse shall place a date-opened sticker and enter the date opened and new expiration date.
Missing Medication Refrigerator Temperature Monitoring
Penalty
Summary
The facility failed to monitor temperatures in 3 of 3 medication refrigerators. A review of the temperature logs for Station 1, Station 2, and Station 3 for 5/2026 showed multiple missing daily temperature entries, including 10 missing days for Station 1, 9 missing days for Station 2, and 12 missing days for Station 3. On 6/4/26, the Regional Director of Clinical Operations provided the logs, and on 6/5/2026 the Administrator stated staff were expected to check the medication refrigerators daily and confirmed the missing temperatures. The Administrator also stated the facility did not have a back-up temperature monitoring system on the days with blank temperatures.
Expired and Discontinued Medications Left in Medication Carts
Penalty
Summary
Drugs and biologicals were not maintained in accordance with accepted storage and labeling practices because expired and discontinued medications were left in medication carts. During an observation with the DON, the 200-hall upper medication cart contained a Pantoprazole 40 mg medication card with 27 pills remaining and a pharmacy expiration date of 5/31/26, even though the physician’s order had been discontinued on 3/9/26. The expired Pantoprazole remained available for use in the cart. Nurse #1 stated the medication had been overlooked and should have been removed from the cart and placed in the return-to-pharmacy bin in the medication room when the order was discontinued. Additional observations showed similar issues on other carts. The 100-hall medication cart contained a bag of ABH Gel syringes with 15 syringes remaining and a pharmacy expiration date of 6/1/26, although the physician’s order had been discontinued on 6/1/26. The 200-hall lower medication cart contained Propranolol 20 mg tablets with 25 pills remaining and a pharmacy expiration date of 11/30/25, although the order had been discontinued on 7/15/25. Staff interviews indicated that nurses and medication aides were expected to check expiration dates before administration, and that discontinued or expired medications should be removed from the carts and placed in the return-to-pharmacy bin, but these medications remained on the carts and available for use.
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