F0755

D

Failure to Properly Track and Account for Oxycodone Doses

Fairlawn, Ohio Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The facility failed to appropriately track and account for dispensed narcotics for one resident when multiple oxycodone doses were removed from the resident’s medication card without documentation of their final disposition. The resident was admitted with diagnoses including major depressive disorder, pain in the lower leg, and deep vein thrombosis, and had a single oxycodone tablet order that began on 08/24/25 and was discontinued on 08/27/25. Review of the October medication administration record showed no active oxycodone orders or documented administrations during that month. However, observation of the 200-hall medication cart on 03/02/26 revealed a card containing 54 oxycodone tablets for this resident, with the card count matching the narcotic count sheet, and the most recent non-wasted removals documented on 10/01/25, 10/12/25, and 10/31/25. The Administrator confirmed that multiple doses had been removed from the oxycodone card with no documentation of what ultimately happened to those doses.

This deficiency represents noncompliance with the requirement to provide pharmaceutical services that meet each resident’s needs and to properly track and account for controlled substances, as investigated under Complaint Number 2791137.