Failure to Investigate and Prevent Narcotic Diversion Resulting in Misappropriation of Resident Medications
Summary
The deficiency involves the facility’s failure to protect residents from misappropriation of their narcotic medications and to act on clear allegations of drug diversion by a registered nurse, identified as Staff C. The facility’s abuse and misappropriation policy, updated in March 2025, required thorough investigation of suspected misappropriation, immediate reporting of allegations, and protection of residents from harm. Despite this, an email sent on 02/06/2026 by an LPN (Staff D) to the Administrator (Staff A) reported that several alert and oriented residents stated they had not requested or received medications at times when Staff C documented them as given. The email also described Staff C arriving to work appearing impaired, with head-nodding and difficulty staying awake, narcotics signed out for residents who reported not receiving them, unusual dosing patterns, discrepancies in narcotic logs, and Staff C frequently leaving the building and being difficult to locate. The Administrator acknowledged receiving concerns about Staff C nodding off and personally observing this behavior but only counseled Staff C on staying alert, without initiating or documenting an investigation into the diversion concerns. Resident 1, admitted with an infection and inflammatory reaction due to an internal right hip prosthesis, was cognitively intact, required staff assistance for most activities of daily living, and had an order for oxycodone 5 mg every six hours as needed for pain. Review of the narcotic sign-out log and EMAR showed multiple oxycodone doses documented by Staff C over several days, including entries on 03/21/2026, 03/22/2026, 03/23/2026, and 03/24/2026, with one dose documented on the EMAR but not on the narcotic log. On 03/26/2026, oxycodone was documented as administered at 12:40 AM, 3:24 PM, and 10:00 PM. However, Resident 1 later reported not receiving oxycodone during the evening shift on 03/26/2026, stating she requested pain medication after night-shift care and was told she had already received her “quota” of oxycodone and Tylenol, which she denied. Because the medication was documented as already given at 10:00 PM, the night nurse did not administer oxycodone and instead gave Tylenol. Resident 1 maintained that she had not taken the oxycodone that evening and emphasized that she only wanted medication when she requested it. Resident 2, admitted with chronic kidney disease, diabetes, and bilateral lower extremity amputations, was alert, oriented, and generally independent for most activities of daily living, with an order for oxycodone 5 mg every four hours as needed for pain. EMAR review for February and March 2026 showed that Staff C documented administering oxycodone 10 mg on twenty-two occasions between 11:00 PM and 4:30 AM. In interview, Resident 2 stated he takes medication before going to bed in the evening and does not request or receive medications during the night shift, except when he wakes for dialysis at 5:00 AM on Monday, Wednesday, and Friday. He reported not requesting narcotics during the night, which conflicted with the documented nighttime administrations by Staff C. Resident 3, admitted with vascular dementia and spinal stenosis, was cognitively impaired and received scheduled and as-needed pain medications, including hydrocodone 5/325 mg every eight hours as needed. Review of Resident 3’s narcotic log showed that on 03/02/2026, Staff C signed out hydrocodone at 12:38 PM and again at 2:53 PM, only 2 hours and 15 minutes apart, with no documentation of any wasted dose. The EMAR reflected only the 12:38 PM administration. On 03/25/2026, hydrocodone was signed out by Staff C at 6:01 AM at the bottom of one narcotic log page and again at 6:01 AM at the top of the next page, again without any waste documentation, while the EMAR showed a single administration at 6:01 AM. These discrepancies suggested additional unaccounted-for doses removed by Staff C. Multiple staff interviews further described concerns that were not acted upon in a timely manner. A CNA (Staff H) reported observing Staff C showing signs of impairment, including nodding off, and stated that this had been reported and that the Administrator had come in and seen Staff C in that condition; Staff H also noted that Staff C left the floor for long periods. Another LPN (Staff E) reported that Staff C had inappropriate behavior, including calling or texting to demand that shifts be given up to her. Staff D confirmed by telephone that she had reported concerns in February 2026 to the Administrator about Staff C’s behavior and about narcotics being signed out for residents who normally did not take medications on the night shift. When later asked, the Administrator admitted receiving the February email about possible drug diversion and staff behavior but stated he did not complete an incident report and had no documentation of an investigation, and the DON (Staff B) stated she had no knowledge of the email and had not investigated it. The facility’s later review identified multiple discrepancies related to Staff C’s handling of narcotics, but the initial failure to report, investigate, and act on the early allegations allowed the suspected diversion and misappropriation of residents’ medications to continue from 12/09/2025 through 03/26/2026.
Penalty
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Below are regulatory guidelines relevant to this citation:
A CNA/QMA accepted a resident’s offer to cash scratch tickets in exchange for part of the winnings and also took a discharged resident’s Mounjaro injection for personal use. The resident with intact cognition confirmed the money arrangement, and an RN administered the unlabeled injection after the CNA/QMA asked her to do so. The facility’s policies prohibited staff from accepting resident money or gifts and defined diversion of a resident’s medication for personal use as financial abuse.
Missing controlled medications and incomplete narcotic counts: Two residents had opioid medications missing from the narcotic drawer, including a hydromorphone bubble pack and a hydrocodone bubble pack, with related count sheets also missing. Staff interviews and narcotic logs showed shift-to-shift counts were not consistently completed or signed by both nurses, and staff reported that narcotic counts were often not done when carts changed possession. One resident had severe cognitive impairment and chronic pain, and the other had moderate cognitive impairment with acute pain related to fractures and dislocation.
Medication Diversion and Tampered Narcotic Cards: Two residents’ narcotic cards were found tampered with during a routine med review, with prescribed controlled substances removed and replaced by other pills. One resident was cognitively intact and the other had moderate cognitive impairment; both were identified as at risk for abuse. Interviews with nursing staff and record review confirmed drug diversion occurred, but the responsible staff member could not be identified.
A resident with dementia, paranoid schizophrenia, and severe cognitive impairment had trust funds withdrawn after discharge to a board and care facility. The BOM kept $5,744 cash and two SS checks in her purse instead of returning the money to the resident’s trust account after the resident was transferred to a GACH and later readmitted, and the Asst Admin confirmed the funds should have been deposited back into trust.
Misappropriation of a resident's medication occurred when two unlabeled syringes were found in a med cart and video showed a staff member placing them there. Pharmacy identified the contents as oral lorazepam and oral morphine sulfate, and the resident's open lorazepam bottle was short by 2.5 ml compared with the narcotic count sheet. The report states the misappropriation was substantiated.
Two residents’ controlled opioid pain meds went missing from medication carts, along with declining count sheets and shift inventory documentation. One resident’s oxycodone/acetaminophen card was found missing with altered narcotic records, and another resident’s hydrocodone/acetaminophen card and count sheet were also unaccounted for. Staff interviews and record review showed the meds had been delivered to the facility, but the facility could not determine who removed them or when the documentation was altered.
Misappropriation of Resident Property and Medication
Penalty
Summary
The facility failed to protect residents from misappropriation of property when a CNA/QMA accepted a resident’s offer to cash lottery scratch tickets in exchange for half of the winnings and also took a discharged resident’s Mounjaro injection for personal use. The abuse and neglect policy defined financial abuse to include diversion of a resident’s medication for personal use or gain, and the gift policy prohibited employees from accepting cash or other gifts from residents. The employee handbook also stated that accepting gifts, tips, or gratuities from residents was strictly prohibited. One resident, who had a BIMS score of 15 and intact cognition, told the facility’s social worker that she had offered the CNA/QMA half of her scratch ticket winnings if the CNA/QMA would cash them at a gas station. The resident later recalled winning $50 and offering $25 to the CNA/QMA. During observation and interview, the resident confirmed that she had made this arrangement with the CNA/QMA and kept a $25 voucher on her bedside table showing the facility had reimbursed her. There were no notes in the resident’s EMR about the incident. A discharged resident had a physician’s order for Mounjaro 10 mg weekly injections. The CNA/QMA admitted taking that resident’s Mounjaro medication and asked an RN to administer the injection for her. The RN stated the syringe was unlabeled and that she would not have given the injection if she had known it came from a discharged resident’s medication supply. The facility’s medication disposal policy stated that unused medications left after discharge were to be evaluated for return to the pharmacy or destroyed by authorized staff with required witnesses.
Missing controlled medications and incomplete narcotic counts
Penalty
Summary
The facility failed to protect residents from misappropriation of property when controlled medications became missing from the medication carts for two residents. A self-report to the Department of Inspections, Appeals and Licensing documented that 54 doses of hydromorphone for one resident and 13 doses of hydrocodone for another resident were missing from the narcotic drawer. The report also stated that the torn top of one resident’s hydromorphone bubble pack was later found in the shred box, and that the resident’s narcotic count sheet was missing from the binder. The facility also reported that the other resident’s hydrocodone bubble pack and narcotic count sheet were missing, and the pharmacy record showed the resident should have had 13 doses remaining. One resident had a BIMS score of 2 out of 15 and diagnoses including heart failure, hypertension, non-Alzheimer’s disease, anxiety, and depression. That resident’s care plan addressed chronic pain and directed staff to anticipate pain needs and respond immediately to complaints of pain. The physician order was for hydromorphone 2 mg tablets, 0.5 tablet by mouth every 2 hours as needed for shortness of breath or pain, and the June MAR showed multiple doses were administered. The second resident had a BIMS score of 11 out of 15 and diagnoses including non-Alzheimer’s disease, anxiety, and depression. That resident’s care plan addressed acute pain related to fractures and dislocation, and the June MAR ordered hydrocodone-acetaminophen 5/325 mg, 1 tablet by mouth every 6 hours as needed for pain. The narcotic count sign-off logs showed multiple shifts with missing signatures or only one signature, including entries for both medication carts and the Midwest hall. Staff interviews showed that narcotic counts were not consistently completed when carts changed possession. Staff K stated she did not count narcotics with the RN when she came on duty and later found the hydromorphone bubble pack missing when attempting to administer the medication. Other staff stated they did not do narcotic counts, that counts were rarely done, and that they did not always count together at shift change. The DON stated the expectation was to count narcotics any time the cart changed possession, with both staff signing at the same time. The facility policy required the oncoming and outgoing licensed nurses to physically count and reconcile narcotics at each shift change and to document the count and signatures.
Medication Diversion and Tampered Narcotic Cards
Penalty
Summary
The facility failed to protect residents from the wrongful use of their medications when narcotic medication cards for two residents were found tampered with during a routine medication review. The controlled substance cards had been opened, the prescribed narcotic tablets removed, and other non-prescribed pills placed into the blister packs, with tape used to reseal the cards. The facility later substantiated that drug diversion had occurred, but the individual responsible could not be identified after interviews and record review. One resident had diagnoses including osteomyelitis, malignant neoplasm of the endometrium, bilateral foot pain, neuropathy, and osteoarthritis, and had a BIMS score of 15 indicating cognitive intactness. The resident’s care plan identified the resident as at risk for abuse. The second resident had diagnoses including osteoarthritis, gout, chondromalacia of the right knee, patellar tendinitis of the left knee, and myalgia, and had a BIMS score of 12 indicating moderate cognitive impairment. This resident’s care plan also identified the resident as at risk for abuse. The investigation found that the tampered narcotic cards belonged to these two residents and that the prescribed controlled substances had been removed and replaced with other pills. Nursing staff with access to the medication cart were interviewed, including the nurse who had worked the hall before the discrepancy was discovered, but no witness observed the diversion and no admissions were obtained. The administrator, DON, and ADON stated the residents did not receive the tampered medications, and the facility was unable to determine which staff member removed the medications.
Resident Trust Funds Kept in BOM’s Personal Possession
Penalty
Summary
Protecting a resident from the wrongful use of belongings or money was not ensured when the Business Office Manager removed $7,744 from Resident 1’s trust fund after the resident was discharged to a board and care facility. Resident 1 had diagnoses including dementia, pneumonitis, paranoid schizophrenia, and type 2 DM. The History and Physical stated the resident did not have the capacity to make medical decisions but was able to make needs known, and the MDS indicated severe cognitive impairment and need for maximal assistance with activities of daily living. The Business Office Manager stated that $2,000 of the withdrawn funds was paid to the board and care facility and the remaining $5,744 was intended to be returned to the resident. When the resident was transferred to a GACH due to a change in condition and later readmitted to the facility, the funds were supposed to be deposited back into the trust account, but the Business Office Manager kept the $5,744 cash and two Social Security checks in her purse instead of returning them to the facility or trust account. The Assistant Administrator stated the funds should have been deposited back into the trust account and confirmed the Business Office Manager still had the resident’s cash after leaving employment.
Misappropriation of Resident Medication
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when medication belonging to the resident was found missing. A facility-reported incident described that two unlabeled syringes were discovered in a medication cart at the cottage, and video surveillance showed a staff member placing the syringes in the cart. Pharmacy identified the contents as oral lorazepam and oral morphine sulfate. The only open bottle of lorazepam belonged to the resident, and when the bottle was measured, it contained 23.5 ml compared with 26 ml expected on the narcotic sign-out sheet, showing a shortage of 2.5 ml. During observation, staff demonstrated the process for dispensing and documenting oral lorazepam using a syringe and narcotic sign-out sheet. In interview, staff described that the unlabeled syringes were found during medication pass and reported to nursing leadership, and that surveillance review identified the staff member responsible for placing the syringes in the cart. The report states the misappropriation of the resident's medication was substantiated and that the staff member was terminated.
Missing Controlled Opioid Medications and Altered Narcotic Counts
Penalty
Summary
The facility failed to protect residents from the wrongful use of their controlled opioid pain medications when two residents’ narcotic cards and associated declining count sheets went missing from medication carts and were never located. One resident had an order for oxycodone/acetaminophen for pain related to polyneuropathy, and the record showed the resident received a dose shortly before the medication was later discontinued and replaced with other pain orders. Survey findings showed that 30 tablets of oxycodone/acetaminophen 10/325 mg had been delivered to the facility, but 28 tablets were later reported missing along with the resident’s declining count sheet and the shift inventory documentation had been altered. For the second resident, who had osteoarthritis and a standing order for hydrocodone/acetaminophen 5/325 mg four times daily, the facility received 120 tablets in four cards. Later, one card of hydrocodone/acetaminophen and the declining count sheet were discovered missing from the medication cart. The shift change controlled substance inventory sheet had also been restarted without the prior sheet being available to verify the count. Staff interviews showed that nurses and medication aides could not account for when or how the medication and documentation disappeared, and the facility could not determine who removed them. The investigation described that staff found altered narcotic documentation, missing controlled substance cards, and missing declining count sheets on more than one medication cart. Interviews with nurses, medication aides, the DON, the pharmacist, and the NP confirmed that the medications had been delivered to the facility and were supposed to remain accounted for on the carts, but the facility was unable to locate the missing tablets or the related records. The report states that the allegation of diversion was substantiated for one resident and that the facility could not definitively determine what happened to the missing medications for the other resident.
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