PHILADELPHIA, PA — Federal health inspectors cited Willow Terrace for significant controlled substance documentation failures during a January 2025 inspection, finding that narcotic medications on at least one unit had no recorded shift-to-shift counts and that an agency nurse administering medications had received no facility training on controlled substance protocols.
Missing Narcotic Counts on Fourth Floor
During a direct observation on January 29, 2025, at 10:44 a.m., inspectors examined the medication cart on the fourth floor south unit alongside a licensed nurse identified as Employee E7. The inspection revealed that the narcotic log book contained no documentation that shift-to-shift counts had been completed at any time.
Further examination uncovered additional problems: the index within the narcotic log book was incomplete and did not match the individual countdown records maintained for each resident. These countdown records are the primary tool facilities use to track how many doses of a controlled substance remain for a given patient, and discrepancies between the index and individual records represent a serious gap in accountability.
The finding was cited under F759, a federal deficiency tag that addresses a facility's obligation to properly manage and document controlled substances, including narcotics such as oxycodone, morphine, and fentanyl patches.
Agency Nurse Reports No Training
Perhaps most concerning was the statement provided by Employee E7, the licensed nurse assigned to the medication cart that morning. The nurse told inspectors that it was his first day at the facility as an agency nurse, that he had not received any training from the facility regarding medication administration or controlled substances, and that he had not completed a shift-to-shift narcotic count with the previous night shift nurse.
Shift-to-shift narcotic counts are a foundational safeguard in nursing home medication management. At every shift change, the outgoing and incoming nurses are expected to physically count all controlled substances together, verify the totals against documented records, and both sign off confirming the count is accurate. This process ensures that every dose is accounted for — whether administered to a resident, wasted, or still in inventory.
When this count does not occur, there is no verified chain of custody for powerful and potentially dangerous medications. The facility cannot confirm whether the correct number of doses are present, whether any medications are missing, or whether residents received the doses documented in their records.
Why Narcotic Accountability Matters
Controlled substances require rigorous tracking because failures in documentation can mask several dangerous scenarios. Missing or unaccounted-for narcotics may indicate drug diversion — the redirection of prescription medications for unauthorized use — which is a recognized problem in healthcare settings nationwide. Diversion can result in residents not receiving pain medications they need while simultaneously creating risks of substance misuse among staff or others.
Documentation gaps also raise the possibility of medication errors. Without accurate records, a facility cannot verify that residents received the correct dose at the correct time. For elderly nursing home residents, who often have reduced kidney and liver function, even small dosing errors involving narcotics can lead to respiratory depression, excessive sedation, falls, or overdose.
Federal regulations require nursing facilities to maintain complete and accurate records for all controlled substances precisely because these medications carry high risks. The Drug Enforcement Administration and state pharmacy boards establish additional layers of oversight, and facilities are expected to have written policies and staff training programs to ensure compliance.
Untrained Staff Compounds the Risk
The fact that an agency nurse was assigned to manage a narcotic medication cart without any orientation or training from the facility represents a compounding failure. Facilities that use agency or temporary nursing staff are still responsible for ensuring those individuals understand the facility's specific protocols, including where medications are stored, how counts are documented, and what to do if discrepancies are found.
Without this orientation, even a competent and well-intentioned nurse cannot follow a facility's documentation system correctly, creating exactly the kind of gaps inspectors identified at Willow Terrace.
Inspection Outcome
The January 31, 2025 health inspection resulted in the F759 citation. Residents and families seeking the full inspection details can review the complete report through the Centers for Medicare & Medicaid Services (CMS) Care Compare database or through NursingHomeNews.org's [facility page for Willow Terrace](/facility?name=willow-terrace&state=PA).
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willow Terrace from 2025-01-31 including all violations, facility responses, and corrective action plans.
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