Downey Community Health Center: Narcotic Count Errors - CA
The April 10 inspection by federal surveyors caught the gap in real time. At 9:45 in the morning, an inspector standing at Station 3 Cart 1 counted the bubble pack for Resident 155's tapentadol, a Schedule II opioid prescribed twice daily for pain management. Four tablets remained. The Controlled Drug Record said there should be five.
One tablet was missing from the count. No documentation explained where it went.
The licensed vocational nurse assigned to the cart, identified in the report as LVN 2, was present during the inspection. She told surveyors she had administered the tapentadol to Resident 155 earlier that morning, at 7:29 a.m., and that she believed she had recorded it. She had not. LVN 2 acknowledged that after removing a tablet from the bubble pack, she was responsible for logging the remaining count on the Controlled Drug Record immediately. She acknowledged that an inaccurate count could cause confusion about whether the resident had actually received the medication.
The last entry on the Controlled Drug Record was dated 4/9/2025 at 7:25 a.m. The entire day of April 9 and the morning of April 10 passed without a single notation.
Resident 155 was in their late stage of care with moderate cognitive impairment, according to a Minimum Data Set assessment completed March 1. The resident needed supervision with eating and personal hygiene. Despite the cognitive limitations, a history and physical examination completed February 28 noted the resident retained the capacity to understand and make decisions. The tapentadol order, written February 26, called for 100 milligrams by mouth twice daily.
Tapentadol is a centrally acting opioid analgesic. Controlled substances in nursing homes require precise documentation at every step, not because of paperwork formality, but because the count is the only mechanism a facility has to verify a resident received what they were supposed to receive, and to detect diversion or error when the numbers don't match. When the count is wrong, the question the record can no longer answer is a serious one: did the resident get the medication, or didn't they?
LVN 2 believed she had given it. The electronic medication administration record reflected an administration at 7:29 a.m. But the Controlled Drug Record, the dedicated narcotic log that exists precisely to cross-check that entry, showed nothing. The two records that are supposed to confirm each other told different stories.
The facility's own policy on controlled drug handling states that licensed nurses must record every controlled medication administered on both the medication administration record and the narcotic count sheet. The policy had no date on it. Neither did the Controlled Drug Record that LVN 2 left blank.
Surveyors classified the violation as causing minimal harm or potential for actual harm, and noted that few residents were affected. The citation fell under the federal tag governing a facility's responsibility to ensure accurate medication records and safe medication practices.
What the inspection report does not resolve is what Resident 155's morning actually looked like. The eMAR says the tapentadol was given. LVN 2 says she gave it. But a resident with moderate cognitive impairment, dependent on staff for basic daily tasks, receiving a twice-daily opioid for pain, had no independent way to confirm or dispute any of it. The count was off, the log was blank, and the nurse who was supposed to reconcile both had moved on to other tasks before anyone noticed the numbers didn't add up.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Downey Community Health Center from 2025-04-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 4, 2026 · Our methodology
DOWNEY COMMUNITY HEALTH CENTER in DOWNEY, CA was cited for violations during a health inspection on April 10, 2025.
The April 10 inspection by federal surveyors caught the gap in real time.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.