Fir Lane Care: Controlled Drug Documentation Failures - WA
Federal inspectors found that Fir Lane Care failed to properly track controlled substances for two residents, creating conditions that could allow drug diversion or leave patients without their prescribed medications.
Staff A, a registered nurse, was preparing dronabinol for Resident 1 when the inspector arrived on August 13. The appetite-stimulating controlled substance was ordered twice daily for the resident's malnutrition. But the nurse's documentation in the required logbook jumped from August 10 at 10:22 PM directly to August 13 at 10:20 AM.
When asked about the missing August 11 and 12 entries, Staff A said, "Oh I guess I forgot to document those days, but I did administer the medication." The nurse then wrote in the missing documentation on the spot.
The medication administration records showed Resident 1 received dronabinol twice daily from August 1 through August 12, and once on August 13. But the controlled substance logbook told a different story. It showed only one administration recorded on August 4 and August 6, three entries on August 10, and one entry each for August 11 and 12.
Staff A admitted to not counting the dronabinol during shift changes on August 10, 11, and 12. The nurse explained they "only had counted the medications that were in the medication cart and the dronabinol was stored in a medication refrigerator."
Facility policy required staff to count all controlled drugs at each shift change and document every administration in the bound logbook with date, time, amount, and signature.
The documentation failures extended beyond forgotten entries. In July, staff discovered a more serious problem with Resident 2's oxycodone records.
An internal incident report dated July 11 revealed that staff found documentation showing Resident 2 received the pain medication on multiple days when the resident wasn't even at the facility. The entries also lacked required time stamps.
The facility concluded in its report that "irregularities identified in the Controlled Substance Record Book" raised "concerns for potential controlled substance diversion activity and/or misappropriation of the resident's medication."
Staff B, the Director of Nursing, told inspectors on August 21 that nurses were expected to document medications in both the electronic medical record and the controlled substance logbook "at the time of administration."
The director acknowledged that licensed nurses had failed to follow procedures for documenting and reconciling controlled substances. Staff should have been "reviewing all the pages of the Controlled Substance Record Book and ensuring the medication count is correct during each shift change," not just counting medications in the cart.
The documentation errors created multiple risks. Without accurate tracking, controlled substances could be diverted by staff members. Residents might miss doses if nurses believed medications had already been given when they hadn't been. And facilities couldn't verify whether residents received their prescribed pain relief or other critical medications.
Dronabinol, the medication Staff A failed to properly document, is prescribed to stimulate appetite in patients with severe weight loss. For Resident 1, who was admitted with malnutrition, missing doses could worsen an already serious condition.
Oxycodone, the medication documented as given to Resident 2 on days the resident wasn't present, is a powerful pain reliever that requires careful monitoring due to its potential for abuse and diversion.
The inspection found that multiple nurses had made documentation errors, suggesting the problems weren't isolated incidents but reflected broader failures in the facility's controlled substance management system.
Federal regulations require nursing homes to maintain detailed records of all controlled substance administrations to prevent diversion and ensure residents receive prescribed medications. The regulations exist because controlled substances are frequently targeted for theft by healthcare workers, and elderly residents may be unable to advocate for themselves if they don't receive prescribed pain relief or other medications.
The facility's own policy recognized these requirements, mandating that staff document controlled substances in the bound logbook and count all such medications at every shift change. But inspectors found the policy wasn't being followed consistently.
Staff A's admission that controlled substances in the refrigerator weren't being counted during shift changes revealed a fundamental misunderstanding of the requirements. Location doesn't matter. All controlled substances must be accounted for.
The case of Resident 2 showed how documentation failures can mask more serious problems. When staff found entries for medications given to an absent resident, it raised immediate concerns about whether someone had been taking the medications for themselves.
For families of nursing home residents, the violations highlight the importance of asking about medication management policies and how facilities track controlled substances. When documentation systems fail, residents may suffer without their families knowing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Fir Lane Care from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
FIR LANE CARE in SHELTON, WA was cited for violations during a health inspection on August 21, 2025.
Staff A, a registered nurse, was preparing dronabinol for Resident 1 when the inspector arrived on August 13.
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.
Frequently Asked Questions
- What happened at FIR LANE CARE?
- Staff A, a registered nurse, was preparing dronabinol for Resident 1 when the inspector arrived on August 13.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in SHELTON, WA, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from FIR LANE CARE or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 505230.
- Has this facility had violations before?
- To check FIR LANE CARE's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.