The missing pain medication was discovered during a routine narcotic count in November 2024. Federal inspectors who investigated a complaint in August found that nursing assistants and nurses on the night shift were not counting controlled substances correctly, leading to the loss of Resident 26's oxycodone.
The resident had been prescribed oxycodone 2.5 mg every four hours as needed for pain. Oxycodone is a Schedule II controlled substance, the most strictly regulated category of prescription drugs due to high potential for abuse and dependence.
Staff 16, a certified medication aide, noticed the missing card during a shift change count. "He noticed a card of oxycodone was missing for Resident 26," inspectors wrote. The aide reported the incident to a nurse, but the medication was never found.
The facility's internal investigation concluded that staff had likely thrown the card away by mistake. Staff 3, a registered nurse case manager, told inspectors that "the narcotic drawer was not counted properly, and the card was likely thrown away by mistake."
Resident 26, who was admitted in June 2024 with an abdominal wall infection, remained unaware of the missing medication. When inspectors interviewed the resident in August, they said they had not missed any needed oxycodone doses since admission and were not aware any medication was missing.
The resident's medical records showed they were cognitively intact, according to their annual assessment completed in June 2025.
Federal inspectors determined the incident constituted misappropriation of resident property, placing residents at risk for unmanaged pain. The facility's own investigation reached the same conclusion, finding that misappropriation had occurred and the claim was substantiated.
After discovering the missing medication, Willowbrook implemented what it called immediate corrective action. The facility provided education and demonstration on proper narcotic counting procedures to all certified medication aides over six weeks.
All medication aides and nurses were required to review the PharMerica instruction manual regarding procedures for pulling controlled medications and maintaining narcotic record books. Each staff member signed an attestation confirming they had reviewed the manual.
The director of nursing conducted weekly narcotic count audits for six weeks following the incident. Inspectors noted the facility had corrected the deficient practice by November 21, 2024, classifying it as past noncompliance.
The inspection took place in August 2025, nine months after the missing medication was discovered. Inspectors reviewed records and interviewed staff as part of their investigation into the complaint.
Willowbrook Post Acute is located at 707 SW 37th Street in Pendleton. The facility provides post-acute care and rehabilitation services.
The missing oxycodone represents a breakdown in basic medication security protocols that nursing homes are required to maintain. Federal regulations mandate that facilities protect residents from wrongful use of their belongings or money, including prescription medications.
Controlled substances require especially strict handling due to their potential for diversion and abuse. The loss of even a single card of medication can leave residents without needed pain relief while potentially putting dangerous drugs into unauthorized hands.
Staff 3 acknowledged to inspectors that the facility had implemented a corrective plan over the six weeks following the discovery. The plan focused on ensuring proper counting procedures and documentation for all controlled substances.
The incident affected what inspectors classified as "few" residents, though the exact number beyond Resident 26 was not specified in the inspection report.
Resident 26's case illustrates how medication handling errors can occur even when residents remain unaware of problems with their care. The resident continued to receive pain medication as needed and reported no missed doses, despite the facility's internal finding that their medication had been misappropriated.
The facility's investigation timeline showed staff discovered the missing medication during routine counting procedures designed to prevent exactly this type of loss. The failure of those safeguards led to the corrective actions implemented across all shifts handling controlled substances.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Willowbrook Post Acute from 2025-08-22 including all violations, facility responses, and corrective action plans.