Olympia Convalescent Hospital: Narcotic Count Failures - CA
Federal inspectors documented both failures during a complaint inspection completed August 25, 2025.
The director of nursing confirmed that two licensed vocational nurses, identified in inspection records as LVN 2 and LVN 5, had signed the facility's narcotic count sheets before conducting the physical inventory those signatures were supposed to certify. The director was direct about what those signatures mean: when an oncoming nurse and an outgoing nurse both sign the narcotic sheet at shift change, it means both nurses physically counted the controlled substances and gave report to each other. That is the whole point of the dual signature.
Neither nurse had done that.
The facility's own policy, in effect since January 2022, requires two licensed nurses to conduct a physical inventory of all controlled substances at every shift change and document the results on the narcotic sheet. Signing the sheet is the documentation of a count that already happened. Signing it ahead of time inverts that entirely — it records a count that hasn't happened and may never happen.
The director of nursing put the risk plainly. Signing ahead of time means the nurse has no way of knowing whether any situation has occurred that could make the count inaccurate. A discrepancy, a diversion, a missing dose — none of it would surface if the count is never done.
The tramadol problem had already illustrated exactly that kind of gap. Tramadol is a narcotic analgesic. The pharmacy delivered it to a different facility by mistake. The director of nursing confirmed the misdirected shipment during the inspection. The facility's policy on receiving medications from the pharmacy requires a licensed nurse to verify what was delivered against the pharmacy receipt before signing for it, and to report any discrepancy or omission to the pharmacy and a supervisor immediately.
The inspection record does not specify whether the tramadol was ever recovered, whether the residents prescribed it went without doses during the period it was missing, or how long the error went undetected.
What the record does show is a system where the controls designed to catch exactly this kind of problem — the physical count, the verified receipt, the dual nurse signature — were being treated as paperwork rather than safeguards. A nurse who signs a narcotic sheet without counting doesn't know what's there. A nurse who doesn't verify a pharmacy delivery against the receipt doesn't know what arrived. Both failures happened at the same facility.
Inspectors cited the violations under F0755, the federal tag covering pharmacy services and the accurate administration of controlled substances. The level of harm was cited as minimal harm or potential for actual harm, affecting a few residents.
The director of nursing acknowledged both nurses had signed the sheets improperly and confirmed the pharmacy error. The inspection record does not indicate what, if any, disciplinary action followed.
The residents whose tramadol was sent elsewhere are not named in the inspection record. Whether they received their medication on time, or at all, during the period the shipment was missing is not addressed.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Olympia Convalescent Hospital from 2025-08-25 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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 29, 2026 · Our methodology
Olympia Convalescent Hospital in LOS ANGELES, CA was cited for violations during a health inspection on August 25, 2025.
Federal inspectors documented both failures during a complaint inspection completed August 25, 2025.
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.