On August 27, inspectors watched RN 2 conduct a narcotic drug count on the East unit medication cart at 10:51 a.m. The count log showed 23 hydrocodone-acetaminophen tablets available, but only 22 remained in the drug pack. A second hydrocodone medication showed 30 tablets on the log with 29 actually present.
RN 2 told inspectors she "must have been in a hurry and forgot to sign the medications out after giving them." She said she typically signs the narcotic log as she administers doses.
Thirteen minutes later, inspectors observed similar problems on the facility's second unit. QMA 2 conducted a narcotic count on the unit's medication cart and found discrepancies with two controlled substances.
The count log indicated 17 clonazepam tablets remained available, but QMA 2 found only 16 in the drug pack. Ativan showed 8 tablets on the log with 7 actually present.
QMA 2 explained she was passing medications on two halls and was "just behind." Like the registered nurse, she said she normally signs medications out as she gives them.
Both nurses blamed their rushed schedules for failing to follow the facility's own medication tracking procedures.
The facility's controlled substance policy, dated July 22, 2023, requires staff to record each dose at the time of administration. Nurses must confirm the controlled drug supply is correct both before and after assembling doses for residents.
The policy specifically requires verification of the date, time, dosage, signature of the administering nurse, and number of doses remaining. None of these steps were properly completed in the cases inspectors witnessed.
Waters of Princeton operates two nursing units where staff routinely handle controlled substances including hydrocodone, clonazepam, and Ativan. These medications require strict tracking under federal regulations due to their potential for abuse and diversion.
The inspection occurred in response to a complaint filed against the facility. Federal inspectors cited the nursing home for failing to maintain proper drug records and accurate accounts of controlled substances.
The Director of Nursing provided inspectors with the current medication policy the day after the violations were observed. The policy had been in effect for over a year before the inspection, indicating staff were aware of proper procedures but failed to follow them.
Federal regulations require nursing homes to employ or obtain services from a licensed pharmacist to ensure pharmaceutical services meet each resident's needs. Accurate narcotic tracking is a fundamental component of safe medication management.
The inspection found that staff on both units had developed a pattern of administering controlled substances first and attempting to document them later. This practice creates gaps in the medication record that make it impossible to verify whether residents received prescribed doses.
When nurses fail to immediately record narcotic administration, the facility cannot account for missing medications. The practice also makes it difficult to identify potential diversion or medication errors that could harm residents.
RN 2 and QMA 2 both acknowledged they knew proper procedures but admitted cutting corners when busy. Their explanations suggest the violations were routine rather than isolated incidents.
The facility's medication management failures affected controlled substances across multiple drug classifications. Hydrocodone is a Schedule II narcotic, while clonazepam and Ativan are Schedule IV controlled substances.
Each missing tablet represents a dose that could have been diverted, double-administered, or simply lost due to poor record-keeping. Without accurate counts, the facility cannot ensure residents receive prescribed medications or prevent unauthorized access to controlled substances.
Waters of Princeton's policy clearly outlined the steps nurses must take to maintain controlled substance security. The fact that violations occurred on both inspected units suggests systemic problems with medication management oversight.
The inspection citation relates to a specific complaint investigation, indicating someone raised concerns about the facility's medication practices. Federal inspectors confirmed those concerns by witnessing the violations firsthand during their two-day visit.
Residents at Waters of Princeton depend on accurate medication administration for pain management and other medical needs. When nurses fail to properly track controlled substances, they compromise both resident safety and regulatory compliance.
The facility must now develop a plan of correction to address the medication tracking failures before continuing to participate in federal healthcare programs.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Waters of Princeton, The from 2025-08-28 including all violations, facility responses, and corrective action plans.