Countryside Care Center: Missing Morphine Uninvestigated - IL
The corporate nurse, identified in inspection records as V23, told inspectors on August 30, 2025 that the contracted LPN, identified as V6, had been working a 13-week contract when the facility terminated it on August 11. The reason was the missing morphine. What came after the termination was, by the corporate nurse's own account, almost nothing.
"We did not do an entire investigation on this missing Morphine," V23 told inspectors. "I cannot see where Pharmacy, Physician, Residents or other employees were interviewed."
The empty bottle was never recovered.
That admission came from inside the facility's own corporate structure. Countryside Care Center did not need an outside investigator to identify the gap. The corporate nurse said it plainly: the pharmacy was not contacted, the prescribing physician was not contacted, residents were not interviewed, and other employees were not interviewed. The investigation, such as it was, ended when the contracted employee's paperwork did.
Morphine is a Schedule II controlled substance, meaning its dispensing, storage, and disposal are subject to strict tracking requirements. When a dose or a bottle goes unaccounted for, the range of explanations, diversion by staff, documentation error, theft, or improper disposal, each carries different consequences for residents who depend on it for pain management.
None of those explanations were pursued here.
The contracted LPN was gone. The bottle was gone. And as of the inspection, conducted September 3, 2025, the facility had no documented record of having asked the people most likely to know what happened: the pharmacist who dispensed it, the doctor who ordered it, the residents in whose care it was used, or the colleagues who worked alongside the nurse during her 13-week contract.
CMS rated the violation as causing minimal harm or potential for actual harm, affecting a few residents.
What the corporate nurse could not explain, and what the inspection record does not answer, is where the morphine went.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Countryside Care Center from 2025-09-03 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 25, 2026 · Our methodology
COUNTRYSIDE CARE CENTER in MACOMB, IL was cited for violations during a health inspection on September 3, 2025.
The reason was the missing morphine.
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.