Magnolia Lane Nursing: Opioid Tracking Failures - NC
That was one of the findings federal inspectors documented during a September 4 complaint inspection at the Burke County facility. The inspection also turned up a DEA controlled substance order form with what appeared to be an altered date, missing narcotic count sheets covering at least two months, and a director of nursing who could not produce records showing when the emergency opioid supply had actually run out.
The oxycodone in question was stored in a controlled medication emergency kit, a backup supply the facility kept on hand for residents who needed controlled substances that hadn't yet been filled through the normal pharmacy ordering process. When a resident arrived on a late admission in August 2025 with multiple unusual medications, staff turned to the emergency kit. What happened next took weeks to untangle, and some of it still hasn't been.
The pharmacy president told inspectors that a DEA 222 form, the federal document required to order Schedule II controlled substances like oxycodone, is normally sealed in an envelope and placed in a courier tote, where it can take up to 24 hours to be processed. The pharmacy's own records showed the form it received was dated August 19, 2025.
The director of nursing told a different story. She said the pharmacy never picked up the form when the courier came on August 18, so the date was changed and it was refaxed the following day as an emergency order. When inspectors examined the copy she provided, the date appeared to have been changed from a 19 to an 18. The director of nursing said she did not make that change. She said she had a copy with the August 18 date on it. She could not produce it.
The missing paperwork didn't stop there. Inspectors asked for the declining count sheets for the oxycodone from the emergency kit covering June and July of 2025, the records that would show when the supply was depleted and when a reorder was triggered. The director of nursing could not provide them.
Her explanation involved a policy change, a vacation, and two employees who no longer worked at the facility. She said completed narcotic count sheets had previously been placed in a binder after staff put them in her box, but a new policy started in the third week of August requiring them to go into a locked black box she accessed with a key. She said she had been on vacation at the end of July, and the former administrator and staff development coordinator were supposed to cover the filing in her absence. Both of those staff members were gone by the time inspectors arrived.
As for how she monitored the emergency kit in the meantime, the director of nursing said she checked it on Mondays and Fridays, but kept no written record of those inventory checks. She would look at the declining inventory sheet, jot something on a loose piece of paper, and order what was needed. Sometimes, she said, a nurse on the hall would just text her the count.
She told inspectors she now understood the specifics of the reorder policy and would follow it going forward. She said she had been managing it alone but had support now.
The administrator told inspectors he expected the policy to be followed and expected medications to be available for residents.
The pharmacy president attributed the root cause of the problem to the timing of the admission and the complexity of the resident's medication regimen. A late arrival with an unusual combination of drugs, he said, was what set the chain of events in motion.
What the inspection record does not contain is any documentation showing exactly when the emergency oxycodone supply ran out, who was responsible for reordering it at that point, or how long the gap lasted before the August order was placed. The count sheets that would answer those questions, covering at least June and July, are gone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Magnolia Lane Nursing and Rehabilitation Center from 2025-09-04 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: July 2, 2026 · Our methodology
Magnolia Lane Nursing and Rehabilitation Center in Morganton, NC was cited for violations during a health inspection on September 4, 2025.
That was one of the findings federal inspectors documented during a September 4 complaint inspection at the Burke County facility.
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.