Westminster Village Kentuckiana: Missing Narcotic - IN

The incident, which federal inspectors documented following a complaint investigation completed September 4, 2025, began two days earlier when a shipment of narcotic pain medication arrived at the facility on August 16. LPN 6 signed for it. The medication was logged, received, and then, at some point in the hours that followed, it was gone.

The resident at the center of the case is identified in inspection records only as Resident B. What is clear is that by the morning of August 18, Resident B did not have the pain medication they needed. A registered nurse, identified as RN 7, called the pharmacy to find out why. The pharmacy told her the medication had already been delivered — two days prior, on August 16 — and that a staff member had signed for it. RN 7 asked for a copy of the requisition. The pharmacy sent it over. LPN 6's signature was on it.

The medication had arrived. It had been signed in. And now it was not there.

RN 7 notified the Director of Nursing. The Director of Nursing, in an interview with inspectors on September 3, confirmed she was told about the missing narcotic and opened an investigation. She requested drug screens from five staff members: QMA 5, LPN 6, RN 7, LPN 8, and LPN 11. All five screens came back negative.

LPN 9 refused.

The refusal came by text message. The Director of Nursing confirmed this to inspectors. The inspection report does not say what happened to LPN 9 after that refusal, whether the facility pursued the matter further, or whether LPN 9 remained on staff.

What the report does describe is what happened on the morning of Sunday, August 17, the day after the medication arrived and the day before anyone realized it was missing. LPN 8, in a telephone interview on September 4, said that when she arrived for her shift that morning, LPN 9 was waiting to leave. LPN 9 asked LPN 8 to count the narcotics with her so she could go. The two nurses counted together. The medication cards and sheet counts were correct.

That count, on that morning, showed nothing wrong. By the next day, a resident's narcotic pain medication could not be found.

The facility cited this incident as a violation of Resident B's right to be free from misappropriation of property, a right guaranteed under both federal and state law. The inspection report notes that the deficient practice began on August 16 and was corrected by August 20.

In the four days between the medication's disappearance and the facility's declaration that the problem was fixed, the facility completed a 30-day lookback narcotic audit for all residents, educated all nursing staff on abuse and misappropriation of resident property, implemented a new narcotic count sheet, and completed drug screens for the staff members who agreed to take them.

The audit was completed August 18. The staff education happened August 19. The new count sheet was put in place August 19. Drug screens were finished August 20.

The inspection report does not say what the 30-day audit found. It does not say whether any other residents were missing medications. It does not say whether the investigation into Resident B's missing narcotic ever identified who took it, or whether anyone was disciplined or terminated.

What it says is that the deficiency was cited at a level of minimal harm or potential for actual harm, and that few residents were affected.

For Resident B, the medication was gone for at least two days before anyone discovered it. The inspection report does not describe what those two days looked like for the resident — whether they asked for pain relief that didn't come, whether staff noticed, whether anyone connected the absence of medication to the resident's condition. The report is silent on all of that.

The narcotic count on the morning of August 17 showed the numbers added up. LPN 9 left her shift. Resident B's medication was already gone, or would be shortly. No one knew yet. The count sheet said everything was fine.

By August 18, RN 7 was on the phone with the pharmacy trying to understand why a resident's pain medication had not arrived, and learning that it had, in fact, arrived two days before, and that someone had signed for it.

The Director of Nursing launched her investigation. She sent texts. She collected drug screens from the staff who would give them. She did not get one from LPN 9.

The facility told inspectors the matter was resolved. The new count sheet was in place. The staff had been educated. The audit was done. The citation was written at the lowest level of harm.

Resident B's name does not appear in the report. Neither does any description of what the resident's pain condition required the narcotic medication to treat, or what it meant for them to go without it for two days while the pharmacy records sat unexamined and the count sheets showed everything in order.

The report does not say whether law enforcement was contacted. It does not say whether the state licensing board was notified about the nurse who refused a drug screen by text. Those details, if they exist, are not in the inspection record.

What is in the record is a signature on a pharmacy requisition, a count that came out correct, a text message declining a drug screen, and a resident who needed pain medication that was not there.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Westminster Village Kentuckiana from 2025-09-04 including all violations, facility responses, and corrective action plans.

Additional Resources

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