Northern Pines Rehab: Illegal Drug Doses Given - MT
The facility's own controlled substance log documented each unauthorized dose of lorazepam, a medication for anxiety that was supposed to stop on February 24. Instead, nurses administered it on February 25, March 2, and March 3.
Staff member B told inspectors during a September 9 interview that she didn't know why the medication card wasn't removed from the cart when the drug was discontinued. She didn't know why the nurse gave the medication after the discontinuation date. The medication should not have been given, she said.
The resident's physician had ordered lorazepam 0.5 mg at bedtime for anxiety, but only for one week. The order, dated February 18, specified the medication would end on February 24 at 11:59 p.m.
Yet the facility's controlled substance log shows nurses removed doses for administration on February 25 at 7:00 p.m., March 2 at 7:00 p.m., and March 3 at 8:00 p.m.
The medication administration record confirmed there was no active physician's order for lorazepam after February 24.
Northern Pines didn't identify the medication errors until April 12 — over a month after they occurred. The facility documented the violations in what it called a "Misappropriation Report."
Two staff members explained the facility's protocol for controlled substances during inspector interviews. Staff member E said each resident had their own supply of narcotic medications in the medication cart. When there was a change to the order or the medication was discontinued, the card should be pulled from the cart and destroyed.
Staff member F said when a narcotic was discontinued, the medication card should be pulled from the locked narcotic box and destroyed by two nurses. This was to help ensure the medication wasn't given after it was discontinued.
The facility's own policies prohibited exactly what happened. A medication administration policy adopted in December 2016 stated that medications must be administered in accordance with orders. The person giving the medication must verify the right resident, right medication, right dosage, right time, and right method before administration.
After the violations were discovered, Northern Pines updated its controlled substance training. A document dated April 15 emphasized that when narcotics are discontinued or there's no longer an active order, the director of nursing must be alerted and the medication destroyed by two nurses.
The training document stated it was "unacceptable and a violation of the standard of practice to administer medications without an order." It specified that administering medications without a current order was "not acceptable."
NF1, a facility administrator, told inspectors on September 10 that a controlled substance should not be administered without a current physician's order. When a narcotic was discontinued, the medication should have been removed from the medication cart and all pills destroyed with two nurses present.
The violations occurred with lorazepam, a benzodiazepine medication commonly prescribed for anxiety disorders. The resident was receiving 0.5 mg doses at bedtime, a typical starting dose for elderly patients.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm. The facility failed to ensure nursing staff followed professional standards for medication administration before giving a controlled substance.
The inspection was conducted in response to a complaint. Inspectors reviewed physician orders, medication administration records, the controlled substance log, and the facility's misappropriation report. They interviewed multiple staff members about the facility's protocols for handling discontinued controlled substances.
The medication errors highlight systemic failures in the facility's controlled substance management. Despite having written policies and training materials that clearly prohibited administering medications without orders, staff gave unauthorized doses on three separate occasions.
The month-long delay in discovering the violations suggests inadequate oversight of controlled substance administration. The facility's own documentation systems recorded each unauthorized dose, yet supervisors didn't notice the discrepancies between the medication orders and the controlled substance log until weeks later.
Northern Pines operates in Cut Bank, a small city near the Canadian border in north-central Montana. The facility provides rehabilitation and long-term nursing care services.
The September inspection found that one of 12 sampled residents was affected by significant medication errors involving controlled substances.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Northern Pines Rehabilitation and Nursing from 2025-09-11 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: June 20, 2026 · Our methodology
NORTHERN PINES REHABILITATION AND NURSING in CUT BANK, MT was cited for violations during a health inspection on September 11, 2025.
The facility's own controlled substance log documented each unauthorized dose of lorazepam, a medication for anxiety that was supposed to stop on February 24.
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.