The September inspection at Cedars of Lebanon Care Center found three tablets sitting in a medication cup inside Resident 18's bedside table. Two were yellow Tylenol Cold and Flu tablets. One was blue oxycodone with acetaminophen, a controlled narcotic.
The resident told inspectors on September 19 that staff "always left medications on his bedside table." He said the agency nurse had left these particular pills "a couple days ago" and he kept them because he was going to take them later if he needed them.
The resident had no doctor's order allowing medications to be left at his bedside.
Resident 18 had been admitted to the 45-bed facility with diabetes, chronic kidney disease, congestive heart failure, and chronic pain syndrome. His September physician's orders included oxycodone-acetaminophen 5-325 milligrams every six hours for pain and Tylenol Cold and Flu 500 milligrams four times daily for 14 days.
A quarterly assessment showed he had intact cognition and received opioid pain medication.
Licensed Practical Nurse 225 confirmed the medications during an interview with inspectors. The nurse verified the two yellow tablets were Tylenol Cold and Flu 500 milligrams and the blue tablet was oxycodone with acetaminophen 5-325 milligrams.
The facility's own policy required staff to remain with residents until all medication had been taken. The 2010 policy stated its purpose was "to provide guidelines for the safe administration of oral medication."
Federal regulations require nursing homes to store all medications in locked compartments, with controlled drugs kept in separately locked areas. Facilities must ensure drugs are labeled according to professional standards and properly secured.
The violation emerged from a complaint investigation. Inspectors reviewed medical records for three residents and found medication storage problems affecting one of them.
Leaving controlled substances accessible to residents creates risks beyond the individual patient. Oxycodone is a Schedule II controlled substance under federal law, meaning it has high potential for abuse and dependence. The Drug Enforcement Administration requires strict accounting and security measures for such medications.
The resident's multiple medical conditions made proper medication management particularly critical. His diagnoses included mood disorder, personality disorder, major depressive disorder, and anxiety disorder alongside his physical ailments.
Agency nurses, who work temporary shifts through staffing companies, may be less familiar with individual facility policies than regular staff. The inspection found this gap in oversight allowed controlled substances to remain unsecured for multiple days.
The facility policy dating to 2010 clearly outlined expectations for medication administration. Staff were supposed to watch residents swallow their pills before leaving the room. Instead, the agency nurse left a narcotic pain medication and other pills for the resident to take at his discretion.
Resident 18's statement that staff "always" left medications on his bedside table suggested this was not an isolated incident. The practice violated both federal regulations and the facility's internal policies.
The inspection classified the violation as causing minimal harm or potential for actual harm to few residents. However, unsecured controlled substances present risks for medication errors, drug diversion, and potential overdoses.
Federal inspectors completed their review as part of complaint number 2577683. The facility must submit a plan of correction to continue participating in Medicare and Medicaid programs.
The case highlights ongoing challenges with medication security in nursing homes, particularly when facilities rely on temporary agency staff who may not follow established protocols for controlled substance handling.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedars of Lebanon Care Center from 2025-09-19 including all violations, facility responses, and corrective action plans.
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