Federal inspectors found dozens of missing signatures across two wings during their October 7 investigation. In the 500 wing alone, nurses failed to sign drug records on 22 separate occasions between September 1 and October 5.
The violations were systematic. On September 3, 5, and 6, no nurses signed the controlled substance book for any shift — day, evening, or night. September 19, 20, and 21 showed the same pattern: complete absence of required signatures across all three shifts.
October brought no improvement. Inspectors documented missing signatures on October 2, 4, and 5 for all shifts in the 500 wing.
The 600 wing showed similar problems. September 19 had no signatures from any shift. September 26 was missing signatures from all three shifts. September 29 showed the same complete breakdown in required documentation.
Each missing signature represented a failure to verify narcotic counts between shifts. RN-E told inspectors that both the departing nurse and the arriving nurse are responsible for counting narcotics in medication carts and signing the record book at every shift change.
"The book should be signed each day at each change of shift," RN-E explained during the October 7 interview.
The facility's Director of Nursing acknowledged the violations had persisted despite education efforts. DON-B told inspectors that training on controlled substance record requirements had been completed with all nursing staff on September 12.
Yet the missing signatures continued after that training date. September 13 showed missing signatures for night-to-day and day-to-evening shifts in the 500 wing. September 14 had gaps in day-to-evening and evening-to-night documentation.
The education materials DON-B provided to inspectors emphasized the seriousness of the requirement: "It is imperative at the beginning of your shift when taking narcotic keys from the nurse who is ending their shift, that you both sign the nurse to nurse controlled substance count verification sheet after narcotics have been counted."
The training document warned staff that failures would result in "progressive disciplinary action that could lead up to and include termination."
But the warnings appeared to have little effect. Even after the September 12 education session, inspectors found missing signatures on September 13, 14, 19, 20, 21, 23, 25, 26, 29, and 30.
The controlled substance record books are located in the back of each wing's narcotic record book. The verification sheets require signatures from both the outgoing and incoming nurses after they complete their narcotic count together.
Federal regulations require this documentation as a safeguard for controlled substances in healthcare facilities. The dual signature system creates accountability for narcotic inventory and helps prevent diversion or loss of controlled medications.
At North Ridge, that system broke down repeatedly across multiple weeks. September 1 started with missing night and day shift signatures in the 500 wing. September 2 was missing evening-to-night shift documentation.
The pattern continued through early October. October 1 in the 600 wing was missing the evening-to-night shift signature. October 2 had gaps in night-to-day and day-to-evening documentation.
Some days showed partial compliance. September 4 in the 500 wing had missing signatures for night-to-day and day-to-evening shifts, but evening-to-night appeared complete. September 7 was missing only the night-to-day signature.
But other days showed complete breakdowns. September 3, 5, 6, 19, 20, and 21 in the 500 wing had no signatures from any shift. October 2, 4, and 5 showed the same pattern.
The 600 wing violations followed similar patterns but different dates. September 18 was missing day-to-evening and evening-to-night signatures. September 23 and 25 each lacked night-to-day documentation.
DON-B provided inspectors with an undated list containing 10 nurse signatures along with the education materials, demonstrating that staff had been informed of the requirements.
The education materials stated that completing the controlled substance verification was "mandatory on both state and federal levels regarding narcotics." Staff were told that not completing the documentation would trigger disciplinary action up to termination.
Despite these warnings and the September 12 training session, the missing signatures continued through the inspection date. The violations affected both wings of the facility and occurred across all three shifts, indicating a facility-wide breakdown in controlled substance documentation protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Ridge Health and Rehabilitation Center from 2025-10-07 including all violations, facility responses, and corrective action plans.
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