The facility received allegations on September 3rd that opioid medications were missing from Resident #51's supply. Regional Nurse #200 confirmed during interviews with federal inspectors that the facility never completed a summary or conclusion of their investigation into the missing narcotics.
Resident #51 went without any oxycodone from August 28th through August 31st when replacement medication finally arrived from the pharmacy.
The documentation problems centered on RN #227, who was observed working day shifts on B-Hall during the federal inspection in mid-September. On August 28th, she signed in only one card and one sheet of Alprazolam for Resident #81, documenting 45 pills total. The actual delivery included two sheets and two cards — one containing 30 pills, another with 15 pills.
"By only signing in one sheet and one card, you would be able to take out a card and sheet belonging to someone else without the count being off," inspectors noted in their report.
The timing coincided with Resident #51's missing oxycodone card, which staff discovered was gone on August 29th.
Medication administration records showed Resident #51 received 78 tablets of 15-milligram oxycodone between July 10th and August 23rd. She should have had 102 tablets remaining on August 23rd. The pharmacy delivered 30 additional tablets that day, bringing the total to 132.
Between August 24th and August 29th, records showed she received seven tablets. When LPN #195 noted on August 29th that no oxycodone was available, Resident #51 should have had 125 tablets left.
Regional Nurse #200 confirmed during her September 17th interview that the missing oxycodone "are not accounted for from the documentation."
The facility drug tested RN #227 on September 6th after the allegations focused on her. The test came back negative.
But administrators never investigated the Alprazolam documentation discrepancy for Resident #81, according to Regional Nurse #200. LPN/Unit Manager #175 confirmed during her September 17th interview that RN #227's improper count would make the numbers wrong "unless a card and sheet were removed by someone."
Regional Nurse #200 told inspectors she provided education to nursing staff on September 3rd "after it was determined what a mess it was." The pharmacy was notified the same day but wasn't involved in investigating the missing narcotics.
The night before the inspection interview, administrators learned that Resident #51 had told staff she didn't receive a pain pill. The unit manager called RN #227 to verify she had given the medication.
Regional Nurse #200 wasn't aware that Resident #51 had directly accused RN #227 of stealing her medications.
Federal regulations require nursing homes to report allegations involving misappropriation of resident property to state survey agencies within 24 hours. The facility's own policy, last revised in October 2017, defines misappropriation as "the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent."
The policy states administrators must notify the State Survey Agency of all alleged violations "as soon as possible but in no event later than 24 hours from the time the incident/allegation was make known to the staff member."
Country Lane Gardens never reported the missing narcotics allegation to state authorities prior to the September 17th federal inspection. Regional Nurse #200 confirmed the facility failed to make the required report.
The violation was investigated under multiple complaint numbers spanning several months, indicating ongoing concerns about the facility's handling of controlled substances and resident property.
RN #227 continued working regular shifts throughout the investigation period, with inspectors observing her on duty during both September 16th and 17th site visits.
The missing medications left Resident #51 without prescribed pain management for four consecutive days while administrators failed to conduct a thorough investigation or reach any conclusions about what happened to the controlled substances.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Country Lane Gardens Rehab & Nursing Ctr from 2025-10-15 including all violations, facility responses, and corrective action plans.
Additional Resources
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