The theft occurred between 6:00 AM and 7:00 AM on October 9th at Cedar Ridge Center. LPN #7 had relieved another nurse for one hour and possessed keys to the medication cart during that time. When the oncoming nurse reported at 7:00 AM, LPN #7 declined to recount the medications as required by facility policy.
The incoming nurse obtained additional staff to conduct the count. They discovered seven 7.5-200 mg hydrocodone tablets missing from Resident #10's supply.
Resident #10 denied any previous missing doses of pain medication. The resident has a cognitive assessment score of 15 and maintains decision-making capacity according to physician determination.
The facility's investigation revealed that LPN #7 was responsible for the drug diversion. She was terminated and reported to the West Virginia Licensed Practical Nursing Board. A Drug Enforcement Agency form was also filed.
This incident followed a larger pattern of narcotic disappearances at Cedar Ridge Center during the summer months.
Between July 9th and July 29th, substantial quantities of opioid medications vanished from the facility's destruction log. Twenty-two oxycodone tablets scheduled for destruction on July 9th went missing. On July 14th, inspectors documented missing supplies from three residents: 22 hydrocodone tablets, 22 hydrocodone/Norco tablets, and 9 hydrocodone tablets.
Two weeks later, another 28 hydrocodone tablets disappeared, along with 27 additional hydrocodone tablets and 15 oxycodone tablets, all scheduled for destruction on July 29th.
When the facility pharmacist arrived on August 15th to destroy the medications listed in the logbook, none of the narcotics were in the locked box where they should have been stored.
The facility reported these disappearances to law enforcement. While investigators substantiated the allegation of drug diversion and misappropriation, they could not determine how, when, or by whom the medications were taken.
Cedar Ridge Center's policy for controlled drug management requires physical inventory of narcotics at each shift change, conducted by two licensed clinicians and documented on an audit record. The policy states that discontinued controlled substances must be retained in a securely double-locked area with restricted access until destruction.
The facility obtained replacement pain medication for Resident #10 to maintain proper pain control after the theft was discovered.
Federal inspectors confirmed the findings with the administrator, director of nursing, and corporate resource nurse on October 16th. All three agreed the missing narcotics constituted drug diversion and misappropriation of personal property.
The investigation into LPN #7's theft took six days to complete. The facility's prompt reporting to multiple agencies, including law enforcement and the state nursing board, followed federal requirements for suspected narcotic diversion.
Resident #10's missing medication represented a direct threat to pain management for someone with documented cognitive capacity who relied on the prescribed hydrocodone for comfort. The resident's denial of any knowledge about missing doses suggested no complicity in the disappearance.
The summer thefts involved larger quantities across multiple residents, with 141 narcotic tablets missing from the destruction process over a three-week period. The August discovery that none of these medications reached the pharmacist for proper disposal indicated systematic removal from the facility's secure storage.
LPN #7's refusal to participate in the medication count represented a clear violation of facility policy requiring two-person verification of controlled substances. Her possession of medication cart keys during the one-hour period when the theft occurred provided the opportunity for diversion.
The facility's double-locked storage system and shift-to-shift counting procedures, designed to prevent exactly this type of theft, failed to stop either the individual incident or the larger pattern of disappearances. The investigation confirmed that proper policies existed but proved insufficient to prevent narcotic diversion by staff with authorized access.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedar Ridge Center from 2025-10-16 including all violations, facility responses, and corrective action plans.