The incident at Golden Age Care Center occurred around 9 p.m. on October 11, involving a resident with moderate cognitive impairment, non-Alzheimer's dementia, diabetes, and depression who had lived at the facility since July 2022.
Staff A, the licensed practical nurse, had removed the hydrocodone-acetaminophen tablet from locked storage for a resident with a history of back and leg pain. The 5-325 mg tablet was prescribed for bedtime pain management. Instead of immediately administering the medication and watching the resident swallow it, she placed it in a pill cup on the bedside table and left the room.
While she was gone, Staff A observed Staff B, a certified nursing assistant, leaving the resident's room.
When Staff A returned, the pill cup was empty.
She searched the room and trash bins. The medication was never found.
The facility's controlled drug record shows a count of negative one tablet at 8:05 p.m. that evening, signed by Staff A.
During interviews with federal inspectors, the Director of Nursing said her expectation was clear: Staff A should have administered the hydrocodone immediately after removing it from locked medication storage. The nurse acknowledged she was supposed to give the medication directly to the resident and observe it being taken, not leave it unattended.
Staff B, the nursing assistant who was seen leaving the room, denied seeing any medications when interviewed by inspectors.
The resident involved has moderate cognitive impairment, scoring 9 out of 15 on a standard mental status assessment that indicates significant cognitive decline. Federal inspection records show the resident entered the facility in July 2022 and had been receiving the bedtime pain medication since September 2024.
Golden Age Care Center houses 40 residents. The facility's medication administration policy, updated in September 2025, states that medications must be provided to residents as ordered by physicians, but the policy excerpt in inspection records cuts off before detailing specific handling requirements.
Federal regulations require all drugs and controlled substances to be stored in locked compartments, with controlled drugs kept in separately locked areas. The regulations also mandate that medications be labeled according to accepted professional standards and remain inaccessible to unauthorized staff and residents.
The inspection found the facility failed to keep medications secure and inaccessible to unauthorized people. By leaving the hydrocodone unattended in the resident's room, staff created a situation where the controlled substance could be accessed by the cognitively impaired resident or other unauthorized individuals.
Hydrocodone-acetaminophen is a Schedule II controlled substance combining an opioid pain reliever with acetaminophen. The combination medication carries risks of addiction, abuse, and misuse, and federal law requires strict tracking and secure storage of all quantities.
The missing tablet represents a breakdown in multiple safety protocols. Staff A violated medication administration procedures by leaving a controlled substance unattended. The facility's tracking system recorded the discrepancy, but the physical medication disappeared without explanation.
The incident occurred despite the resident's established care plan documenting pain management needs and medication timing preferences. The care plan, initiated in November 2022, specifically noted the resident's history of back and leg pain and usual bedtime medication schedule.
Staff interviews revealed conflicting accounts of what happened in the resident's room. The licensed practical nurse admitted leaving the medication unattended, while the nursing assistant denied seeing it during her visit to the room.
The Director of Nursing reported the incident promptly, but the investigation could not determine what happened to the missing hydrocodone tablet. The medication remains unaccounted for, and facility staff found no trace of it despite searching the resident's room and surrounding areas.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, the incident highlights systemic problems with medication security and staff adherence to controlled substance protocols at the 40-bed facility.
The missing narcotic tablet and the facility's inability to account for its disappearance demonstrate failures in both individual staff practices and institutional oversight of controlled substances.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Golden Age Care Center from 2025-10-21 including all violations, facility responses, and corrective action plans.