Foxwood Springs: Narcotic Count Errors Uncovered - MO
Inspectors cited Foxwood Springs Living Center following a complaint investigation completed October 22, 2025, finding the facility had failed to maintain accurate narcotic tracking records for a resident receiving oxycodone. The violation was tagged at the level of minimal harm or potential for actual harm.
The breakdown involved two separate records that are supposed to mirror each other: the narcotic count sheet, which tracks how many controlled substance pills are on hand at any given moment, and the medication administration record, known as the MAR, which documents when a nurse actually gives a dose to a resident. On two dates, a nurse pulled oxycodone from the medication card and signed it out on the narcotic sheet. The MAR, which should have reflected those same administrations, was never signed.
That alone was a documentation failure. But the problem ran deeper.
The orders written on the narcotic count sheet were not the same orders that appeared on the MAR. The physician's orders on the MAR were the correct ones for administering oxycodone to the resident. The narcotic sheet was operating off something different. The count on that sheet showed 20 pills remaining. It should have shown 30.
At shift change, nurses are required to count the narcotics together, then both sign the count sheet to confirm the tally matches the medication cards. Two nurses did exactly that, both signing off that the count was complete and accurate. Because the count sheet itself contained the wrong starting number, the error wasn't caught. The system designed to catch discrepancies validated one instead.
When inspectors reviewed the narcotic sheet, they found the count had been written over, meaning someone had altered the number on the existing sheet rather than discarding it and starting a new one.
The administrator and the director of nursing reviewed the records with inspectors during an interview at 4:00 p.m. on October 22. The director of nursing confirmed that the orders on the narcotic record and the MAR were not the same, and that the MAR carried the correct physician's orders. Both the administrator and the director of nursing acknowledged that staff should have made sure the two documents reflected identical orders, that a new narcotic sheet should have been started when the orders changed, and that writing over the count on the existing sheet was not the correct procedure.
Controlled substance tracking in nursing homes exists precisely because oxycodone and drugs like it are subject to diversion, meaning they can be taken by staff rather than given to residents. When the paper trail contains mismatched orders, an altered count, and unsigned administration records, there is no clean way to reconstruct what actually happened to those ten pills. The records that would answer the question are the same records that contain the errors.
The facility's own shift-change verification process, the double-signature count meant to serve as a safeguard, did not flag the problem. Both nurses signed. The count appeared complete. The discrepancy sat in the records until a complaint brought inspectors through the door.
The resident at the center of the complaint received oxycodone, a Schedule II opioid, for pain. Whether they received every dose they were prescribed, on the dates and in the amounts their physician ordered, is a question the available documentation cannot fully answer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Foxwood Springs Living Center from 2025-10-22 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 7, 2026 · Our methodology
FOXWOOD SPRINGS LIVING CENTER in RAYMORE, MO was cited for violations during a health inspection on October 22, 2025.
The violation was tagged at the level of minimal harm or potential for actual harm.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.