The falsified medication record at Civita Care Center involved Alprazolam, a controlled substance prescribed for a resident's anxiety disorder. LPN #5 signed electronic records on June 26 at 10:12 AM indicating she had administered the 1-milligram extended-release tablet to Resident #178. But pharmacy delivery records show the medication didn't arrive until June 27.
When confronted by inspectors on August 19, the nurse acknowledged signing the administration record but admitted she "could not identify where she obtained the medication or if the medication was actually administered."
Resident #178 had been admitted to the facility just one day earlier, on June 25, from an acute care hospital. The resident suffered from depression and anxiety disorder and was alert and oriented to person, place and time. A physician's order dated June 26 directed staff to administer the Alprazolam tablet once daily at 9:00 AM for anxiety disorder.
The facility's emergency medication supply didn't stock Alprazolam extended-release tablets. Inspectors reviewed controlled medication transactions for all residents from June 1 through June 26 and found no other residents had orders for the same medication that could have been borrowed.
During her interview, LPN #5 revealed a troubling practice. She told inspectors that "when a medication is unavailable, she would normally notify the nursing supervisor and if the resident needed the medication emergently, she identified that she would borrow the medication from another resident."
The Director of Nursing Services contradicted this approach entirely. She told inspectors that nurses "should not borrow from another resident" when medications are unavailable. Instead, the charge nurse should notify the supervisor, contact the pharmacy, check the emergency supply, and notify the physician.
The pharmacist who supplies medications to the facility confirmed receiving the prescription for Alprazolam on June 26 and delivering it on June 27. This timeline made it impossible for LPN #5 to have legitimately administered the medication when she claimed.
A day after the initial interview, the Director of Nursing Services conducted her own review of controlled medication records. She confirmed that no resident in the facility was prescribed Alprazolam extended-release 1-milligram tablets during the period when LPN #5 documented the administration.
"LPN #5 could not have administered the medication and the eMAR documentation was incorrect," the Director concluded.
The facility has written policies addressing medication shortages and unavailable medications. The policy states that when medications are not received or unavailable, "the licensed nurse will urgently initiate action in cooperation with the attending physician and pharmacy provider."
But LPN #5's actions violated this protocol entirely. Rather than following proper procedures for unavailable medications, she signed records indicating successful administration of a controlled substance that didn't exist at the facility.
The violation occurred during a vulnerable period for Resident #178, who had just arrived from a hospital stay and required assistance with dressing, hygiene, eating, bathing and toileting. The resident's care plan specifically noted the need for psychotropic medication to manage anxiety and depression.
Federal regulations require nursing homes to maintain accurate medication administration records and ensure residents receive prescribed medications as ordered. The falsified documentation at Civita Care Center represents both a medication error and a record-keeping violation that could have serious consequences for resident care and regulatory compliance.
The inspection found that few residents were affected by the violation, which was classified as causing minimal harm or potential for actual harm. But the incident highlights broader concerns about medication management practices and staff adherence to established protocols at the facility.
Resident #178's case illustrates what can happen when proper medication procedures break down. A resident prescribed anxiety medication during a difficult transition period may not have received the prescribed treatment, while official records indicated otherwise. The discrepancy remained undetected until federal inspectors reviewed controlled substance records months later.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Civita Care Center At Newington from 2025-11-12 including all violations, facility responses, and corrective action plans.
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