The missing drugs were discovered during a routine review on March 26, according to the facility's former director of nursing services. Staff immediately launched an investigation, but their March 31 report concluded they were "unable to determine what happened to the missing narcotic medication."
Federal inspectors cited the facility in November for failing to maintain proper records of controlled substances, finding that narcotic drug records were not in order. The violation placed residents at risk for drug diversion.
The facility's own policy, revised in November 2022, required detailed tracking of all controlled substances. Nursing staff were supposed to count narcotic inventory at the end of each shift, with the departing nurse and incoming nurse conducting the count together. Any discrepancies had to be documented and reported immediately to the director of nursing services.
But when inspectors interviewed staff members in November, they found a concerning pattern of ignorance about the missing medications.
Staff 8, a certified medication aide, told inspectors on November 14 that she "remembered hearing about missing narcotic medication" but denied knowing any information about what happened. An hour and a half later, Staff 6, a licensed practical nurse, gave virtually identical responses. She "remembered reports of two missing narcotic cards but denied knowledge of what happened to the medication."
The former director of nursing services provided the most detailed account. During the March 26 review of narcotic books, she discovered two cards were missing entirely. The facility's investigation found no explanation for their disappearance.
Following the failed investigation, administrators conducted an immediate audit of all remaining narcotics and provided education to staff responsible for medication management. But the damage was already done. The controlled substances had vanished without a trace, and nobody could explain how.
The facility's narcotic tracking system was supposed to include multiple safeguards. Records of personnel access and usage, medication administration records, declining inventory records, and destruction and return-to-pharmacy documentation should have created a paper trail for every controlled substance.
None of those systems prevented the March disappearance.
Federal inspectors classified the violation as "past noncompliance" because administrators had identified and corrected the problem by April 1. The facility's corrective action plan included a complete audit of all narcotic books, which found no additional discrepancies.
Staff received new education on the facility's updated protocol for counting narcotic medications. The revised procedure required nurses to count the number of narcotics in each book and record the amount next to their initials on signature pages during every shift change.
All remaining narcotics were transferred into new tracking books to create fresh records for each controlled substance.
But the March incident exposed fundamental gaps in the facility's medication security. Two cards containing narcotic medications simply disappeared from locked storage areas, and despite having multiple staff members with access and detailed policies governing their handling, nobody could account for what happened.
The facility's investigation lasted five days. Administrators interviewed staff, reviewed records, and examined their tracking systems. They found nothing.
In nursing homes, narcotic medications are typically prescribed for residents experiencing severe pain from conditions like cancer, post-surgical recovery, or end-stage illnesses. These controlled substances require the highest level of security because of their potential for abuse and illegal diversion.
Federal regulations mandate strict accountability for every pill, patch, or liquid dose. When narcotics go missing, facilities must be able to demonstrate exactly what happened through their documentation systems.
Tigard Rehabilitation and Care couldn't do that.
The November inspection found that one of the facility's three narcotic books lacked proper records and accountability. While the March incident had been resolved through policy changes and staff retraining, it demonstrated how controlled substances could disappear from a licensed care facility without explanation.
Staff members interviewed months later still claimed no knowledge of the missing medications, despite the incident triggering facility-wide audits and mandatory education sessions.
The missing narcotic cards were never recovered. Their contents were never accounted for. And eight months later, the people responsible for securing controlled substances at Tigard Rehabilitation and Care still couldn't explain where they went.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Tigard Rehabilitation and Care from 2025-11-17 including all violations, facility responses, and corrective action plans.
Additional Resources
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