LPN #275 at Wickliffe Country Place signed the controlled packing slip on August 9, 2025, acknowledging receipt of the anti-anxiety medication for Resident #181. The next morning, when it came time for the resident's scheduled dose, the clonazepam wasn't available.
The nurse told investigators she never saw the clonazepam listed directly under tramadol on the packing slip when she signed for the delivery. During the morning shift change on August 10, another nurse told her the medication was "already on order," so she didn't call the pharmacy or contact a physician for a new prescription.
Three days later, the mystery deepened. LPN #347 documented a note revealing the pharmacy had flagged an unusual pattern: "Clonazepam oral tablet disintegrating 0.25 mg give one tablet by mouth two times a day for bipolar. Patient has requested refill too soon. Order will be dispensed on 08-21-2025."
The pharmacy's alert suggested someone had been requesting refills ahead of schedule. But the facility's Director of Nursing confirmed no investigation was launched on August 11 to determine where the original medication had gone or why the refill request came too early.
"I would have to look into it," the DON told inspectors when asked about the pharmacy's warning.
Account Manager #392 from the pharmacy confirmed their records showed the clonazepam was delivered and properly signed for by the facility nurse. Director of Clinical Services Pharmacist #393 verified the same information. The facility's standard procedure requires nurses to check and count all medications while the delivery driver remains present, then sign confirming receipt.
LPN #275 admitted during her September 15 interview that she had never been asked to undergo drug screening following the incident. She also confirmed she received no additional education on proper medication receipt procedures after the initial training in April 2025.
The missing controlled substance triggered a facility-wide response, but not immediately. On August 13, four days after the delivery and three days after the missing dose, the DON conducted an in-service for nurses on controlled substances. Sixteen nurses signed the training log.
LPN #275 didn't sign it.
"She was educated in April on controlled substances," the DON explained when asked why the nurse involved in the incident missed the remedial training.
Eight days later, on August 21, LPN #275 received a final written warning. The disciplinary form stated the employee was "not adequately following policies and procedures for accepting controlled substances from pharmacy." The form indicated previous warnings, with a checkmark dated April 18, 2025, when all nurses received initial training on pharmacy delivery procedures.
The DON confirmed LPN #275 was re-trained on correct procedures when she received the written warning, but acknowledged the disciplinary form didn't document the training.
The facility's investigation file provided to state inspectors was incomplete. The DON confirmed that medication administration records and nursing notes were missing from the documentation. When inspectors asked about the pharmacy's August 11 alert regarding the "too soon" refill request, the DON admitted she hadn't seen that note.
Wickliffe Country Place's own policy on abuse, neglect, exploitation and misappropriation of resident property, reviewed January 6, 2025, requires immediate reporting of all incidents to the Administrator. The policy mandates notification to the Ohio Department of Health within 24 hours of any alleged violations involving mistreatment, neglect, abuse, exploitation, or misappropriation of resident property.
The policy also requires facilities to review employment records if an employee is accused, document investigation evidence, and provide staff training based on investigation results.
But no formal investigation was documented when the clonazepam disappeared between the delivery truck and the resident's medication cup. No investigation was launched when the pharmacy flagged suspicious refill timing three days later.
The controlled medication in question, clonazepam, is prescribed for Resident #181's bipolar disorder. The 0.25 mg disintegrating tablets were ordered twice daily. Missing even a single dose can affect mood stabilization in patients with bipolar disorder.
Federal inspectors classified the violation as having potential for minimal harm affecting few residents. But the incident exposed gaps in the facility's controlled substance tracking that could affect any resident receiving scheduled medications.
The pharmacy's computer systems flagged the unusual refill pattern automatically. The facility's systems did not.
LPN #275 had been working at the facility since at least April 2025, when she received initial training on controlled substance procedures. The August incident occurred four months later, suggesting the training hadn't prevented the medication from going missing.
The final written warning remained the only disciplinary action taken against the nurse. No drug screening was conducted. No additional monitoring was implemented for future medication deliveries.
Resident #181 eventually received their clonazepam when the pharmacy's system allowed the refill to be processed on August 21, twelve days after the original delivery was signed for and eleven days after the missing morning dose.
The facility never determined where the first bottle of clonazepam went.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wickliffe Country Place from 2025-11-17 including all violations, facility responses, and corrective action plans.