The theft occurred on June 17, 2025 at Blue Springs Wellness & Rehabilitation during the routine controlled substance count that happens when shifts change. LPN A had been passing medications on the 100 and 200 hall while another nurse, RN A, handled the 300 hall.
When the assistant director of nursing began reviewing the narcotic book, something looked wrong. The count didn't match what should have been there.
The ADON called RN A to witness a recount of the controlled medications. Together with LPN A, they confirmed the discrepancy. Four pills of Norco were missing from Resident #4's bottle, and three more narcotic pills were gone from Resident #5's supply.
"The bottle had 4 missing pills, and they had not been on shift long enough to use that many for the one resident," RN A told investigators months later.
Following facility protocol for missing narcotics, the ADON contacted the director of nursing and instructed that LPN A and RN A remain together until released by management. The DON ordered the ADON to call 911.
Police arrived at 11:15 p.m. The officer was briefed on the missing controlled substances, with Residents #4 and #5 listed as victims in the police report. The ADON and RN A served as witnesses to the theft.
LPN A denied knowing what happened to the missing medications.
During the investigation, no loose pills were found in the medication cart or anywhere else that would indicate "pre-popping" - the practice of removing pills from packaging ahead of time. The ADON asked LPN A to write a statement about the incident.
The police report noted that LPN A had tried to sign out medication but hadn't recorded a time, a critical documentation failure in controlled substance handling.
RN A, who was new to the facility and working nights, recalled the incident during a September interview. "LPN A was going to be here for his/her last night of orientation," RN A said. "When they went to count, the count was not correct, so he/she went to the ADON who stepped in and took care of it."
The timing raised additional concerns. RN A came on shift at 6:00 p.m., and the missing pills were discovered shortly after. "They had not been on shift long enough to use that many for the one resident," RN A explained.
LPN A had accepted the narcotic count as correct at the start of the shift, making the disappearance even more suspicious. The missing medications included 10-325 mg Norco tablets, powerful opioid pain relievers commonly prescribed for nursing home residents with chronic pain conditions.
When investigators interviewed LPN A in September, nearly three months after the incident, the nurse's memory seemed selective. LPN A confirmed working at the facility for a month and being told there was a narcotic missing.
"He/She denied knowing there were missing narcotics or what happened," according to the inspection report. "He/She recalled counting narcotics when coming on shift with an RN and the count was correct. He/She denied remembering the second time narcotics were counted."
This convenient memory lapse occurred despite the dramatic nature of the evening - police being called, an immediate investigation, and being required to remain with another nurse until released by management.
The ADON described the incident during a September interview: "LPN A was passing night medications because there was an extra nurse. After passing medications LPN A was to go to the floor and help the Certified Nursing Assistant. ADON started looking the narcotic book and something looked off."
The theft left two elderly residents without their prescribed pain medications. Resident #4 lost four Norco tablets, while Resident #5 was missing three narcotic pills. For nursing home residents, many of whom suffer from chronic pain conditions, missing doses can mean hours of unnecessary suffering.
Federal regulations require nursing homes to maintain strict controls over narcotic medications, including accurate counts at every shift change and immediate reporting of any discrepancies. The facility followed protocol by calling police, but the incident highlighted vulnerabilities in medication security.
LPN A's denial of knowledge about the missing pills, combined with the inability to explain the discrepancy and the selective memory during interviews, led to the investigation. The nurse had been responsible for distributing medications to the very residents whose pills went missing.
The case remained under police investigation as of the inspection report, with Residents #4 and #5 still listed as victims of the alleged theft of their prescribed pain medications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Blue Springs Wellness & Rehabilitation from 2025-11-18 including all violations, facility responses, and corrective action plans.
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