Westwood Hills Nursing: Narcotic Tracking Failures - NC
That was the finding that triggered a complaint inspection at the facility, where inspectors determined that controlled substances were not being properly tracked from shift to shift, and that declining count sheets, the paper trail that follows narcotic medications through a nursing home, were not being consistently maintained.
The violation was cited under F0602, which covers a facility's obligation to operate with integrity in its management of controlled substances. Inspectors rated the harm level as minimal, affecting few residents, but the breakdown they documented pointed to something more systemic: a facility that had lost its grip on one of the most tightly regulated categories of medication in any care setting.
Narcotic medications in nursing homes require a specific chain of custody. When a pill is administered, it gets logged. When a prescription is discontinued, the medication is supposed to come off the cart and go back to the pharmacy. Shift changes require nurses to hand off accountability for every controlled substance in the locked box. When any link in that chain goes unverified, the question of where a medication ended up, whether it was given to the resident it was prescribed for, or whether it was diverted, becomes impossible to answer with confidence.
At Westwood Hills, inspectors found that chain had broken down.
The facility's own corrective action plan, included in the inspection record, described what the response looked like once the problem was identified. Starting September 13, the Director of Nursing and Assistant Director of Nursing began reviewing an order listing report every day to confirm that narcotic medications were physically present in the medication cart or the narcotic lock box, and that any discontinued medications had actually been removed. The plan also called for re-education of licensed nurses and medication aides, with the Director of Nursing conducting audits weekly for four weeks, then monthly for an additional month, reviewing and initialing each one.
The findings were to be brought before the facility's Quality Assurance Performance Improvement Committee. Those meetings happened on September 22 and October 21.
When inspectors returned on November 19 to validate whether the corrective plan had worked, they found the count sheets at 100 percent accuracy. Staff had been educated. Residents interviewed during the survey said their pain was being treated. The compliance date the facility had set for itself, September 16, was confirmed as met.
What the inspection record does not explain is how long the tracking failures had been occurring before someone filed a complaint. The record does not say whether any medication was unaccounted for, whether any resident went without a prescribed narcotic, or whether any diversion was suspected or investigated. The violation was classified at the lowest level of harm, but that classification reflects what inspectors could confirm, not necessarily what the full picture looked like before the audit tools went into place.
Narcotic diversion in nursing homes is not a rare problem. It tends to surface the same way it did here: a complaint, an inspection, a paper trail that doesn't add up. The residents most at risk are those who depend on controlled substances for pain management and who cannot always advocate for themselves when a dose doesn't arrive.
The residents at Westwood Hills who were interviewed told inspectors they had no untreated pain. That is the best available evidence of what they experienced. It does not answer the question of what happened to every pill that moved through that medication cart before someone started watching more carefully.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westwood Hills Nursing and Rehabilitation Center from 2025-11-19 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Westwood Hills Nursing and Rehabilitation Center in Wilkesboro, NC was cited for violations during a health inspection on November 19, 2025.
The violation was cited under F0602, which covers a facility's obligation to operate with integrity in its management of controlled substances.
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.