Park Place Nursing: Narcotic Count Failures Found - TX
When federal inspectors arrived on November 20, 2025, they found that staff had not been consistently counting narcotics at shift changes, that signatures were absent from count sheets that were supposed to document those counts, and that one tablet of hydrocodone/acetaminophen 5mg/325mg prescribed to a resident identified in inspection records as Resident 3 had gone unaccounted for long enough to require a conversation with the resident herself to explain it.
The director of nursing told inspectors she had not been aware of how many signatures were missing from the shift count sheets. That's a significant gap. The count sheets exist precisely so that someone in her position can verify, at a glance, that controlled substances are being tracked every time one shift hands off to the next. Missing signatures don't just mean paperwork is incomplete. They mean nobody can say, with certainty, that the narcotics were actually counted.
The facility's own controlled substances policy, dated 2001, is explicit on this point. Nursing staff coming on duty and nursing staff going off duty are required to count controlled medication inventory together, at the end of every shift, and to document the count. Any discrepancy gets reported to the director of nursing. A signature from the nurse who administered a controlled substance is required on each resident's individual controlled substance record.
That policy has been on the books for more than two decades. The signatures were still missing.
The administrator, interviewed the same morning inspectors were on site, acknowledged the stakes plainly. He said staff were expected to count narcotics at shift change. He said anyone who failed to do so would be counseled and re-educated. And then he said something that cut to the center of why this matters: he said there was the risk of drug diversion if the counts weren't done.
Drug diversion is the theft of controlled substances, usually by a staff member, for personal use or resale. It happens in health care settings with enough regularity that regulatory agencies track it as a distinct category of risk. Narcotic count procedures exist specifically because facilities need a mechanism to catch diversion early, ideally before a pattern develops. When those counts don't happen, or happen without documentation, the mechanism fails. There is no way to know whether a missing tablet was administered to a patient, dropped on the floor, or taken by someone who wasn't supposed to have it.
In the case of Resident 3's missing hydrocodone tablet, the director of nursing said staff had eventually figured out where it went. She said she had spoken with Resident 3 directly, and the resident confirmed she had received the medication when she requested it. That's a resolution of a kind. The tablet was accounted for.
But the fact that tracking down one tablet required a conversation with the resident, rather than a review of complete and signed documentation, points to exactly the problem inspectors cited. If the count sheets had been properly completed and signed at every shift change, the question of where that tablet went would have had a clear, documented answer before it became a question at all.
One of the nurses involved, identified in inspection records as LVN C, could not be reached for an interview on the day of the inspection. The director of nursing told inspectors the nurse was asleep at the time.
The inspection classified the violation under F0755, which covers the safe and accurate provision of medications, including controlled substances. The level of harm was listed as minimal harm or potential for actual harm, and the finding was noted to affect some residents.
That classification, minimal harm, can be misleading if read too quickly. It reflects what inspectors were able to document, not the outer boundary of what could have occurred. Narcotic documentation failures are the kind of violation where the harm, if any occurred, may be nearly impossible to reconstruct after the fact. A resident who was shorted a pain medication may not have reported it, or may not have known they were entitled to it. A tablet that left the building in someone's pocket leaves no trace in a count sheet that was never signed.
The facility's policy requires one prescription per page on each resident's controlled substance record, with the administering nurse's signature on every entry. The count is supposed to happen at the end of every shift, with both the outgoing and incoming nurse present and signing. Those requirements exist as a chain of documentation, each link dependent on the one before it. Pull one link, and the chain doesn't hold.
Park Place Nursing & Rehabilitation Center is a long-term care and rehabilitation facility in Tyler, in East Texas. The inspection that produced this finding was a complaint inspection, meaning it was triggered by a specific complaint rather than a routine survey cycle.
The administrator's response, that staff who skipped counts would be counseled and re-educated, is the standard corrective language. It may well be sufficient. Counseling and retraining are appropriate responses to documentation failures, and the fact that the director of nursing and administrator were both cooperative with inspectors and forthcoming about what had happened suggests the facility wasn't attempting to minimize the finding.
What the inspection record doesn't answer is how long the count sheets had been accumulating missing signatures before inspectors arrived. The director of nursing said she had not been aware of the gaps. That means either the sheets weren't being reviewed regularly, or they were reviewed and the missing signatures weren't flagged, or the review process itself had broken down somewhere between the nursing floor and the director's office.
Any of those possibilities points to a supervision problem that runs deeper than one missed count or one nurse who needed to be reached for comment and couldn't be because she was asleep.
Resident 3 got her hydrocodone. That much is established. She said so herself when the director of nursing asked her. But she was asked because the documentation had failed, and the documentation had failed because the counts weren't being done the way they were supposed to be done, and the counts weren't being done that way despite a policy that has required otherwise for more than twenty years.
She confirmed she received her medication. The question the count sheets were supposed to answer before anyone had to ask her is one the facility still hasn't fully explained.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Park Place Nursing & Rehabilitation Center from 2025-11-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 29, 2026 · Our methodology
Park Place Nursing & Rehabilitation Center in Tyler, TX was cited for violations during a health inspection on November 20, 2025.
The director of nursing told inspectors she had not been aware of how many signatures were missing from the shift count sheets.
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.