The facility's director of nursing learned on October 29 that a staff nurse was unable to reorder medications for two residents. Further review revealed the facility couldn't account for one card of 30 alprazolam tablets for each resident — 60 pills total of the controlled anxiety medication.
Both residents lived with severe cognitive impairment and complex behavioral problems that made them particularly vulnerable.
Resident 6, who received the 0.5 milligram alprazolam tablets twice daily, had documented behaviors including "laying on floor and wallering" and delusions that police were coming to take her away. Her pharmacy packing slip from October 8 showed she had received two cards of 30 tablets each, signed for by a licensed practical nurse.
Yet her progress notes contained no documentation that she had missed any of her prescribed alprazolam medication during the period when the cards went unaccounted for.
Resident 7, also prescribed the same twice-daily alprazolam regimen, lived on the locked dementia unit in the men's section of the building. When an inspector encountered him on November 20, he was wandering and unable to answer questions about whether he had ever missed his medications.
His medical record documented diagnoses of Parkinson's disease, asthma, hypotension, dementia with agitation, bipolar disorder, anxiety, insomnia and difficulty swallowing. His most recent assessment classified him as severely cognitively impaired for activities of daily living.
The missing medication cards represented a 21-day gap between when Resident 6 received her October supply and when staff discovered the discrepancy. During this period, neither resident's medical records reflected any missed doses or medication concerns.
Facility leadership immediately made all required notifications to medical doctors, powers of attorney and local police when the discrepancy was discovered. The investigation documentation shows the facility replaced both missing medication cards at its own expense.
Staff conducted a comprehensive narcotic reconciliation that found no additional concerns with other controlled substances. But the initial reports for both residents noted that neither was identified as the offender in the missing medication case.
The facility's abuse prevention policy explicitly states a "zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property." Staff are prohibited from permitting anyone to engage in misappropriation of resident property, according to the undated policy document.
Following the discovery, facility administrators implemented multiple corrective measures. All staff and residents were interviewed about the incident. Every employee received in-service training on medication destruction, controlled substance disposal, narcotic count verification and logging procedures for narcotic medication cards.
The director of nursing began conducting daily narcotic audits. The social service director started daily psychosocial audits for all residents. Staff also assessed all residents for behavioral changes that might indicate medication issues.
Both affected residents required careful medication management due to their complex conditions. Resident 6's combination of behavioral issues and delusions made consistent medication administration crucial for her safety and the safety of others. Resident 7's multiple diagnoses, including Parkinson's disease and dementia with agitation, similarly required precise medication timing.
The facility's controlled drug receipt records for October documented both residents' prescriptions for 0.5 milligram alprazolam tablets, to be taken twice daily. These medications help manage anxiety and agitation that can be particularly severe in dementia patients.
Federal regulations require nursing homes to safeguard resident property, including medications, and to immediately investigate any suspected misappropriation. The facility's policy acknowledges that residents have the right to be free from misappropriation of their property.
The investigation began on October 29 when the discrepancy was first discovered. Initial reports were filed the same day, with final reports to follow the investigation's completion. The facility documented that medical doctors and powers of attorney were notified along with local police.
Alprazolam is a controlled substance requiring strict tracking and documentation. The medication cards that went missing each contained 30 tablets, representing a significant quantity of controlled medication for two vulnerable residents who depended on consistent dosing for behavioral management.
The pharmacy packing slip showed Resident 6's medications were delivered on October 8 and properly signed for by licensed staff. However, the gap between delivery and discovery of the missing cards raised questions about the facility's medication tracking procedures during the intervening weeks.
Neither resident could provide information about their missing medications when staff investigated. Resident 6's documented delusions and floor-laying behaviors, combined with Resident 7's severe cognitive impairment and wandering, made them unlikely to notice or report medication irregularities themselves.
The facility's response included comprehensive staff retraining on multiple aspects of medication management. The training covered not just basic medication administration but also the specific procedures for handling controlled substances, proper disposal methods, and the verification processes meant to prevent such discrepancies.
Daily auditing procedures implemented after the incident were designed to catch any future medication discrepancies quickly. The director of nursing's daily narcotic audits and the social service director's daily psychosocial assessments created multiple checkpoints for medication and resident welfare monitoring.
The October incident occurred despite the facility's written policies requiring standardized methodology for preventing, identifying, investigating and reporting misappropriation of property. The policy specifically required staff to protect residents and maintain proper screening and training programs.
Both residents continued to live with their complex medical and behavioral conditions while facility staff worked to ensure the medication tracking failures that led to the missing alprazolam cards would not recur.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evercare of Lebanon from 2025-11-21 including all violations, facility responses, and corrective action plans.