Pembroke Center failed to act on Consultant Pharmacist #2's August recommendation to pull discontinued hydrocodone tablets from Resident #3's medication supply, federal inspectors found during a November complaint investigation.
The resident had been readmitted to the facility in July with a stage IV pressure wound and bone infection. A hospital physician ordered hydrocodone-acetaminophen tablets for pain management — first a five-day supply, then a 14-day supply totaling 56 tablets.
The pharmacy delivered 54 tablets on July 15, signed for by two nurses. Staff administered the medication as needed throughout July and once in August. The prescription expired July 29 after the prescribed 14 days.
But the pills stayed on the medication cart.
During an August 14 controlled substance audit, Consultant Pharmacist #2 randomly selected Resident #3's medication card for review. She discovered the hydrocodone order had been discontinued in July and wrote a note to the Director of Nursing: pull the medication from the cart and return it to the pharmacy for disposal.
Nobody acted on the recommendation.
The missing tablets weren't discovered until November 5, when Nurse #10 noticed the discrepancy on the narcotic count sheet and reported it to the Director of Nursing. By then, 20 tablets were unaccounted for.
During a November 18 phone interview, Consultant Pharmacist #2 explained her standard audit process. She randomly selected four or five medication cards during each visit, checking documentation, final counts, and verifying orders matched the cards.
"She typically did not go back and review the previous months recommendations that were sent to the Director of Nursing and just expected the recommendations would be followed," inspectors wrote.
The pharmacist had sent her August report noting that Resident #3's hydrocodone remained on the medication cart despite the discontinued order. She expected the nursing staff to remove it.
They didn't.
The Director of Nursing acknowledged responsibility for acting on monthly pharmacy reports during her November 18 interview. She received the consultant pharmacist's audit reports each month and was supposed to complete necessary recommendations.
"The DON indicated that the Pharmacist's note to pull Resident #3's discontinued medication from the medication cart on the 8/14/25 review was missed in error," the inspection report stated.
The nursing director admitted the obvious: had staff removed the hydrocodone when the order was discontinued, or at least after the pharmacist's August recommendation, the missing medications would not have occurred.
The facility's own investigation, completed by the Administrator on November 5, confirmed the timeline. The drugs had been sitting accessible on the medication cart for more than three months after discontinuation, and nearly three months after the pharmacist specifically flagged them for removal.
Federal regulations require nursing homes to ensure licensed pharmacists conduct monthly drug regimen reviews and follow established policies for reporting irregularities. The rules exist precisely to prevent controlled substances from remaining accessible after orders expire.
Consultant Pharmacist #2 had done her job correctly. She identified the discontinued medication during her random audit and provided clear instructions for its removal. The breakdown occurred in the facility's follow-through on her professional recommendations.
The missing hydrocodone tablets represent more than a paperwork error. Controlled substances left accessible beyond their prescribed period create opportunities for diversion, misuse, or unintended administration. The drugs contained both hydrocodone, an opioid pain reliever, and acetaminophen.
For nearly four months, from late July through early November, the discontinued narcotics remained available on the medication cart. Staff signed them out sporadically — the count sheet showed administration continuing into August, a month after the prescription had expired.
The facility received a minimal harm citation affecting few residents. But the violation illustrates a fundamental breakdown in medication management systems designed to track controlled substances.
Resident #3, recovering from a serious bone infection and stage IV pressure wound, had legitimate medical need for pain management during the prescribed period. The hospital physician's orders were appropriate and time-limited. The pharmacy delivered the correct quantity. Nursing staff administered the medication properly while the order remained active.
The system failed only after the prescription ended, when established protocols for removing discontinued controlled substances weren't followed. The pharmacist's August warning sat ignored while 20 narcotic tablets remained unaccounted for on the facility's medication cart.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Pembroke Center from 2025-11-21 including all violations, facility responses, and corrective action plans.