The facility's Director of Nursing told inspectors that blister packs for narcotics should never be taped. She explained that punctured blister packs require the narcotic to be wasted and witnessed by two nurses to ensure proper accountability for all controlled substances.
Yet staff had been taping the medication packages anyway.
The violation centers on Resident #4, though inspection records don't specify exactly what staff did with this person's medications or how inspectors discovered the improper handling. The nursing director's statements to investigators reveal the facility's own leadership understood the correct procedures but staff weren't following them.
Federal inspectors found the facility had comprehensive written policies covering narcotic handling. The 2025 Medication Administration and General Guidelines policy states that only licensed personnel who prepare medications may administer them, and they must record administration on the resident's medication record immediately when giving the dose.
The policy requires the person administering medications to review all records at the end of each shift to verify all necessary doses were given and documented. Staff cannot go off duty without first recording any medication administration.
A separate 2025 policy on medication storage mandates immediate removal of outdated, contaminated, or deteriorated medications, along with those in cracked, soiled, or insecurely closed containers. These must be disposed of according to destruction procedures and reordered from the pharmacy if current orders exist.
The facility's controlled substance procedures, dating to a 2003 policy still in effect, require specific documentation when narcotics are wasted. Any controlled medication waste must be recorded on the accountability sheet for that specific drug and witnessed by two nurses. Both staff members must sign the sheet verifying the drug was properly wasted.
These policies exist precisely because narcotic accountability represents one of the most serious responsibilities in nursing home care. Controlled substances require chain-of-custody documentation from delivery through administration or disposal. Taped blister packs can compromise this security by making it unclear whether medications have been tampered with or removed.
The nursing director's acknowledgment that staff shouldn't tape blister packs suggests this wasn't an isolated incident or misunderstanding of policy. Her detailed explanation of proper waste procedures indicates the facility trains staff on these requirements.
But knowing the rules and following them proved to be different things at Cedar Creek.
The inspection occurred following a complaint, though records don't reveal who filed the complaint or what specific concerns prompted the federal investigation. Complaint-driven inspections often focus on particular incidents or patterns that someone inside or outside the facility reported to state health officials.
Cedar Creek operates as a 159-bed facility on Montague Avenue in Bandera, a small city in the Texas Hill Country about 50 miles northwest of San Antonio. The facility provides both nursing care and rehabilitation services.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting some residents. This suggests the improper narcotic handling didn't result in documented injuries or overdoses, but created conditions where harm could occur.
The violation falls under federal tag F0755, which covers medication administration requirements. Facilities must ensure medications are given safely, accurately, and according to physician orders while maintaining proper documentation and security for controlled substances.
Narcotic mishandling violations can escalate quickly in severity if they involve missing medications, unauthorized access, or patient harm. While this incident received a minimal harm classification, it represents exactly the type of policy breakdown that federal regulators monitor closely.
The facility must submit a plan of correction explaining how it will prevent future narcotic handling violations and ensure staff follow established controlled substance procedures. This typically includes additional staff training, policy reinforcement, and enhanced monitoring of medication administration practices.
For families with loved ones at Cedar Creek, the violation raises questions about medication safety oversight and whether staff consistently follow the facility's own written procedures for handling their relatives' medications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cedar Creek Nursing and Rehabilitation Center from 2025-12-21 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Cedar Creek Nursing and Rehabilitation Center
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