Bridgeville Rehab: Missing Oxycodone, Altered Records - PA
So was the paperwork.
The resident had been receiving pain medication, but nobody had documented it in the computer as given. When nurses went looking for the controlled substance tracking records, they found the original shift change count sheet, the one that showed a nurse had acknowledged receipt of an Oxycodone card and counted 29 cards against 29, folded in half inside the recycling bin. It had not been signed by the nurse coming on shift, as required at every key exchange.
The Oxycodone card itself was never found.
The count had also changed. Records from the evening of November 8 showed 27 cards where the morning had shown 29. Only two registered nurses had keys to the medication cart during that window, from 11 p.m. on November 7 through approximately 10:15 a.m. on November 9. The facility identified them as RN Employee E4 and RN Employee E5.
The facility placed both nurses on ten-day leave, but not until November 9 at 10:15 a.m., after RN Employee E5 had already left work citing a family emergency. The facility never required drug screening for either nurse. RN Employee E4 independently arranged a hair follicle test, which reportedly came back negative. No test was ever requested of RN Employee E5.
Both nurses returned to work after ten days. Then, around December 20, RN Employee E5 asked to leave early because of illness and has not returned since.
The facility filed a police report and ultimately concluded it could not identify a perpetrator. The Oxycodone remains missing.
There is no record that anyone interviewed the resident about what she experienced. There is no record that RN Employee E5 was ever asked to explain why she didn't sign the shift change count sheet, or how the card count dropped from 29 to 27 on her watch.
When inspectors arrived on December 22 and asked to see the original shift change count sheets, the Director of Nursing said they were missing. Copies were available. The originals were not.
That same morning, inspectors walked the facility with the Director of Nursing and found two medication room doors unlocked, on the Harmony Unit and on the TCU, with medications designated for return sitting out on the counter. The doors are supposed to be locked with a key.
The facility told inspectors it had completed staff education in November in response to the November incident, covering controlled substance administration, ordering, storage, handling, and disposal.
At 2:45 p.m. on December 22, both the Nursing Home Administrator and the Director of Nursing confirmed to the surveyor that the facility had failed to properly investigate the misappropriation of a resident's property.
What that means, in plain terms: a resident's prescribed narcotic pain medication was taken. The records documenting it were altered or destroyed. The two people with the only keys were sent home and brought back without being tested. The original documents are gone. And the resident who needed the medication at 4:45 in the morning waited alone for over an hour while nurses searched for pills that were never there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bridgeville Rehabilitation & Care Center from 2025-12-26 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 19, 2026 · Our methodology
BRIDGEVILLE REHABILITATION & CARE CENTER in BRIDGEVILLE, PA was cited for violations during a health inspection on December 26, 2025.
The resident had been receiving pain medication, but nobody had documented it in the computer as given.
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.