Bridgeville Rehab: Missing Oxycodone, Falsified Records - PA
The resident waited until 6:00 a.m. to receive pain medication. Seventy-five minutes.
The incident at Bridgeville Rehabilitation & Care Center unfolded over the overnight hours of November 8 into November 9, 2025. Federal inspectors documented the findings during a complaint inspection completed December 26, 2025. By the time the investigation was over, the facility had filed a report with local police, conducted staff education, and arrived at a conclusion that offered no real resolution: they could not identify who took the drug.
The nurse working the overnight shift, identified in inspection records as RN Employee E4, had counted narcotics at 11:06 p.m. on November 9 alongside the nurse she was relieving, RN Employee E5. The count was 27 of 27 narcotic cards. Everything checked out. E4 documented the count and began her shift.
Then, just before 5:00 a.m., Resident R1 asked for oxycodone.
E4 looked for the controlled substance tracking sheet. Gone. She looked for the medication card. Also gone. She checked the shift change inventory count signoff sheet from the prior day. Missing too. The resident told the nurse she had been receiving the pain medication. It had not been documented in the computer as given.
E4 called in a licensed practical nurse, Employee E6, to help sort through what had happened. Together they reviewed the controlled substance tracking binder. What they found raised the stakes considerably. The original tracking sheet, the one E4 herself had filled out on November 8 acknowledging receipt of the oxycodone card, recording the card identification number, and documenting a count of 29 of 29 narcotic cards, had been removed from the binder. A new sheet had been placed in its position. The new sheet contained none of E4's entries.
Then LPN Employee E6 found the original sheet. It was in the recycling bin, folded in half.
The document was unsigned. Shift change count sheets at the facility require the nurse coming on shift to verify the count of all controlled substances with the nurse going off shift, and to sign off any time medication cart keys are exchanged. The sheet in the recycling bin, the one documenting 29 of 29 narcotic cards, had never been signed by RN Employee E5 during the shift change on the morning of November 8.
That unsigned document, discarded and folded, was the thread that unraveled the count. Between the 7:00 a.m. shift change on November 8, when E4's sheet showed 29 cards, and the 11:00 p.m. count that same night, which showed 27 cards, two oxycodone cards had disappeared. No one has explained how.
The Director of Nursing confirmed to inspectors on December 22, 2025 that only two nurses had keys to the medication cart during the relevant window: RN Employee E4, who worked the overnight shift beginning November 7 at 11:00 p.m., and RN Employee E5, who left her shift on November 9 at approximately 10:15 a.m. due to a family emergency. No one else had access.
Inspectors found no evidence that RN Employee E5 was ever asked to provide a statement. Not about why she didn't sign the shift change count sheet on the morning of November 8. Not about how the count changed from 29 to 27 between her shift and the next. Not about the tracking sheet that ended up in the recycling bin. The inspection report is direct on this point: there is no evidence of an interview being conducted with E5.
There is also no evidence that anyone interviewed Resident R1.
The resident had told nurses she had been receiving the pain medication. That statement, that she had been getting oxycodone but it hadn't been documented in the computer as given, appears in the inspection record without any follow-up. Whether she actually received doses that were never recorded, or whether she believed she had received medication she was never given, the inspection report does not say. The facility did not appear to pursue the question.
What the facility did do: it completed staff education in November on abuse, neglect, and exploitation policy. It filed a report with the local police department. And on December 22, the Nursing Home Administrator and Director of Nursing confirmed to inspectors that the facility had failed to ensure Resident R1 was free from misappropriation of property.
That word, misappropriation, is the regulatory term for what happens when a resident's belongings or medications are taken without authorization. The facility used it. The administrator and director of nursing confirmed it applied here. They confirmed it to inspectors while also confirming they had no idea who was responsible.
The earlier statement from RN Employee E4, written on November 9, described the moment she realized what she was looking at. She had flipped to the shift change inventory count signoff sheet from the prior day. It was missing. She looked for the controlled substance tracking sheet and card. There were none. A resident was in pain and asking for medication that existed somewhere in the paper trail but not on the cart.
RN Employee E5 had offered one explanation for the earlier confusion around the binder, telling investigators that on approximately 1:00 p.m. on November 8 the binder had fallen off the medication cart and she had to put all the papers back in the narcotic book. That detail appears in the record. Whether the papers were put back correctly, whether anything was removed during that process, whether the binder falling was incidental or relevant, the investigation did not resolve.
What the inspection record shows is a controlled substance that vanished, documentation that was removed and replaced, a key piece of paperwork found folded in a recycling bin, and a nurse who was never interviewed. The facility's own conclusion, stated plainly to federal inspectors, is that they cannot identify who took the oxycodone.
Resident R1 eventually received pain medication at 6:00 a.m. The inspection report does not say what she was given, or whether it was the oxycodone she had been prescribed, or something else. It notes only that she did not receive medication until that hour due to the missing medication and associated documents.
She had asked for it at 4:45 in the morning.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 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 waited until 6:00 a.m.
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.