Resident #22 lost 30 tablets of oxycodone between November 5 and November 10, 2025. Five days later, all 28 tablets belonging to Resident #6 vanished from the medication cart at Salisbury Rehabilitation and Nursing Center.
The first theft came to light when Medication Aide #1 discovered Resident #22's missing pills during a routine count. She immediately notified Director of Nursing #1, who began an investigation.
But the problems ran deeper than two missing bottles.
When DON #1 reviewed narcotic counting forms, she found staff had repeatedly failed to count the number of medication cards in the cart during shift changes. The forms showed blank spaces where counts should have been recorded, spanning multiple days.
"The staff had not been counting the number of cards when they did a narcotic count," DON #1 told inspectors. She couldn't determine who had taken the medication cards belonging to both residents.
The second theft emerged during the investigation into the first. A hospice nurse visiting Resident #6 on November 10 found the woman's oxycodone completely gone. The hospice nurse had counted 28 tablets with Medication Aide #1 just five days earlier.
Resident #6 rarely used the oxycodone anyway. She had an order for liquid morphine sulfate, which was easier for her to swallow. The unused pills sat in the medication cart, apparently an easy target.
Neither Medication Aide #1 nor Nurse #2 were suspended during the investigation. More remarkably, neither were asked to provide drug tests.
DON #1 explained the facility's policy: "The facility did not drug test staff unless they showed signs of impairment due to drug use."
No signs of impairment were noted, even as nearly 60 narcotic pills disappeared under their watch.
The facility's contracted pharmacy never received notification about either theft. The pharmacist told inspectors by phone that the facility would be responsible for investigating and reporting missing medications to authorities.
DON #1 did file required reports with the state agency, police, and adult protective services. She also audited all other residents' narcotic medications and found additional problems with the counting system.
Her corrective measures included installing a locked safe in her office closet for medications awaiting return to the pharmacy. She restricted narcotic handling to herself and the Assistant Director of Nursing only.
She also educated nurses and medication aides on proper narcotic counting procedures at shift changes. The training covered counting both individual pills and the total number of medication cards in the cart.
But the education came after the fact. Administrator #1 acknowledged that "the nursing staff should have counted the narcotics following the facility's policy and ensured there was no missing narcotic medications."
The investigation revealed systematic failures in narcotic security. Staff weren't counting cards. Forms weren't being completed. Missing medications went undetected for days.
DON #1 told inspectors she "could not determine who had taken the narcotic medication cards" belonging to either resident. The pills, worth hundreds of dollars on the street, simply vanished into a system with multiple gaps in oversight.
The facility implemented its plan of correction only after both thefts were discovered and reported. For Resident #22 and Resident #6, the security measures came too late. Their prescribed pain medications were already gone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Salisbury Rehabilitation and Nursing Center from 2026-01-02 including all violations, facility responses, and corrective action plans.