The missing medications included 30 tablets of oxycodone 5 milligrams from Resident #22 and 28 tablets of the same drug from Resident #6. Both thefts occurred because nursing staff failed to follow basic pill-counting procedures during shift changes.
Medication Aide #1 discovered Resident #22's missing pills on November 5, 2025, when she found an empty medication card that should have contained 30 oxycodone tablets. She immediately notified the Director of Nursing.
Five days later, the same medication aide made another disturbing discovery. While counting narcotics with a hospice nurse during a routine visit to Resident #6, they found all 28 oxycodone tablets had vanished. The hospice nurse had counted 28 tablets just five days earlier on November 5.
"Resident #6 did not usually take the Oxycodone because she had an order for another narcotic pain medication (Morphine Sulfate) which was liquid and easier for her to swallow," the hospice nurse told investigators by phone.
The Director of Nursing launched an investigation but took no disciplinary action against the staff members responsible for the medication counts. Neither Medication Aide #1 nor Nurse #2 were suspended during the investigation. Neither were asked to provide drug tests.
"The facility did not drug test staff unless they showed signs of impairment due to drug use," the Director of Nursing explained to inspectors.
The investigation revealed systemic failures in medication security. Staff had not been counting the number of medication cards during narcotic counts at shift changes, a basic safety requirement. When the Director of Nursing reviewed counting forms, she found multiple days where staff had skipped the card count entirely.
"The staff had not been counting the number of cards when they did a narcotic count," she admitted.
The facility's contracted pharmacy never received notification about either theft. The pharmacist told investigators by phone that the nursing home would be responsible for investigating and reporting missing medications to authorities.
Following the discoveries, the Director of Nursing submitted required 24-hour reports to the state agency, police, and adult protective services. She conducted an audit of all residents' narcotic medication cards and provided additional training to nursing staff on proper counting procedures.
New security measures included installing a locked safe in the Director of Nursing's office closet, with an additional lock on the closet door. Only the Director of Nursing and Assistant Director of Nursing would be authorized to remove narcotics designated for return to the pharmacy.
The Administrator acknowledged the failures during a December 19 interview. "The nursing staff should have counted the narcotics following the facility's policy and ensured there was no missing narcotic medications," he told inspectors.
Despite the investigation and new policies, the Director of Nursing could not identify who had stolen the medication cards from either resident. The missing pills represented significant quantities of controlled substances that could be diverted for illegal use or sale.
Both residents were left without their prescribed pain medications while staff scrambled to replace the missing drugs and implement new security protocols.
The case highlights vulnerabilities in nursing home medication management, where controlled substances worth hundreds of dollars on the street can disappear without immediate detection. Federal regulations require facilities to maintain strict accounting of narcotic medications, with detailed records of every pill dispensed or returned.
For Resident #6, who rarely used the oxycodone due to her liquid morphine prescription, the missing pills went unnoticed for days. The theft only came to light during a routine hospice visit, raising questions about how long other medication diversions might go undetected.
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.