Meadowbrook Health: Missing Oxycodone Investigation - NC
The missing narcotics were discovered weeks apart. A medication aide counting narcotics with a hospice nurse on November 10, 2025 found that 30 oxycodone tablets belonging to one resident, identified in inspection records as Resident #22, were gone. A separate count revealed that 28 tablets belonging to Resident #6, another hospice patient, had also vanished. Both residents were on oxycodone 5 milligram tablets. Resident #6 also had a prescription for liquid morphine sulfate, which the hospice nurse said the resident preferred because it was easier to swallow, meaning the oxycodone tablets were largely untouched, making their disappearance harder to explain.
The hospice nurse and the medication aide reported the missing oxycodone to the director of nursing immediately both times. Neither staff member was suspended during the investigation. Neither was asked to submit to a drug test.
The director of nursing, identified in the report as DON #1, told inspectors on December 18, 2025 that the facility did not drug test staff unless they showed visible signs of impairment.
The pharmacy that supplied the medications was not notified either time. The contracted pharmacist, reached by telephone during the inspection, told investigators the facility had never communicated that any resident's narcotics were missing. She said the facility was responsible for investigating and reporting missing medication to authorities. Whether that reporting happened in a timely way, and what investigators found, the inspection report does not say. What it does say is that the pharmacy was still in the dark when inspectors called.
What inspectors also found was a counting system that had been failing quietly for some time. Staff were supposed to count not just individual tablets but the number of narcotic medication cards in the cart at the start of each shift. When DON #1 reviewed the forms after the thefts were discovered, she found days where that card count had simply not been done. Nobody had caught it.
After the second disappearance was reported, DON #1 said she submitted a 24-hour report to the state agency, police, and adult protective services, audited narcotic medication cards for all other residents, and educated nurses and medication aides on proper counting procedures. She had a locked safe installed in her office closet, with a separate lock on the closet itself, and established a new rule that only she and the assistant director of nursing could remove narcotics designated for return to the pharmacy.
The administrator, interviewed on December 19, 2025, said nursing staff should have been counting narcotics according to policy all along.
The inspection report notes the harm level as minimal or potential for actual harm. That classification applies to the regulatory finding. For the two hospice patients whose pain medications went missing, the report offers no account of whether either experienced uncontrolled pain during the period the oxycodone was gone, or whether anyone asked.
Resident #6 had 28 tablets on November 5, 2025. Five days later, she had none.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Meadowbrook Health & Rehabilitation from 2026-01-02 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
Meadowbrook Health & Rehabilitation in Salisbury, NC was cited for violations during a health inspection on January 2, 2026.
The missing narcotics were discovered weeks apart.
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.