The missing medications included 30 oxycodone tablets from one resident and 28 tablets from another. Staff discovered both thefts during routine narcotic counts in November 2025, according to inspection records.
Medication Aide #1 found the first theft on November 5 when counting narcotics for Resident #22. The aide told inspectors that 30 tablets of oxycodone 5 milligrams were missing from the resident's medication card. She immediately notified Director of Nursing #1.
Five days later, the same medication aide discovered the second theft. While counting narcotics with a hospice nurse for Resident #6, they found 28 oxycodone tablets missing. The hospice nurse had counted 28 tablets during her visit on November 5, but by November 10, none remained.
The hospice nurse told inspectors by phone that Resident #6 rarely used the oxycodone because she had liquid morphine sulfate, which was easier for her to swallow. Both the aide and hospice nurse reported the missing pills to the director of nursing immediately.
Neither staff member involved in discovering the thefts was suspended during the investigation. The director of nursing told inspectors that neither Medication Aide #1 nor Nurse #2 was asked to provide drug tests. She said the facility only tested staff when they showed signs of impairment.
The investigation revealed systematic failures in narcotic monitoring. The director of nursing found that staff hadn't been counting the number of medication cards when performing narcotic counts. Review forms showed multiple days where card counts were incomplete or missing entirely.
"The staff had not been counting the number of cards when they did a narcotic count," the director told inspectors. She discovered gaps in documentation where the total number of cards in the medication cart hadn't been recorded.
The facility's contracted pharmacy never received notification about the missing medications. The pharmacist told inspectors by phone that the nursing home would be responsible for investigating and reporting missing drugs to authorities.
Following the discoveries, the director of nursing implemented several changes. She filed 24-hour reports with the state agency, police, and adult protective services. She conducted audits of all residents' narcotic medication cards and provided additional training to nurses and medication aides.
New policies restricted who could handle returned medications. Only the director of nursing and assistant director of nursing could now remove narcotics designated for return to the pharmacy. The director had a locked safe installed in her office closet, with an additional lock on the closet door.
Staff received education on proper narcotic counting procedures, including counting medication cards at the beginning of each shift and verifying the total number of cards in the medication cart.
The administrator acknowledged the policy violations during interviews. Administrator #1 told inspectors that nursing staff should have followed facility policies for counting narcotics and ensuring no medications went missing.
Despite the investigation and corrective measures, the director of nursing admitted she couldn't identify who had taken the medication cards belonging to both residents. The thefts occurred over a period when multiple staff members had access to the narcotic medication cart.
The facility began developing a plan of correction for the misappropriation of narcotic medications after Resident #22's pills were reported missing. The plan expanded when Resident #6's missing medications were discovered during the ongoing investigation.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, affecting some residents. The inspection occurred as part of a complaint investigation on January 2, 2026.
The case highlights vulnerabilities in nursing home narcotic security systems, where inadequate counting procedures and documentation gaps can mask medication theft for extended periods.
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.