The facility's director of nursing discovered unaccounted fentanyl patches during a September review. She found discrepancies between the amount delivered by the pharmacy, what was ordered for residents, and what remained in inventory for four residents.
Most narcotic prescription requests from the two nurses occurred on weekends when an on-call nurse practitioner was working, the investigation found.
During a September 30 interview, RN 2 told administrators she applied the fentanyl patches because LPN 4 claimed to be allergic to the medication. When asked to take a drug test, RN 2 complied and tested negative. She was suspended and left the building.
LPN 4 confirmed she told her colleague she was allergic to fentanyl and that RN 2 applied the patches to residents. But when asked to take a drug test, LPN 4 said she had taken Percocet that morning for back pain.
Her test came back positive for opioids.
LPN 4 was also suspended and left the facility.
The director of nursing said she now reviews narcotic logs more frequently since the incident. The facility's nurse practitioner also discussed the issue with colleagues about notifying her of weekend narcotic prescription requests.
Facility policy requires all controlled substances to be recorded in both the resident's medication administration record and the controlled substances inventory record at the time of administration. Shift change verification forms must be maintained for 24 months.
The pharmacy had questioned why the facility was requesting more fentanyl patches after recently sending a month's supply, according to the investigation report.
Neither nurse was available for follow-up interviews during the state inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for North Capitol Nursing & Rehabilitation Center from 2026-01-29 including all violations, facility responses, and corrective action plans.