The incident at River Bend Health and Rehabilitation involved missing oxycodone prescribed to two residents and triggered reports to state regulators and local law enforcement in November.
Nurse #2, an agency worker who had been at the facility since June, told the Director of Nursing in a November 17 email that she "had signed the narcotic sheets as a witness to the disposal of medications for Residents #6 and #9 at Nurse #1's request without observing the medication disposal."
The scheme unraveled when Nurse #3 noticed excessive pain medication being signed out for residents by Nurse #1 and reported her concerns to management. Resident #6, who had been prescribed one oxycodone 10 mg tablet three times daily for pain, denied taking the medication that records showed had been dispensed.
Nurse #1 had signed out oxycodone tablets for both residents on November 14 at multiple times throughout the evening shift. For Resident #6, records showed tablets dispensed at 7:30 PM and 11:30 PM. For Resident #9, who had an order for oxycodone every three hours as needed, tablets were signed out at 7:30 PM and 10:30 PM.
In each case, Nurse #2 signed as a witness to the disposal, though the times were illegible on the narcotic records.
The missing medications weren't discovered until three days later. On November 17 at 9:00 AM, Nurse #3 reported her concerns to the Director of Nursing about as-needed narcotics being signed out for a resident who usually didn't request pain medication.
Federal inspectors found that Nurse #3 had noticed Resident #6 "had some as needed oxycodone medication missing" and that the medications "were not signed as administered on the MAR." When questioned, Resident #6 denied taking the pain medication.
The facility moved quickly once the theft was reported. Management contacted state regulators at 2:02 PM the same day and local law enforcement at 2:30 PM. Both agency nurses were blocked from working at the facility as of November 17.
Nurse #1 had worked only a single 12-hour shift at River Bend, from 7:00 PM on November 14 until 7:00 AM on November 15. Nurse #2 had been working multiple shifts since June 12 but hadn't worked at the facility since November 15.
The Administrator told inspectors it was "standard practice for nurses to visually witness narcotic medication being wasted prior to signing as a witness on the narcotic sheet" and said she didn't know why Nurse #2 had violated this protocol.
Both nurses were no longer employed at the facility when federal inspectors arrived in January, and attempts to interview them were unsuccessful.
The investigation revealed systemic failures in narcotic oversight. Despite facility policies requiring visual confirmation of drug disposal, Nurse #2 was able to repeatedly sign false witness statements without detection. The scheme only came to light because another nurse noticed unusual patterns in medication requests.
Resident #9's case showed similar documentation problems. The physician had ordered oxycodone every three hours as needed for pain, but like Resident #6, the medications that were signed out as dispensed were never actually administered according to medication administration records.
The facility's investigation, completed November 21, confirmed that Nurse #2 had signed as a witness to Nurse #1's disposal of narcotic medications for both residents without actually observing the waste process.
Federal inspectors cited the facility for failing to maintain effective systems for accurate narcotic reconciliation, finding that the false witness signatures compromised the facility's ability to track controlled substances and protect residents from medication theft.
The case highlights vulnerabilities in nursing home narcotic controls when facilities rely heavily on temporary agency staff who may be unfamiliar with proper procedures or willing to circumvent safety protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River Bend Health and Rehabilitation from 2026-01-30 including all violations, facility responses, and corrective action plans.