McMurray Hills Rehab: Missing Opioid Doses - PA
Federal inspectors visited the facility on March 30, 2026, responding to a complaint. What they found in the controlled drug records was a gap that ran across multiple residents and multiple weeks — doses of hydrocodone and Tramadol signed out of the facility's controlled substance log with no matching documentation that any resident ever got them.
Nineteen doses in total. Three residents. Nearly a month.
One resident, identified in the inspection report as R9, had a prescription for hydrocodone and acetaminophen, the combination opioid painkiller, to be taken twice daily as needed. The medication administration record for March 2026 showed two doses given between March 2 and March 9. The controlled drug record told a different story. Three additional doses had been signed out on March 3 — twice — and again on March 4. No documentation showed those doses reached R9.
A second resident, R10, was prescribed Tramadol 50mg every twelve hours as needed for severe pain. The MAR recorded three administrations across the back half of the month. The controlled drug record showed four more doses signed out — on March 15, March 26, March 27, and March 29 — with nothing to show they were administered.
The numbers were worst for R11.
That resident also had a Tramadol prescription, this one for every six hours as needed for severe pain. Between March 10 and March 30, the MAR documented three administrations. The controlled drug record showed twelve additional doses signed out: March 13, 14, 17, 18, 19 twice, 20, 21, 22, 26, 27, and 29. Twelve doses. No documentation of administration for any of them.
For R11 alone, that means roughly one unaccounted-for dose every other day for more than two weeks.
The inspection report does not say where the drugs went. It does not name the staff members who signed them out. It does not explain why the controlled drug records and the medication administration records diverged so sharply, or for so long, without anyone at the facility catching it or reporting it.
What it does say is that when inspectors sat down with the Nursing Home Administrator and the Interim Director of Nursing on the afternoon of March 30, both confirmed the facility had failed to make certain controlled substances were accurately accounted for. Not just for these three residents. For eleven of the sixteen residents whose records were reviewed.
Controlled drug records exist precisely because opioids require a chain of custody. Every dose signed out is supposed to correspond to a dose administered and documented. When those two records diverge, there are a limited number of explanations: documentation error, medication waste that wasn't properly recorded, or diversion — meaning someone took the drugs.
The inspection report does not reach a conclusion about which explanation applies here.
What it establishes is the pattern. Doses signed out. No record of administration. Repeated, across residents, across weeks, with a frequency that makes a single clerical error an insufficient explanation for all of it.
R11's twelve missing doses span seventeen days. If each of those doses was simply forgotten to be charted, that would mean a nurse or aide correctly pulled a controlled substance, gave it to a resident in severe pain, and then failed to document it — not once, not twice, but twelve times in a row, on different dates, without a supervisor noticing. The facility's own administrator did not contest the finding.
The residents at the center of this were people prescribed strong pain medication because they were in severe pain. Whether they received those doses, or whether the doses went somewhere else, the inspection report cannot say. What it can say — and does — is that the facility had no reliable way to answer that question either.
McMurray Hills received a deficiency citation under Pennsylvania nursing home regulations covering pharmacy services and nursing services. The inspection was classified as causing minimal harm or potential for actual harm.
For eleven residents whose pain medication records couldn't be reconciled, the distinction between those two categories may not have felt especially meaningful.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mcmurray Hills Rehabilitation and Healthcare Cente from 2026-03-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 17, 2026 · Our methodology
McMurray Hills Rehabilitation and Healthcare Cente in MCMURRAY, PA was cited for violations during a health inspection on March 30, 2026.
Federal inspectors visited the facility on March 30, 2026, responding to a complaint.
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.