Bridgeville Rehab: Missing Oxycodone, Falsified Records - PA
Federal inspectors documented the incident during a complaint inspection completed December 26, 2025.
The sequence of events, reconstructed from staff statements and facility records reviewed by inspectors, began on the evening of November 8. RN Employee E5 was working the medication cart and, at some point during the shift, told colleagues a binder had fallen off the cart and she'd had to reassemble the narcotic book, putting papers back in order. That detail would matter later.
At 11:00 p.m. on November 8, RN Employee E4 came on shift and counted narcotics with RN Employee E5 at shift change. The count was 27 of 27 narcotic cards. Both nurses signed off. The cart keys changed hands.
What the inspection report makes clear is that earlier that same day, RN Employee E4 had documented something different: a count of 29 of 29 narcotic cards, along with a receipt acknowledgment for an oxycodone card and its card identification number. That documentation was on the shift change count signoff sheet from the prior count. By the time the 11:00 p.m. count happened, the number had dropped to 27. Two cards were gone. The sheet documenting the 29-card count was gone with them.
At approximately 4:45 a.m. on November 9, Resident R1 asked for her oxycodone. RN Employee E4 went to pull the medication and found nothing. No card. No corresponding tracking sheet. The resident told the nurse she had been receiving the pain medication. But there was no documentation in the computer showing it had ever been given.
RN Employee E4 consulted LPN Employee E6. Together they went through the controlled substance tracking book. What they found, according to LPN Employee E6's written statement, was that the original tracking sheet had been removed and a new one substituted in its place. The new sheet was missing RN Employee E4's earlier entries: the November 8 acknowledgment of the oxycodone card receipt, the card identification number, and the 29-of-29 count.
LPN Employee E6 kept looking. She found the missing sheet folded in half in the recycling bin. It was the document RN Employee E4 had filled out, the one that recorded 29 cards. It had not been signed by RN Employee E5 at shift change, as required. The oxycodone itself was not found. The drug count record that should have accompanied it was not found either.
Resident R1 did not receive pain medication until 6:00 a.m., an hour and fifteen minutes after she asked for it.
In a written statement dated November 9, RN Employee E4 described the 11:00 p.m. count as correct and said she had never given Resident R1 anything stronger than Tylenol because the resident had not requested anything stronger. That statement directly contradicted what the resident told staff: that she had been receiving pain medication, even though no administration had been recorded in the computer.
The inspection report notes there is no evidence that RN Employee E5 was ever asked to provide a statement. Not about why she didn't sign the shift change count sheet. Not about how the count went from 29 cards to 27 between her daytime shift and the 11:00 p.m. handoff. Not about the binder that fell and had to be reassembled.
There is also no evidence that anyone interviewed Resident R1.
The Director of Nursing confirmed during an interview on December 22, 2025, that only RN Employee E4 and RN Employee E5 had keys to the medication cart during the relevant window, from 11:00 p.m. on November 7 through approximately 10:15 a.m. on November 9, when RN Employee E5 left her shift early due to a family emergency.
The facility filed a report with the local police department. It also conducted staff education in November on abuse, neglect, and exploitation policy. During the December 22 interview, the Nursing Home Administrator and the Director of Nursing both confirmed the facility had failed to ensure that Resident R1 was free from misappropriation of property.
The facility's own conclusion was that it could not identify a perpetrator.
What the record shows is narrower than that. Two nurses had the keys. The count dropped by two cards on one nurse's watch. The documentation of the higher count was removed from the binder and found in a recycling bin, unsigned. The nurse whose shift covered that period was never asked to explain any of it.
Resident R1 told staff she had been getting her pain medication. The computer showed no record of it being given. The oxycodone was gone. The paper trail that would have shown who last accounted for it had been pulled out of the binder and thrown away.
She lay in pain for over an hour while nurses sorted through a recycling bin looking for paperwork that should have been locked in a cart.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bridgeville Rehabilitation & Care Center from 2025-12-26 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 21, 2026 · Our methodology
BRIDGEVILLE REHABILITATION & CARE CENTER in BRIDGEVILLE, PA was cited for violations during a health inspection on December 26, 2025.
Federal inspectors documented the incident during a complaint inspection completed December 26, 2025.
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.