Stonebridge Maryland Heights

During an interview on 8/20/25 at 11:30 A.M., LPN D said, licensed nurses and/or CMTs should count controlled substances when they came on duty and when they went off duty. He/She tried to make sure the controlled substances were counted each day he/she came in and left work.

Each building had its own narcotic account book.

Each resident had an individual count sheet and then there was a sheet to document how many cards and/or bottles of controlled substances were in each building. He/She had never poured a liquid controlled substance from the bottle into a measuring cup to assure the count was accurate. He/She was aware of the missing controlled substances from [NAME]. He/She worked the morning shift the day prior to the medications going missing.

He/She counted the medications at the end of his/her shift. 11.

During an interview on 8/20/25 at 2:30 P.M., the Administrator and DON said they were unaware staff were not always counting the controlled medications shift to shift.

They were unaware staff routinely left the medication cart keys unattended in the nurse's station.

They were unaware staff were not accounting for liquid medications by pouring it into a measuring cup to assure accuracy.

Controlled medications should be counted shift to shift by the on-coming and off-going nurse or CMT.

The documentation in the narcotics books should be complete and accurate.

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