The missing narcotics came to light in a sequence that a licensed practical nurse described in detail to inspectors on November 21, 2025.
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It said staff should use three-compartment trays, serve his diet as ordered, and give him his supplements.
That is what inspectors found at Evercare at Stearns after a complaint investigation completed in November 2025.
The inspection, conducted following a complaint, centered on a single resident with a urinary catheter.
The facility is disputing the citation.
The violation was cited under F0602, which covers a facility's obligation to operate with integrity in its management of controlled substances.
The inspection, conducted November 20, 2025, was triggered by a complaint.
Inspectors arrived at the resident's room on the morning of November 17, 2025, at 10:28 a.m.
The resident who died, identified in inspection records as R3, had morphine remaining in the medication cart at the time of his death.
The antibiotic was Macrobid, typically used to treat urinary tract infections.
The pattern shows up in the resident council meeting minutes with unusual clarity.
Staff called the nursing home administrator, the NHA, directly.