Inland Valley Care: Controlled Drug Records Missing - CA
The nurse at Inland Valley Care and Rehabilitation Center gave a resident Pregabalin 100 mg at 8:40 am and 1 pm on August 21, but failed to record either dose on the facility's controlled substances log.
Licensed Vocational Nurse 7 told federal inspectors during an interview that afternoon she had administered the medication but "did not document on the Record of Controlled Substances because she was too busy."
The nurse acknowledged she was supposed to document the administration immediately after the resident took the medication "to prevent any mistakes from happening." She described Pregabalin as "an opioid for pain" that "could pose a danger to the resident."
Federal inspectors discovered the documentation gap while reviewing the facility's controlled substances record for Pregabalin 100 mg capsules. The record covered August 3 through August 20, but showed no documentation for doses that should have been given on August 21 at 9 am and 1 pm.
The missing documentation violated federal requirements for tracking controlled substances at nursing homes. These medications have "strong potential for abuse" and must be carefully monitored to prevent diversion or medication errors.
Pregabalin, sold under the brand name Lyrica, is classified as a Schedule V controlled substance used to treat nerve pain and seizures. While the nurse called it an opioid, Pregabalin belongs to a different drug class but carries addiction risks and requires the same documentation standards as other controlled substances.
The Director of Nursing explained the facility's procedures during an interview the following day. When giving controlled drugs, nurses must document administration on both the medication administration record and sign the controlled drug record to track remaining quantities and record the date and time of administration.
"Once the medication is removed from the medication blister pack it should be documented timely to avoid it being forgotten," the Director of Nursing told inspectors.
The nursing director emphasized that signing the controlled substances record was critical "so every medication that was used had a record and the next shift would know when it was utilized."
This documentation serves multiple purposes beyond simple record-keeping. It helps prevent medication errors, tracks inventory to identify potential theft or diversion, and ensures continuity of care between nursing shifts.
The facility's own policy, last revised in November 2022, requires compliance with all laws and regulations related to controlled medication handling, storage, disposal and documentation. The policy specifically covers substances listed as Schedule II through V under the Comprehensive Drug Abuse Prevention and Control Act of 1976.
According to the policy, controlled substance inventories must be "monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up."
The policy states the facility's system for tracking controlled substances includes medication administration records as a key component of accountability.
The violation occurred despite these written procedures requiring immediate documentation. The nurse's admission that she was "too busy" to follow protocol raises questions about staffing levels and time management at the facility.
Missing controlled substance documentation creates multiple risks. Other nurses coming on shift have no way to know when the last dose was given, potentially leading to dangerous double-dosing or missed doses. Pharmacy reconciliation becomes impossible without complete records.
The documentation gap also makes it difficult to account for the medication itself. Without records showing when doses were removed and administered, facilities cannot properly track their controlled substance inventory or identify potential diversion.
Federal regulations require nursing homes to maintain detailed records of all controlled substances to ensure patient safety and prevent drug diversion. These requirements exist because controlled substances carry higher risks for abuse, addiction, and adverse effects if not properly managed.
The inspection found that some residents were affected by the documentation failures, though the level of harm was classified as minimal. However, the potential for actual harm exists when controlled substances are not properly tracked and documented.
Nursing homes face significant penalties for controlled substance violations. The Drug Enforcement Administration and state health departments can impose sanctions ranging from fines to license suspension for facilities that fail to maintain proper controlled substance records.
The violation at Inland Valley Care highlights ongoing challenges nursing homes face in maintaining accurate controlled substance documentation while managing heavy patient care loads. However, federal regulators consider proper documentation of these potentially dangerous medications a non-negotiable safety requirement.
The facility's acknowledgment that documentation should occur "timely to avoid it being forgotten" suggests awareness of the problem, but the nurse's statement about being "too busy" indicates systemic issues may prevent staff from following established procedures.
For Resident 47, who should have received the documented Pregabalin doses for pain management, the missing records created uncertainty about their medication history and proper dosing schedule. This documentation gap could affect future treatment decisions and pain management strategies.
The incident occurred during a complaint investigation at the facility on August 22, 2025, suggesting ongoing concerns about medication management practices at Inland Valley Care and Rehabilitation Center.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Inland Valley Care and Rehabilitation Center from 2025-08-22 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 20, 2026 · Our methodology
INLAND VALLEY CARE AND REHABILITATION CENTER in POMONA, CA was cited for violations during a health inspection on August 22, 2025.
The record covered August 3 through August 20, but showed no documentation for doses that should have been given on August 21 at 9 am and 1 pm.
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.