Trabuco Hills Post Acute: Anxiety Meds Missing - CA
Trabuco Hills Post Acute failed to provide clonazepam to Resident 3 from June 22 to June 28, 2025, despite physician orders for the antianxiety medication to be given nightly at bedtime. The facility had simply run out of the drug.
Licensed Vocational Nurse 5 told inspectors that nursing staff "were signing the resident's medical record to show the clonazepam medication was administered" even though it wasn't available. The nurse said the facility was supposed to reorder a 30-day supply on June 2 but never did.
Resident 3 had been admitted with generalized anxiety disorder. The physician had ordered 2 mg tablets of clonazepam each night for "anxiety manifested by verbalization of anxiousness."
The medication administration record for June showed the drug was marked with code 6 — meaning "absent from facility with meds ineffective" — on multiple dates between June 22 and June 28. On June 25, the record was left completely blank.
Licensed Vocational Nurse 4 confirmed to inspectors that the medication wasn't available during that week-long period. He said he notified the resident's family, the facility's pharmacy, and the attending physician about the shortage, but failed to document any of these communications in the resident's medical record.
The nurse understood the consequences. He told inspectors that "suddenly stopping the administration of the clonazepam medication could lead to behavioral problems and withdrawal effects."
Federal inspectors found no evidence that the physician, pharmacy, or family had been properly informed about the medication gap through documented channels.
The facility's own policy required valid prescriptions before controlled medications could be dispensed. In emergencies, pharmacies could accept telephone orders, but follow-up prescriptions had to reach the pharmacy within seven days.
LVN 5 explained that Resident 3's family had ordered a 30-day supply of clonazepam on May 2. The facility should have reordered on June 2 to prevent any gap in availability.
The inspection revealed a second problem with the facility's controlled substance tracking. Narcotic count sheets for May and June 2025 — required documentation for clonazepam — were missing from Resident 3's medical record entirely.
Director of Nursing acknowledged both violations when confronted by inspectors on September 9. She said she was unaware that Resident 3's medication had been unavailable and confirmed the narcotic count sheets were not in the medical record.
The director claimed the missing count sheets were located "in an overflow in the medical records department," but couldn't produce them when asked. The documents remained missing.
Review of the medication administration records showed Resident 3 had received clonazepam as ordered throughout May and the first three weeks of June. Only during the final week of June did the documentation show the medication was unavailable.
But LVN 5's allegation suggested a more troubling pattern. If nurses were indeed signing records to indicate doses had been given when the medication wasn't available, it would represent a systematic falsification of medical records during a period when the resident was experiencing withdrawal risks.
Clonazepam belongs to a class of medications called benzodiazepines, commonly prescribed for anxiety disorders. Abrupt discontinuation can cause withdrawal symptoms including increased anxiety, agitation, and in severe cases, seizures.
The inspection found the facility had violated federal requirements to provide pharmaceutical services meeting each resident's needs and to employ or obtain services of a licensed pharmacist to ensure proper medication management.
Trabuco Hills Post Acute serves residents requiring post-acute rehabilitation and long-term care. The September 9 inspection was conducted in response to a complaint about the facility's operations.
The missing narcotic count sheets represented a separate but related violation of controlled substance documentation requirements. Federal regulations require facilities to maintain detailed records of all controlled medications, including daily counts and administration logs.
Without proper documentation, facilities cannot verify that controlled substances are being handled appropriately or identify potential diversion or mismanagement issues.
The inspection classified the violations as causing "minimal harm or potential for actual harm" affecting "few" residents. However, the potential for withdrawal symptoms and the alleged falsification of medical records raised concerns about both resident safety and facility integrity.
Resident 3's experience illustrated broader systemic issues with medication management and documentation at the facility. The combination of inadequate ordering procedures, missing controlled substance records, and alleged falsification of administration logs suggested multiple breakdowns in pharmaceutical oversight.
The Director of Nursing's acknowledgment that she was unaware of the medication shortage raised questions about supervisory oversight and communication systems within the facility's nursing department.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Trabuco Hills Post Acute from 2025-09-09 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
TRABUCO HILLS POST ACUTE in LAKE FOREST, CA was cited for violations during a health inspection on September 9, 2025.
The facility had simply run out of the drug.
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.