Sunland Post Acute: Drug Diversion Risk in Lorazepam Records - CA
The gap appeared in records at Sunland Post Acute, an 8647 Fenwick Street skilled nursing facility, and was confirmed by the facility's own Director of Nursing during a September 2025 inspection. The Director could not explain where the documentation went.
The resident at the center of the discrepancy, identified in inspection records as Resident 6, was readmitted to the facility on July 31, 2025. The admission record listed metabolic encephalopathy, a condition in which underlying systemic disruptions impair brain function, along with type 2 diabetes with abnormally high blood sugar levels and a designation for palliative care, the specialized approach focused on quality of life for people with serious illness. A formal assessment completed on August 8 found the resident's cognition moderately impaired. Staff provided partial to moderate help with eating and oral hygiene, substantial to maximal assistance with personal hygiene, and handled all toileting hygiene entirely.
This was not a resident who could advocate for themselves if something went wrong with their medication.
On August 4, a physician ordered lorazepam oral concentrate at a concentration of two milligrams per milliliter, with instructions to give 0.25 milliliters by mouth every four hours as needed for anxiety manifesting as restlessness leading to distress. The order ran for 14 days.
On August 11 at 10:04 in the morning, a nurse entered a notation in Resident 6's Medication Administration Record, the daily log where licensed nurses document each drug given to each resident, showing that the lorazepam had been administered.
The Individual Count Sheet Record for lorazepam showed nothing.
The Individual Count Sheet is the accountability document kept specifically for controlled substances, the category of medications the Drug Enforcement Administration classifies as carrying strong potential for abuse. Every time a controlled drug is removed from supply and given to a resident, the nurse handling it is required to document the date, the time, the amount, and their signature on the accountability record at the moment of removal, and then separately initial the MAR after administration. The two records are supposed to match, always, because the only way to know a controlled substance reached a patient and wasn't diverted somewhere else is to have both documents saying the same thing at the same time.
On August 11, they did not say the same thing.
When a state inspector sat down with the Director of Nursing on September 10 and walked through both records, the Director confirmed what the documents showed. The MAR indicated lorazepam was given to Resident 6 at 10:04 a.m. on August 11. The Individual Count Sheet had no entry for that administration. The Director searched the accountability record and could not find it.
The Director explained the process as it is supposed to work: assess for pain first, document on the Individual Count Sheet what medication is being prepared, administer it, then document on the MAR. The Director said the Count Sheet should always coincide with the MAR. The Director said the purpose of that requirement is to ensure there is no drug diversion happening in the facility.
The Director did not say why, in this case, it didn't.
The facility's own written policy, last reviewed on May 14, 2025, four months before the inspection, lays out the same sequence in explicit steps. Controlled medications require immediate entry on the accountability record at the time the dose is removed from supply, with the date, time, amount, and the administering nurse's signature. The MAR gets initialed after the medication is actually given. The policy exists, in the Director's own words, to keep the count accurate and to keep drugs from being diverted.
Federal inspectors classified this as a deficiency with minimal harm or potential for actual harm, affecting a small number of residents. One resident appeared in the sampled records with the discrepancy. Two others did not show the same problem.
The classification of minimal harm reflects the regulatory framework's threshold for documented injury, not a judgment that a missing controlled-substance entry is a minor administrative matter. Lorazepam belongs to the benzodiazepine class, a category of drugs with well-documented potential for misuse and dependency. Facilities handle them under DEA oversight for that reason. The accountability record is not a redundant bureaucratic form. It is the mechanism by which anyone can verify that a controlled drug administered to a vulnerable patient actually reached that patient.
When the two records diverge, there is no mechanism left.
Resident 6 was receiving palliative care, had moderately impaired cognition, and depended on staff for nearly every basic function. The resident could not have known whether the lorazepam prescribed for anxiety and restlessness was given or not. The resident could not have compared the MAR to the Count Sheet. The resident could not have asked what happened to the entry.
The inspection covered a complaint filed against the facility and was completed on September 11, 2025. The deficiency cited falls under the regulatory category covering pharmacy services and the requirement that a facility operate with the services of a licensed pharmacist, ensuring accurate drug records are maintained.
The plan of correction, if any, was not included in the inspection narrative reviewed. The Director of Nursing acknowledged the gap on the record, confirmed it should not exist, and offered no documented explanation for how it came to be.
A dose of a controlled sedative was signed out in one place and not signed out in another. In a facility caring for residents who cannot speak for themselves, that is the kind of discrepancy the accountability system was built to catch. This time, it caught nothing until an inspector asked.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Sunland Post Acute from 2025-09-11 including all violations, facility responses, and corrective action plans.
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
SUNLAND POST ACUTE in SUNLAND, CA was cited for violations during a health inspection on September 11, 2025.
The Director could not explain where the documentation went.
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.