Sunland Post Acute: Missing Lorazepam Bottle - CA]
The bottle, lorazepam oral concentrate 2mg/mL, prescription number 4005429, was filled on August 1, 2025. Lorazepam is a controlled benzodiazepine, a sedative in the same family as Valium, used to treat anxiety and sometimes prescribed in concentrated liquid form for residents who cannot swallow pills. It is a Schedule IV controlled substance under federal law, meaning it carries recognized potential for abuse and dependency, and facilities are required to track every dose, every transfer, every destruction.
This bottle was never tracked to its end. It was never handed to the Director of Nursing for safekeeping. It was never locked in a cabinet. It was never destroyed in the presence of a pharmacist. When inspectors arrived at Sunland Post Acute on September 11, 2025, the Director of Nursing reviewed the facility's medication destruction log and found no record of it. Then she looked further. The bottle was simply not there.
"The bottle of lorazepam oral concentrate 2mg/mL with the RX# 4005429 dated 8/1/2025 is gone and was not located," the Director of Nursing told inspectors that morning.
She did not hedge it. She confirmed it directly: the facility had failed to keep the lorazepam safe.
The facility's own written policy, last reviewed on May 14, 2025, less than four months before the inspection, lays out exactly how controlled substances are supposed to move through the building. When a resident's narcotic or controlled medication is discontinued, a licensed nurse is to bring both the medication and its Individual Count Sheet Record to the Director of Nursing. The Director of Nursing then locks both in a cabinet. Once a month, the consultant pharmacist comes to the facility and destroys any accumulated controlled medications alongside the Director of Nursing, with each serving as witness to the other.
That process did not happen with this bottle. The Director of Nursing told inspectors she had no record of any nurse ever bringing it to her. It never reached the cabinet. The pharmacist never destroyed it. As of September 11, 2025, more than six weeks after the prescription date, no one at Sunland Post Acute could account for its location.
The Director of Nursing, in her interview with inspectors, placed the responsibility on the nursing staff. Licensed nurses, she said, should have done their jobs by giving correct endorsements and taking accountability for controlled medications during shift change. In nursing homes, shift change is the moment when one nurse hands off to the next, when every controlled substance on the unit is supposed to be counted and verified, when discrepancies are supposed to surface before they become disappearances. The endorsement process exists precisely so that a bottle of lorazepam does not quietly vanish between one shift and the next over the course of weeks.
What the Director of Nursing's explanation does not resolve is the arithmetic of the gap. A bottle filled on August 1 was not reported missing until inspectors prompted a review on September 11. That is more than forty days. The facility's own policy calls for monthly pharmacist visits specifically to destroy discontinued controlled medications. If the system had been working, the absence of this bottle should have surfaced at the most recent monthly visit. It did not.
The inspection report does not identify which resident had been prescribed the lorazepam, how long they had been taking it, or why it was discontinued. It does not say whether the bottle was full, partially used, or nearly empty when it went missing. It does not say whether any nurse reported noticing a discrepancy during shift change, or whether the Count Sheet Record that was supposed to accompany the bottle was also missing. Those details are not in the record.
What is in the record is the Director of Nursing's unambiguous statement: the bottle is gone.
Lorazepam oral concentrate at 2mg/mL is a potent formulation. In concentrated liquid form, it is easier to divert than pill forms of the same drug because small volumes contain significant doses and liquid is harder to visually audit than a pill count. Diversion of controlled substances from long-term care facilities is a documented problem nationally, one that harms both the residents who lose access to medications they need and the staff members, visitors, or others who obtain controlled substances through facilities where oversight has broken down.
The inspection report does not allege diversion. It does not name any individual as responsible for the bottle's disappearance. The finding is categorized at the level of minimal harm or potential for actual harm, affecting a few residents. That classification reflects what inspectors could document, not necessarily the full scope of what occurred.
Sunland Post Acute is a post-acute and skilled nursing facility located at 8647 Fenwick Street in Sunland, a neighborhood in the northeastern corner of Los Angeles. The inspection on September 11, 2025 was a complaint inspection, meaning it was triggered by a specific concern brought to regulators rather than a routine survey cycle.
The facility's policy on controlled medications states explicitly that only authorized licensed nursing and pharmacy personnel have access to controlled substances, and that the Director of Nursing and consultant pharmacist are jointly responsible for maintaining compliance. The policy was reviewed and presumably reaffirmed in May 2025. Four months later, a bottle of a federally controlled sedative was unaccounted for, and the facility's own director confirmed it to inspectors without qualification.
The Director of Nursing told inspectors that nurses should have taken accountability. The policy says the Director of Nursing and pharmacist maintain compliance. The monthly destruction visit exists to catch exactly this kind of gap. None of those layers caught it.
A bottle of lorazepam, filled August 1, 2025, remains unlocated.
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: 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 28, 2026 · Our methodology
SUNLAND POST ACUTE in SUNLAND, CA was cited for violations during a health inspection on September 11, 2025.
The bottle, lorazepam oral concentrate 2mg/mL, prescription number 4005429, was filled on August 1, 2025.
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.