Lone Tree Post Acute: Narcotic Tracking Failures - CA
Inspectors who visited the facility on April 10, 2026 as part of a complaint investigation sat down with the Assistant Director of Nursing and went through the controlled drug records and medication administration records side by side. The ADON confirmed what they were seeing: the dates and times documented in one set of records did not line up with the other.
Resident 4 was prescribed Hydrocodone-Acetaminophen 5-325 mg. The dispensing record showed 56 tablets. The entries that were supposed to document when the drug was given — September 11, September 14 at 8:45 a.m., September 17 at 10:15 a.m. — did not reconcile with the corresponding medication administration record.
Resident 5 had 60 tablets of the same drug. The mismatches stretched across more than a month: September 9, September 20 at 1:57 a.m., October 6 at 4:40 p.m., October 9 at 5:00 p.m., October 11 at 3:40 a.m.
Resident 6 was on the stronger formulation, Hydrocodone-Acetaminophen 10-325 mg, 30 tablets. The records diverged at November 14 at 1:40 a.m., November 15 at 8:58 a.m., November 19 at 2:00 a.m.
Resident 7 was prescribed oxycodone, 5 mg, also 30 tablets. The controlled drug record and the medication administration record failed to match on five separate occasions between October 14 and October 29.
Resident 8, also on the higher-dose hydrocodone combination, had discrepancies on November 4 at 6:30 p.m. and November 5 at 10:02 a.m.
When inspectors asked for the shipping manifests — the documents that record what the pharmacy actually sent to the facility and that are supposed to anchor the entire chain — the ADON acknowledged the facility did not have them. Not for any of these residents. The documents were simply absent.
She stated it was the facility's expectation that all documents be available and accurate.
That expectation had not been met for months, and the facility's own quality assurance process had not caught it. When inspectors asked for the pharmacist inspection reports covering September through December 2023, the ADON located the pharmacy quality assurance reports for that period and for the first quarter of 2024. She reviewed them and stated they did not document any issues with incomplete or inaccurate scheduled medication records.
The consultant pharmacist, whose role the facility's own policy describes as providing consultation on all aspects of pharmacy services and collaborating with the facility to develop and evaluate procedures, had not flagged what the ADON acknowledged to inspectors in a single morning.
The facility's controlled substances policy, dated November 2022, describes a reconciliation system that is supposed to include shipping manifests, controlled drug records, medication administration records, and destruction logs — the full chain of custody from pharmacy to patient. It states that controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss or diversion and detection.
The time between the earliest documented discrepancy and the inspection was more than two years.
What the records cannot answer — and what the inspection report does not resolve — is what actually happened to the medication during those gaps. Whether doses were given and recorded incorrectly, not given at all, or something else, the paper trail that exists to answer that question is broken. For five residents receiving some of the most tightly controlled drugs dispensed in a nursing facility, the system that was supposed to catch any problem did not.
The ADON said the documents should have been complete. The pharmacist reports said everything was fine. The shipping manifests were gone.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Lone Tree Post Acute from 2026-04-27 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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 19, 2026 · Our methodology
LONE TREE POST ACUTE in ANTIOCH, CA was cited for violations during a health inspection on April 27, 2026.
The ADON confirmed what they were seeing: the dates and times documented in one set of records did not line up with the other.
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.