Sunland Post Acute: Missing Lorazepam Bottle - CA
That was what the Director of Nursing told a federal inspector on September 11, 2025. The bottle was gone. It had not been destroyed. It had not been handed over for safekeeping. It had simply vanished.
The drug in question was lorazepam oral concentrate, 2 milligrams per milliliter, prescription number 4005429, dispensed on August 1. Lorazepam belongs to the benzodiazepine class of medications. It is used to treat anxiety and seizures, and it is also a drug with documented potential for abuse, dependency, and misuse — which is precisely why the Drug Enforcement Administration classifies it as a Schedule IV controlled substance and why nursing homes are required to track every dose.
At Sunland Post Acute, that tracking failed completely.
The Director of Nursing explained to the inspector how the system was supposed to work. When a controlled medication is discontinued or a resident no longer needs it, nurses are expected to keep it locked and accounted for. The pharmacist comes to the facility monthly. At that point, the DON and the pharmacist witness each other as they destroy the medication together. The destruction gets logged. That is the chain of custody, start to finish.
For prescription number 4005429, none of that happened.
The DON told the inspector that when she reviewed her medication destruction log, the lorazepam bottle was not there. It had never been turned over to her for safekeeping. It had not been destroyed. By the time of the follow-up interview on the morning of September 11, she confirmed what the investigation had already made plain: the bottle was gone and had not been located.
"The facility failed to ensure that a bottle of lorazepam was kept safe," the DON said.
She placed the responsibility on the licensed nurses who had been handling shift-change endorsements — the process by which nurses account for controlled substances when one shift hands off to the next. "Licensed nurses should have done their job by making sure they are giving the correct endorsements and taking accountability of controlled medications upon shift change," she told the inspector.
That shift-change accounting process exists for exactly this reason. When a controlled substance is removed from its container and not administered — because a resident refused it, or it was discontinued, or it simply wasn't given — it cannot be put back in the bottle. It has to be destroyed, on the spot, witnessed by two licensed nurses, and documented on the accountability record. That documentation creates a paper trail that follows the medication from the moment it arrives at the facility to the moment it no longer exists.
Here, the paper trail ran cold somewhere between August 1 and September 11.
The facility's own written policy, reviewed as recently as May 14, 2025, was unambiguous on this point. Controlled substances are subject to special handling, storage, disposal, and recordkeeping. Only authorized licensed nursing and pharmacy personnel are permitted access to them. The Director of Nursing and the consultant pharmacist are jointly responsible for maintaining compliance. The policy spelled out the destruction requirement in plain language.
None of it prevented the bottle from disappearing.
What the inspection report does not say is also significant. It does not say the bottle was found in a resident's room. It does not say a staff member was caught with it. It does not say there is a clear explanation for where it went. The DON's own words — "the bottle of lorazepam oral concentrate 2mg/mL with the RX# 4005429 dated 8/1/2025 is gone and was not located" — leave the question open. A controlled sedative entered the facility, was dispensed under a specific prescription number, and at some point ceased to be accounted for by anyone.
The inspection was conducted as a complaint survey, meaning someone had raised a concern that triggered the visit. The report does not identify who filed the complaint or what specifically prompted it.
Inspectors rated the harm level as minimal, or potential for actual harm, and noted that few residents were affected. Those designations reflect the regulatory framework inspectors use to categorize deficiencies — they do not mean nothing went wrong. A missing bottle of lorazepam is, by definition, a controlled substance that cannot be accounted for. The entire structure of controlled substance tracking in nursing homes exists because these drugs are dangerous, because they are sought after, and because their disappearance is never a routine paperwork problem.
Lorazepam in liquid concentrate form is particularly potent. At 2 milligrams per milliliter, a small volume delivers a significant dose. The oral concentrate formulation is typically prescribed for residents who cannot swallow pills. A full bottle represents a meaningful quantity of a drug that, outside of medical supervision, can cause sedation, respiratory depression, and, in combination with other substances, death.
The DON's explanation for what went wrong focused on individual nurses failing to follow shift-change protocols. That may be accurate. Shift-change accountability for controlled substances depends on nurses at the end of one shift and nurses at the beginning of the next both counting, both signing, and both catching any discrepancy before it compounds. If that handoff is done carelessly — or not done at all — a bottle can drift out of the count without anyone flagging it at the time.
What the inspection record shows is that by the time the DON reviewed her destruction log in response to the inspector's inquiry, the gap had already grown from August 1 to September 11. Six weeks had passed. The bottle had moved through at least dozens of shift changes during that period, each one an opportunity to catch the discrepancy, and none of them did.
The facility's plan of correction was not included in the inspection document provided. The report directs anyone seeking that information to contact the nursing home or the state survey agency directly.
Sunland Post Acute is located at 8647 Fenwick Street in Sunland, a community in the foothills of the San Gabriel Mountains in Los Angeles County. The facility's CMS identification number is 056031.
As of the date of the inspection, the lorazepam had not been found.
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.
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 22, 2026 · Our methodology
SUNLAND POST ACUTE in SUNLAND, CA was cited for violations during a health inspection on September 11, 2025.
That was what the Director of Nursing told a federal inspector on September 11, 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.