They had not been delivered to him.
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The inspectors found it hadn't.
That's what federal health inspectors documented at Desert Springs Post Acute when they visited the Palm Desert facility on April 24.
The resident, identified in inspection records as R5, approached the inspector on May 20, 2026, and asked if something could be done about her medications.
That was the state of Grove at Kirkwood's facility assessment when federal inspectors arrived on January 29, 2026.
When federal inspectors sat down with the DON on April 23, 2026, she acknowledged she was personally responsible for updating every care plan in the facility.
The January 2026 inspection turned up a gap between what the facility promised on paper and what it delivered in practice.
Both nephrostomy tubes, the drainage tubes running directly from her kidneys through her back, were draining dark amber urine with a foul odor.
The inspection took place on January 28, 2026.
The medication was never filled.
That's not a paperwork problem.
Housekeeper F said no one had told him or her how much of the new cleaner to use.