Monrovia Post Acute: Pain Medication Shortage - CA
The patient, identified as Resident 1 in federal inspection records, was prescribed morphine sulfate 15 milligrams twice daily for pain management starting July 4. The medication supply ran out on August 2, leaving the resident without pain relief on August 3 and the morning of August 4.
Federal inspectors found the facility violated pharmaceutical service requirements during their August 20 complaint investigation. The resident was moderately cognitively impaired and completely dependent on staff for bathing, dressing, toileting and personal hygiene.
Director of Nursing confirmed during interviews that the resident missed two doses on August 3 at 6 AM and 6 PM, plus the 6 AM dose on August 4. She told inspectors the medication shortage occurred because the ordering physician had not signed for the morphine.
The facility's contracted pharmacist provided a different account. During a telephone interview, the pharmacist said the refill request wasn't processed until August 3 — the day after supplies ran out. The medication wasn't actually refilled until August 4.
"The refill request for Resident 1's Morphine Sulfate should have been refilled two days prior to the supply running out at the facility," the pharmacist told inspectors.
Morphine sulfate is a Schedule II controlled substance under federal law, requiring special handling procedures. The facility's own policies specify that Schedule II medications must be reordered when a five-day supply remains in storage.
The nursing home's medication policy, revised in April 2007, states: "Medications should be ordered in advance, based on the dispensing pharmacy's required lead time."
For controlled substances specifically, facility policy requires staff to "inform the pharmacy when a five-day supply remains in the medication storage." The policy warns that automatic refills are not authorized for Schedule II substances.
"Upon nurses reorder request, the Pharmacy then is required by law to communicate and obtain a prescription from the physician before any new or reordered Schedule II medication may be dispensed," the policy states.
The policy emphasizes urgency: "Therefore it is imperative that the facility reorder these medications at least 5 days ahead of running out of medication."
Staff are instructed to "call and speak to a pharmacist if a reorder is urgently needed to expedite the process."
None of these safeguards prevented the medication shortage that left the Parkinson's patient without pain relief.
Resident 1 was originally admitted to Monrovia Post Acute on April 16, 2024, and readmitted on an undisclosed date with multiple diagnoses including Parkinson's disease, dementia, and type 2 diabetes. Parkinson's disease causes uncontrollable movements, shaking, stiffness, and difficulty with balance and coordination.
The resident's July 15 assessment showed moderate cognitive impairment, affecting the ability to make daily decisions. Staff provided complete assistance for all personal care activities.
The morphine prescription called for one 15-milligram tablet every 12 hours specifically for pain management. Federal inspectors noted the medication gap had the potential to cause the resident to experience unrelieved pain.
The inspection found the facility failed to ensure adequate pharmaceutical services for the sampled resident. Inspectors determined the violation caused minimal harm or potential for actual harm, affecting few residents.
Monrovia Post Acute is located at 1220 E. Huntington Drive in Duarte, about 20 miles northeast of downtown Los Angeles. The complaint inspection was completed on August 20, 2025.
The facility's medication management breakdown illustrates broader challenges nursing homes face with controlled substance regulations. Federal law requires physicians to authorize each Schedule II prescription, creating multiple approval steps that can delay critical medications.
But the facility's own policies acknowledged these regulatory requirements and established specific timelines to prevent exactly the type of shortage that occurred with Resident 1's morphine supply.
The gap between written procedures and actual practice left a vulnerable resident with Parkinson's disease and dementia without prescribed pain medication for nearly two full days.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Monrovia Post Acute from 2025-08-20 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 20, 2026 · Our methodology
MONROVIA POST ACUTE in DUARTE, CA was cited for violations during a health inspection on August 20, 2025.
The medication supply ran out on August 2, leaving the resident without pain relief on August 3 and the morning of August 4.
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.