Terrace Post Acute: Expired Morphine Given to Patient - CA
The resident, who was paralyzed in all four limbs and completely dependent on staff for eating, hygiene, and toileting, had been prescribed morphine sulfate for severe pain rated 7 to 10 on a 10-point scale. Federal inspectors discovered that nurses administered the medication on three separate occasions after it had expired.
Licensed Vocational Nurse 1 showed inspectors the resident's morphine bottle during an August inspection. The nurse confirmed the medication had expired in July. Yet medication records showed staff gave the resident doses three times that month after the expiration date had passed.
The Director of Nursing acknowledged the violations during the inspection. "Morphine sulfate should not have been administered because Resident 1's morphine sulfate expired," the director told inspectors. She explained that nurses must always check expiration dates before giving any medication.
When medications expire, she said, they should be immediately removed from medication carts and reordered from the pharmacy. "An expired medication may not have the potency the medication needs to be effective," the director explained.
The resident had been admitted to the facility with quadriplegia and low blood pressure. Despite their physical limitations, their cognitive function remained intact, meaning they were fully aware of their pain and the treatment they were receiving.
The morphine was prescribed as an oral solution, with instructions to give 5 milliliters every eight hours as needed for severe pain. The medication was specifically ordered for leg and knee pain when the resident's discomfort reached the highest levels on the pain scale.
Federal regulations require nursing homes to provide pharmaceutical services that meet each resident's needs and ensure medications are administered safely and as prescribed. The facility's own policy mandated that staff check expiration dates on medication labels before administration.
But that didn't happen for this resident.
The three instances of expired medication administration occurred over multiple days in July. Each time, licensed nursing staff failed to notice or ignored the expiration date clearly marked on the bottle.
For a resident already dealing with complete paralysis and dependence on others for basic care, the potential ineffectiveness of pain medication represented an additional layer of suffering. Pain management is particularly crucial for quadriplegic patients, who may experience chronic discomfort from positioning, muscle spasms, and other complications of their condition.
The inspection found that some residents at the facility were affected by pharmaceutical service failures, though the full scope wasn't detailed in available records.
When inspectors asked about proper procedures, the Director of Nursing demonstrated clear knowledge of medication safety protocols. She knew expired medications could lose potency. She understood the steps nurses should take when they discover expired medications. She was aware of the facility's written policies requiring expiration date checks.
Yet none of that knowledge prevented three separate medication errors involving the same resident and the same expired bottle of morphine.
The facility's medication administration policy, reviewed in 2025, explicitly stated that medications must be given "in a safe and timely manner, and as prescribed." It required checking expiration dates before administration.
The policy existed. The training apparently occurred. The Director of Nursing understood the requirements.
The resident still received expired morphine three times.
Federal inspectors classified the violation as having minimal harm or potential for actual harm. But for a paralyzed resident depending on morphine for severe pain relief, receiving potentially ineffective medication could mean hours or days of unnecessary suffering.
The resident's medical records showed they had been admitted with multiple serious conditions requiring careful monitoring and treatment. Their complete dependence on staff for all activities of daily living made them particularly vulnerable to care failures.
Now they faced the possibility that their pain medication, administered by nurses they trusted to provide proper care, might not work when they needed it most.
The inspection occurred in August, weeks after the expired medication incidents. By then, the morphine bottle sat in the medication cart, its expiration date visible to anyone who looked.
Three times in July, licensed nurses had looked at that bottle and administered its contents anyway.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terrace Post Acute from 2025-08-26 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: August 6, 2026 · Our methodology
Terrace Post Acute in VAN NUYS, CA was cited for violations during a health inspection on August 26, 2025.
Federal inspectors discovered that nurses administered the medication on three separate occasions after it had expired.
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.