Royal Park Health: Morphine Shortage Causes Withdrawal - WA
Resident 1 told inspectors during a September 9 interview that there was a day last month when they did not receive their evening morphine dose or the medication the following day. The resident had been on the same morphine dosage for several years to manage chronic pain and was physically dependent on the medication.
"When they did not get the Morphine in the evening the nurse told them that the medication had not come from the pharmacy, and it would come the next day," according to the inspection report. On the second day without morphine, nursing staff offered hydrocodone instead while waiting for the morphine to arrive from the pharmacy.
The resident experienced unrelieved pain along with body aches and flu-like symptoms consistent with opioid withdrawal. They told inspectors they felt nursing staff "did not take the situation seriously and discounted their complaints of pain and withdrawal."
During the medication shortage, the resident repeatedly asked Staff D, a licensed practical nurse, when the morphine would arrive from the pharmacy. The nurse had verbally contacted the facility's nurse practitioner about the missing medication but had not noticed the morphine supply was running low until the day before it ran out.
Staff D acknowledged the medication should have been reordered when the remaining supply reached a blue line on the medication card, indicating seven doses remained. The nurse thought they had communicated with the nurse practitioner earlier but "could not remember clearly."
The facility's medication reordering policies contained contradictory timelines. Staff B, the resident care manager overseeing Resident 1, said nurses should notify the pharmacy when seven days of medication remained. Staff A, the director of nursing, initially stated the policy required reordering when three days of medication remained, then later clarified via email that reordering should occur at the seven-dose blue line.
Neither the resident care manager nor the director of nursing knew Resident 1 had missed their prescribed twice-daily morphine doses.
Staff C, the nurse practitioner, acknowledged in email correspondence that "this situation of not having the morphine was not planned or recommended." The practitioner noted that Resident 1 was "very aware of their pain management and all of the medications included in their pain management plan" but had not spoken with the resident about the morphine shortage or written a progress note about the situation.
Medical literature cited in the inspection report indicates opioid dependence is common among patients taking these medications long-term. Abrupt cessation or rapid dose reduction can trigger withdrawal syndrome, which matches the symptoms Resident 1 experienced during the two-day period without morphine.
The facility disputed the citation, which inspectors classified as causing minimal harm or potential for actual harm to few residents.
Royal Park Health and Rehabilitation's medication management breakdown left a chronic pain patient to endure withdrawal symptoms while staff offered inadequate substitutes and failed to communicate the crisis to supervisors responsible for the resident's care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Royal Park Health and Rehabilitation from 2025-09-09 including all violations, facility responses, and corrective action plans.
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
Royal Park Health and Rehabilitation in SPOKANE, WA was cited for violations during a health inspection on September 9, 2025.
The resident had been on the same morphine dosage for several years to manage chronic pain and was physically dependent on the medication.
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.