Anoka Rehab: Morphine Left Unused as Resident Cried in Pain - MN
The resident, identified in inspection records only as R1, had a standing prescription for PRN morphine sulfate, meaning his physician had authorized it specifically for moments like this: the daily cares that caused him to cry every time staff made contact with his body. The medication existed. It was available. For reasons that not one person at Anoka Rehabilitation and Living Center could explain to inspectors, it was never used.
The inspection, conducted November 13, 2025, was a complaint survey. What investigators found was a man in recurring, documented pain, a doctor who didn't know his order was being ignored, and three levels of nursing management with no system in place to notice any of it.
When inspectors reached R1's primary care physician by phone at 4:45 p.m. that day, the doctor said the pain regimen he had prescribed should be covering his patient's pain. He was not aware R1 wasn't receiving the PRN morphine. He said he wasn't certain why staff hadn't been using it, and that he was going to make clear to them that was exactly why he had ordered it.
The nurse manager, RN-B, told inspectors she knew R1 experienced pain during cares. She knew he had complained that staff were rough with him. She said the staff had been educated to be gentle and go slowly because of his fragile skin. She understood that the moment anyone touched him, he cried, and she understood that cares still had to happen or his skin would break down. What she could not explain was why nobody had pre-medicated him with the morphine before those cares began. She also acknowledged she had no system for checking whether PRN medications on her unit were being used at all.
The assistant director of nursing went further. Before the survey began on November 12, he said, he had not been aware R1 was in pain. He learned about it only after speaking with the nurse manager and unit staff once inspectors arrived. He had never observed R1's cares himself. He did not know why staff weren't giving the morphine. And like the nurse manager, he was unaware of any system for tracking PRN or narcotic medication use on the unit.
Three people in nursing leadership. None of them knew. None of them had built anything to find out.
PRN medications, short for the Latin "pro re nata," are prescribed for use as needed, typically when a specific condition, like pain, presents itself. They require clinical judgment to administer: a nurse must assess the resident, recognize the need, and give the medication. They also require someone to notice when that judgment is never being exercised. At Anoka Rehabilitation, nobody was watching.
The facility's own pain management policy, dated April 14, 2025, described a systematic approach to recognizing, assessing, treating, and monitoring pain. R1's situation was a test of every one of those steps. He was in pain. Staff recognized it, because he cried every time they touched him. The assessment existed, because his doctor had already determined what treatment he needed. The treatment was prescribed and available. The monitoring never happened.
What the inspection report does not contain is any account of R1's own description of what those care sessions were like, or how long they had been going on that way. It does not say how many times he cried through a bath or a repositioning or a wound treatment without anyone reaching for the medication that was supposed to help him. The nurse manager knew it was happening. She told inspectors his skin was extremely sensitive, that he cried the moment staff touched him, that she had counseled staff to be gentle. Gentleness, without the morphine, was what he got.
His doctor, reached by phone, said he was going to have a conversation with staff about using the medication he ordered. That conversation had not happened yet when inspectors closed their report.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Anoka Rehabilitation and Living Center from 2025-11-13 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 22, 2026 · Our methodology
ANOKA REHABILITATION AND LIVING CENTER in ANOKA, MN was cited for violations during a health inspection on November 13, 2025.
For reasons that not one person at Anoka Rehabilitation and Living Center could explain to inspectors, it was never used.
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.