Regency at St. Clair Shores: Nurse Drug Diversion - MI
The nurse, identified in inspection records only as Nurse A, was working the overnight shift on May 19 when the oncoming morning nurse, LPN B, noticed the controlled substance count was off. What LPN B found when she arrived wasn't just a paperwork problem.
Nurse A was located in a resident's room, lying in the resident's bed, appearing to be asleep.
When staff woke Nurse A and asked about the narcotic documentation, the count sheet showed 82 pills recorded, with the words "actual 80" written underneath. Nurse A's behavior was described as odd. When Unit Manager C pressed for an explanation, Nurse A abruptly said she would go assess the resident and left the room. She was then summoned to the administrator's office. Instead of going, she left the building entirely.
LPN B had already called local police. The administrator paged Nurse A. Nurse A saw the police and walked out.
The resident at the center of the initial discrepancy, identified in the report as R903, is a person living with metabolic encephalopathy, dementia, schizophrenia, and adjustment disorder, with moderate cognitive impairment. They require partial to moderate assistance with bathing and moving in bed. Their physician order, dated November 4, 2024, called for two 50-milligram tablets of tramadol, a narcotic pain medication, by mouth at bedtime for pain.
Whether R903 received those doses as ordered, or whether the pills were taken before they reached the resident, is a question the facility had not fully resolved by the time inspectors arrived ten days later.
Nurse A was suspended and directed to submit to a urine and hair drug screen. She appeared for testing a day late. She submitted to the urine screen but refused the hair drug screen.
A review of R903's controlled drug receipt and disposition form, dated May 7, showed that Nurse A had crossed out information and documented what inspectors described as confusing entries on the form. The director of nursing, in an interview with inspectors on the afternoon of May 29, acknowledged that discrepancies existed in the narcotic count for R903 and said more work needed to be completed regarding misappropriation.
That word, misappropriation, is the facility's own.
The director of nursing described the sequence this way: Nurse A was finishing the midnight shift, LPN B was starting the morning shift, and during the narcotic count handoff, LPN B noticed the numbers didn't add up. Nurse A's behavior struck staff as strange. When asked about the discrepancy, rather than explaining the documentation, Nurse A said she would go check on the resident.
Unit Manager C's account, given to inspectors at 2:13 that afternoon, filled in the detail that Nurse A had been found in the resident's bed. That detail does not appear in the facility's own incident summary submitted to the state agency.
Inspectors noted a compliance date of May 27 on the facility's plan of correction. The surveyor reviewed narcotic sheet discrepancies dated May 28, one day after that compliance date, with additional residents appearing to have been affected by Nurse A's conduct. The report does not specify how many residents or which medications.
Inspectors attempted to reach Nurse A by phone on May 29. The call went unanswered. No voicemail was available.
The inspection report does not say whether R903 reported pain during the period in question, whether anyone assessed them for undertreated discomfort in the days after the discrepancy was discovered, or whether the resident or their family was ever told what happened. R903's diagnoses include conditions that affect the ability to communicate clearly. Metabolic encephalopathy and dementia can impair a person's capacity to say, plainly, that something hurts or that a medication never arrived.
The facility's own pain management policy states that licensed nurses administering routine pain medications will record the drug administration on the medication administration record. The controlled substance forms are meant to create an unbroken chain of accountability, pill by pill, shift by shift. The crossed-out entries and the words "actual 80" written beneath "82" represent a break in that chain.
What the director of nursing called "more work needed" is, in practical terms, an acknowledgment that the facility does not yet know the full scope of what Nurse A did or did not do during her time on that unit.
R903 needed help moving in bed. They needed help bathing. They had a prescription for pain medication that was supposed to arrive every night at bedtime. On at least one night, and possibly more, the nurse responsible for delivering that medication was found asleep in a resident's room, with a count sheet that didn't match, and left before anyone could get a straight answer.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Regency At St. Clair Shores from 2025-05-29 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: July 5, 2026 · Our methodology
Regency at St. Clair Shores in St. Clair Shores, MI was cited for violations during a health inspection on May 29, 2025.
What LPN B found when she arrived wasn't just a paperwork problem.
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.