Roosevelt Park Nursing: Narcotic Diversion Concerns - MI
The inspection was triggered by a complaint.
Norco is a combination of hydrocodone and acetaminophen, a Schedule II controlled substance. When doses of drugs like this go unrecorded, or when a nurse administers them outside the boundaries of a physician's order, it raises a specific concern in nursing home oversight: diversion, the theft or misuse of a resident's medication by a staff member for personal gain.
The inspectors found exactly that pattern here.
The electronic medication administration record, known as an EMAR, showed no documentation for Norco doses on August 23, 2025, at 7:00 PM, September 6 at 4:02 PM, and September 7 at 11:30 PM. Three separate instances. Three gaps in the paper trail for a controlled substance.
The August 23 dose was the one inspectors confirmed had been given outside the physician's order entirely. That dose was administered by LPN C, identified in the report by that designation. No order existed authorizing it.
When inspectors sat down with the Director of Nursing and a registered nurse identified as RN A on the afternoon of September 17, the conversation turned directly to what those gaps meant. The DON and RN A confirmed that licensed nurses were expected to follow professional standards for medication administration and documentation. They said nurses would be reeducated and that the facility would conduct additional audits going forward.
That was the response: more training, more audits.
The facility's own Controlled Substances Standards of Practice policy, last reviewed in January 2025, is unambiguous about what nurses are supposed to do. When a controlled substance is removed from storage, the nurse must document the amount on a Proof-of-Use Sheet using a full last-name signature. That documentation must happen as soon as the drug is removed from the package or cart. The policy says explicitly: avoid waiting until the end of med pass or end of shift.
Three times, across a span of fifteen days, that didn't happen.
The facility's Abuse Prevention Program policy, also last reviewed in January 2025, lists resident drug diversion under the category of exploitation. The policy defines exploitation as taking advantage of a resident for personal gain through manipulation, intimidation, threats, or coercion. It identifies the diversion of a resident's medications, including controlled substances, for staff use or personal gain as a possible indicator of that exploitation.
Under that same policy, the Administrator and Director of Nursing are required to ensure corrective action following any such occurrence. That corrective action is supposed to include analyzing why the incident happened, defining how care will change to protect residents, training staff, identifying who is responsible for implementing changes, setting a date for implementation, and identifying who will monitor that implementation.
Whether that full corrective process was underway at the time of the inspection, the report does not say. What the report does say is that inspectors discussed ongoing diversion concerns with the DON and RN A directly, and that the conversation centered on incomplete and absent documentation for controlled drug administration.
Norco is not a drug with a wide margin for error. Hydrocodone is an opioid. In a nursing home population, where residents may be elderly, cognitively impaired, or medically fragile, receiving the wrong dose or an unauthorized dose carries real risk of harm. Inspectors rated this deficiency at the level of minimal harm or potential for actual harm, and noted that some residents were affected.
That rating, minimal harm or potential for actual harm, is the lower end of the federal harm scale. It does not mean nothing happened. It means inspectors could not confirm, at the time of the inspection, that a resident had suffered measurable injury. The documentation gaps themselves make that determination harder. When doses go unrecorded, it becomes difficult to reconstruct exactly what a resident received, when, and why.
That is part of what makes missing controlled substance documentation so serious. The record is supposed to be the safeguard. When the record is absent, the safeguard disappears.
Roosevelt Park Nursing and Rehabilitation Community is a skilled nursing facility. Residents there depend on staff to manage their medications accurately, and they depend on the documentation system to catch errors and flag concerns. A resident receiving Norco prescribed for pain has no way of knowing whether the dose they received was ordered by their physician, whether it was the right amount, or whether the nurse who removed it from the cart recorded it properly.
LPN C administered a dose of Norco on August 23 that no physician had ordered. The EMAR shows no record of it at 7:00 PM that evening. Two more doses, on September 6 and September 7, also went unrecorded.
The Director of Nursing and RN A, when confronted with those facts, did not dispute them. They confirmed the expectations. They described the plan. Reeducation. Audits.
The residents whose medications were involved are identified in the inspection report only by number, as is standard in these documents. Their names are not public. Whether any of them knew their controlled substances were being administered outside a physician's order, or going undocumented, the report does not say.
What the report does say is that inspectors found enough to call it a diversion concern, document it as a formal deficiency, and flag it under the facility's own exploitation policy. The nurse who gave Norco without an order was a licensed practical nurse. Licensed nurses in Michigan are bound by professional standards that include accurate and timely documentation of every controlled substance they administer. Those standards exist because the alternative, a system where opioids move through a nursing facility without a reliable paper trail, is a system that cannot protect the people living there.
At Roosevelt Park, for at least three doses across fifteen days in late August and early September 2025, that paper trail was missing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Roosevelt Park Nursing and Rehabilitation Communit from 2025-09-17 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 28, 2026 · Our methodology
Roosevelt Park Nursing and Rehabilitation Communit in Muskegon, MI was cited for violations during a health inspection on September 17, 2025.
The inspection was triggered by a complaint.
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.