The Orchards at Roseville: Discontinued Drug Given Anyway - MI
The resident, identified in inspection records only as R700, had been admitted to the facility with fibromyalgia and schizoaffective disorder. A cognitive screening placed them well within the range of intact mental function. Their physician decided to switch their pain management from Tramadol, a synthetic opioid sold under the brand name Ultram, to Norco, a stronger narcotic combining hydrocodone and acetaminophen. The order was direct: discontinue the Tramadol once the Norco arrives from the pharmacy.
The Norco arrived the same day, September 22.
Nobody discontinued the Tramadol.
Over the next eleven days, R700 received the drug the doctor had stopped on four separate occasions: September 24, September 29, October 1, and October 2. Meanwhile, they were also receiving the Norco the doctor had prescribed as its replacement, on September 23, September 26, October 1, October 2, October 4, and October 5.
On October 1 and again on October 2, R700 received both medications on the same day.
Tramadol and Norco are not typically prescribed together. Tramadol carries its own opioid activity and also affects serotonin and norepinephrine in ways that interact with other drugs. Norco is a full opioid. Giving both to the same patient on the same day, without a physician ordering that combination, is the kind of medication error that drug regimen oversight requirements exist to prevent.
The order to formally discontinue the Tramadol in the electronic records wasn't entered until October 13, three weeks after the original stop order and eleven days after the last time R700 received it.
Federal inspectors from the Centers for Medicare and Medicaid Services visited the facility on November 20, 2025, responding to a complaint. When the nursing home administrator was asked about the gap between the physician's order and what actually happened, the response was brief. Physician orders should be followed as written, the administrator said.
That is, of course, exactly what did not happen.
The facility's own medication policy, reviewed by inspectors, states that medications are administered in accordance with written orders of the attending physician. The physician's written order on September 22 said to stop the Tramadol. The Norco was in the building by the end of that day. The order could not have been clearer about when the switch was to happen.
CMS rated the violation at the level of minimal harm or potential for actual harm, meaning inspectors found no documented injury to R700 from the overlapping medications. The citation covered two residents reviewed for unnecessary medication concerns; the error was found in one of them.
What the record does not show is whether anyone told R700 what was happening. The resident had intact cognition. They were aware of their surroundings, able to communicate, capable of understanding their own treatment. Whether they knew they were receiving a medication their doctor had already stopped, or that they were receiving two opioid-class drugs on days when only one had been prescribed, is not addressed anywhere in the inspection findings.
The Orchards at Roseville is a nursing facility in Macomb County. The inspection was a complaint survey, meaning someone contacted regulators about conditions at the facility before investigators arrived.
The administrator's answer to the inspector's question was technically correct as a statement of policy. Physician orders should be followed as written. In this case, for this resident, over eleven days and five doses, they were not.
R700's physician made a clinical decision on September 22. It took until October 13 for the facility's records to catch up to it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Orchards At Roseville from 2025-11-20 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: August 29, 2026 · Our methodology
The Orchards at Roseville in Roseville, MI was cited for violations during a health inspection on November 20, 2025.
The resident, identified in inspection records only as R700, had been admitted to the facility with fibromyalgia and schizoaffective disorder.
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.