Roosevelt Park Nursing And Rehabilitation Communit
Inspection Findings
F-Tag F0602
F 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
was not documented in the EMAR on 8/23/25 at 7:00 PM, 9/6/25 at 4:02 PM, or 9/7/25 at 11:30 PM and confirmed the Norco was administered outside of the provider order by LPN C on 8/23/25.During an
interview on 09/17/2025 at 3:54 PM, concerns regarding ongoing diversion of narcotics due to the incomplete and/or absent documentation for the administration of controlled drugs was discussed with DON and RN A. They confirmed that the licensed nurses were expected to follow professional standards of practice for medication administration and documentation and reported the licensed nurses would be reeducated and they would be completing additional audits to ensure compliance.Review of the facility policy Controlled Substances Standards of Practice last reviewed January 2025 revealed, .Nurses removing controlled substance from the narcotic storage require documentation on the Proof-of-Use Sheet
the amount removed using a full last name signature. Nurse documentation of inventory balance on Proof-of-Use sheet MUST be made as soon as the controlled substance is removed from the package/cart.
Avoid waiting until the end of med pass or end of shift.Review of the facility policies Abuse Prevention Program Policy and Procedure and Abuse Prevention Program 7 Components last reviewed 01/2025 revealed, Resident Drug Diversion (can also be indication of exploitation). Exploitation-Taking advantage of
a resident for personal gain, using manipulation, intimidation, threats, or coercion. Possible Indicators of Exploitation Include, but is not limited to .The diversion of a residents' medication(s), including, but not limited to, controlled substances for staff use or personal gain.The facility Administrator and/or Director of Nursing will ensure corrective action will include the following .Taking all necessary actions as a result of
the investigation, which may include,but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and/or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan.
Event ID:
Facility ID:
If continuation sheet
Roosevelt Park Nursing and Rehabilitation Communit in Muskegon, MI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Muskegon, MI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Roosevelt Park Nursing and Rehabilitation Communit or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.