Roosevelt Park Nursing And Rehabilitation Communit
Roosevelt Park Nursing and Rehabilitation Communit in Muskegon, MI — inspection on September 17, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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.
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