Optalis Health & Rehabilitation at Kent-Crossing

Inspectors wroteThis citation pertains to intakes: 2802001, 2802220, 2798542, & 2737401. Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 8 of 9 Residents (#39, #76, #86, #139, #27, #140, #37, #22) reviewed for medication errors when a.) Medication orders were transcribed and administered incorrectly and B.) medications were not administered as ordered resulting in Resident #39 receiving excessive doses of an antipsychotic medication and Resident's #76, #4, #86, #139, #27, #140, #37, #22's medications were omitted resulting in the decompensation (functional deterioration of a physical or mental system) for Resident #76, and the potential for health complications.

Inspectors wroteThis citation pertains to intakes 2696710. Based on interview and record review the facility failed to report allegations of abuse and neglect to the State survey agency and/or other officials when applicable for 13 (Residents #13, 22, 27, 35, 37, 41, 75, 77, 86, 97, 122, 139, and140) of 13 residents reviewed for reporting of alleged violations resulting in the State survey agency and/or nurse licensing department not being notified or notified timely, a delay in officials being aware of abuse/neglect allegations, and the potential for abuse and/or neglect to occur and/or reoccur.

Inspectors wroteThis citation pertains to intake 2696710 Based on observation, int erview, and record review, the facility failed to ensure that residents received care in accordance with professional standards in 17 (#130, #4, #5,#13,#22,#27,#35,#37,#41,#75,#77,#86,#97,#122,#139,#140,and #2) out of 17 residents reviewed for quality of care resulting in missed medications, inaccurate documentation of medications and treatments administered, medications given without order parameters, and missing neurological (neuro) assessments after unwitnessed falls.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure oxygen was consistently provided per physician's orders for 2 (Residents #25 and 130) of 2 residents reviewed for respiratory care resulting in oxygen flow rates being provided above and below orders with the potential for difficulty breathing.

Inspectors wroteBased on observation and interviews, the facility failed to maintain a safe, functional, sanitary, and comfortable environment. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living. Findings Include:On 3/18/26 at 9:12 AM, observation of the underside of the three-compartment sink found a volleyball sized hole in the wall. On 3/18/26, starting at 9:42 AM, observation of station one and station three pantries found the underside cabinetry under a sink and the ice machine shows increased accumulation of debris, black spots, and water damage. On 3/18/26 at 10:35 AM, observation of the 500-hall soiled utility room found a strong odor emanating from the room. A review of the room found a mop sink positioned behind the door. [...]

Inspectors wroteThis citation pertains to intake 2749417 Based on observation, interview, and record review the facility failed to provide an environment that promoted and enhanced resident dignity in 1 Resident (#130) of 3 residents reviewed for dignity resulting in feelings of humiliation, frustration, embarrassment, and negative psychosocial outcomes impacting the residents' quality of life.

Inspectors wroteThis citation pertains to intakes: 2802001, 2802220, 2798542, & 2737401Based on interview and record review, the facility failed to inform the resident representative, in advance, of care to be provided for 2 (Resident #15 and Resident #39) of 6 residents reviewed for resident rights, resulting in: 1. Resident #15 receiving psychotropic medication without consent from his resident representative. 2. Resident #39 attended an offsite medical appointment without representation from her Durable Power of Attorney (DPOA).

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents maintained their right to self-determination for 1of 4 residents (Resident #5), reviewed for choices, resulting in Resident #5 experiencing feelings of frustration and anxiety, and interference with maintaining her highest practicable level of independence.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate and consistent code status documentation and advanced directive information for 1 resident (Resident #84) of 2 residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility, or other healthcare providers.

Inspectors wroteThis citation pertains to intakes: 2802001, 2802220, 2798542, & 2737401. Based on interview and record review, the facility failed to ensure proper notifications were made after the identification of a significant medication error for 1 (Resident #39) of 2 residents reviewed for notifications, resulting in the lack of assessments, monitoring, and potential for worsening medical conditions.

Inspectors wroteBased on interview, and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) form in 2 of 3 residents (Resident #4 & #13) reviewed for timely provision of notifications, resulting in the potential for frustration and the resident or resident representative to be unaware of changes regarding financial liability.

Inspectors wroteThis citation pertains to intake 2731057. Based on observation, interview, and record review, the facility failed to maintain a clean and comfortable environment for 3 residents (R8, R108, and R12) of 4 residents reviewed for a sale/clean/comfortable homelike environment, resulting in unclean/unkempt resident rooms and the potential for cross contamination, bacterial harborage, and the potential for a reasonable person to experience feelings of embarrassment, shame, and/or loss of self -esteem.

Inspectors wroteThis incident is linked to intake 2612225. Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by staff for 1 resident (R14) of 3 reviewed for abuse, resulting in facility staff verbally assaulting R14 resulting in feelings of frustration, mental anguish, and a loss of autonomy (freedom from external control or influence).

Inspectors wroteThis citation pertains to intake #2608884Based on interview and record review, the facility failed to safeguard credit card numbers for 1 resident (Resident #127) of 3 residents reviewed for abuse, resulting in a staff member making an unauthorized purchase using a resident's credit card.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were not prescribed PRN (as needed) psychotropic medications for greater than 14 days for 1 resident (Resident #18) of 5 residents reviewed for unnecessary medications, resulting in lack of monitoring and medical necessity documented to extend use of PRN anti-anxiety medication.

Inspectors wroteThis citation pertains to intakes 2612225. Based on interview and record review the facility failed to ensure facility staff implemented the abuse policy in 1 of 1 residents (R108) reviewed for abuse, resulting in a delay in reporting of staff to resident verbal abuse to the state agency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a significant change Minimum Data Set (MDS) assessment for a resident admitted to hospice, in 1 resident (Resident #18) of 23 residents sampled for MDS accuracy, resulting in the potential for unassessed physical, mental, emotional, and psychosocial needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a significant change Preadmission Screening and Resident Review (PASARR) Level 1 screening was submitted and a Level II PASARR evaluation was completed for 1 (Resident #15) of 1 resident reviewed for PASARR Screening, resulting in the potential for unmet mental health and inappropriate placement in the skilled nursing facility.

Inspectors wroteThis citation pertains to intake 2731057. Based on observation, interview, and record review, the facility failed to ensure adequate labeling, dating/timing, and maintain cleanliness of enteral feeding equipment for 2 residents (R108 and R8) of 2 residents reviewed for enteral feeding, resulting in the potential for spoiled enteral feeding supplement and infections.

Inspectors wroteThis citation pertains to intakes 2802001, 2802220, 2798542, & 2737401. Based on interview and record review, the facility failed to identify incorrect medication orders during the monthly medication regimen review for 1 of 6 residents (Resident #39), reviewed for medication regimen reviews, resulting in the unnecessary administration of an antipsychotic medication and the potential for worsening medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to provide requested immunizations to 2 of 5 residents (R12 and R108) reviewed for immunizations, resulting in the potential for acquiring, transmitting, or experiencing complications from communicable diseases.

Inspectors wroteBased on interview and record review the facility failed to ensure residents' personal funds held by the facility were accessible to residents for 40 residents in the facility, including 3 (Residents #110, 104, and 114) out of the total facility census of 111 resulting in frustration and being upset without access to their money and the inability to make personal purchases.

Inspectors wroteThis citation pertains to intake # 1214940 & 2567893. Based on interview, and record review, the facility failed to protect the residents' right to be free from sexual and verbal abuse by a resident in 5 of 6 residents (Resident #101, #102, #104, #103 & #105) reviewed for abuse prevention, resulting in multiple instances of resident-to-resident sexual abuse, verbal abuse, and the potential for emotional distress.

Inspectors wroteThis citation pertains to intake # 1214940 & 2567893. Based on interview, and record review, the facility failed to report allegations of resident-to-resident sexual and verbal abuse to the State Agency in a timely manner in 5 of 6 residents (Resident #101, #102, #104, #103, & #105) reviewed for abuse prevention and reporting, resulting in the potential for incomplete investigations, and further instances of abuse to go unreported.

Inspectors wroteThis citation pertains to intakes #1214940, 2568025, 2569731, and 2583148. Based on interview and record review the facility failed to ensure sufficient staffing to meet resident care needs for 7 (Residents #103, 105, 110, 111, 112, 106, and 109) of 14 residents reviewed for staffing, resulting in feelings of staff not knowing their needs, medications being administered late, extended call light wait times, and negative resident emotions.

Inspectors wroteThis citation pertains to intake # 2568025. Based on interview, and record review, the facility failed to notify family of a change in resident condition requiring hospitalization in 1 of 3 residents (Resident #107) reviewed for notification of changes, resulting in family being unaware of a resident's decline with resulting hospitalization and the potential for emotional distress.

Inspectors wroteThis citation pertains to intake #2574473Based on observation, interview, and record review, the facility failed to provide timely and consistent ADL (activities of daily living) care to 1 resident (Resident #109) of 3 reviewed for ADL care, resulting the resident experiencing back pain from remaining in bed, missing showers, feelings of frustration, and embarrassment.

Inspectors wroteBased on interview and record review, the facility failed to employ an Activity Director who possessed the required qualifications resulting in the potential for unmet psychosocial needs, feelings of boredom and a lack of person-centered activities. This citation has the potential to impact all 126 residents within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food in the kitchen.

Inspectors wroteDPS B Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in water borne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility.

Inspectors wroteThis citation pertains to Intake MI00147770 Based on observation, interview and record review, the facility failed to maintain the dignity of 4 (Resident #26, Resident #55, Resident #57 and Resident #112) of 25 residents reviewed for dignity, and 3 of 6 residents who attended a confidential meeting, resulting in feelings of decreased self-worth, frustration, and residents receiving assistance with eating in a disrespectful manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide individualized activities for 4 of 6 Residents (Resident #26, Resident #39, Resident #42 and Resident #55) reviewed for activities, resulting in feelings of boredom, and a potential for a decline in physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely and consistent weight measurements; follow-up of residents at risk for altered nutrition status; and on-going nutritional assessment for 4 (Residents #59, #89, #111, and #121) of 5 residents reviewed for nutritional care and services, resulting in missed re-weights (Resident #59), incomplete nutrition status monitoring of a tube fed resident with a stage IV pressure ulcer (Resident #111), inconsistent weight measurements for a newly admitted resident (Resident #121), missed nutritional assessments (Resident #89, #111) and the potential for unidentified weight loss, nutritional status decline, and unmet nutritional needs for all residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This resulted in an increased potential for contamination and a possible decrease in the satisfaction of living, affecting residents in following areas: Findings Include: During a tour of the facility, at 1:18 PM on 1/28/25, a review of empty resident room [ROOM NUMBER] found an accumulation of dust, dirt, sand, and dead ants under the register on the far side of the room. During a tour of the 600 hall spa room, by resident room [ROOM NUMBER], at 1:21 PM on 1/28/25, it was observed that the spa room was hot and humid upon entering the room. A temperature of the wall with an infra-red thermometer found it to be 82F with moisture dripping down the windowsills. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were in reach for 1 (Resident #27) of 5 residents reviewed for accommodation of needs, resulting in the inability to call for staff assistance, and potential unmet care needs.

Inspectors wroteThis citation pertains to Intake # MI00149017. Based on interview, and record review, the facility failed to report allegations of abuse to the State Agency in a timely manner in 2 of 2 residents (Resident #115 & #127) reviewed for abuse and reporting, resulting in the potential for additional allegations of abuse and to go unreported and delayed investigation.

Inspectors wroteBased on interview, observation and record review, the facility failed to complete Minimum Data Set (MDS) assessments that accurately reflect resident status in 1 of 25 residents (Resident #121), resulting in an inaccurate reflection of resident status and the potential for physical complications due to unidentified needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASARR) evaluation was completed for 1 (Resident #55) of 4 residents reviewed for PASARR Screening, resulting in the potential for unmet mental health and psychiatric care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive care plans in 3 of 25 residents (Resident #73, #97, & #27) reviewed for comprehensive care plans, resulting in the potential for unmet medical, physical, mental, and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for wound care and documentation of meal intake in 3 of 25 residents (Resident #230, #27, & #89) reviewed for professional standards, resulting in missed wound treatments and inaccurate documentation.

Inspectors wroteBased on interview and record review, the facility failed to properly assess a resident after a fall in 1 (Resident #48) of 25 residents reviewed for quality of care, resulting in a potential for unidentified injuries after a fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who was a trauma survivor received care and services that addressed their psychosocial needs for 1 (Resident #39) of 25 residents reviewed for trauma-informed care, resulting in a potential for Resident #39 to experience re-traumatization.

Inspectors wroteBased on interviews and record review, the facility failed to facilitate outside dental services in a timely manner for 1 of 1 residents (Resident #55) reviewed for dental care, resulting in Resident #55 having prolonged poor condition of teeth, and the potential for a life threatening infection.

Inspectors wroteBased on interview and record review, the facility failed to provide written notification of the facility bed hold policy upon discharge to an acute care hospital for 2 (Resident #102 and #103) of 3 residents reviewed for emergency hospital transfer resulting in the potential for unanticipated expense or the loss of desired room placement in the facility.

Inspectors wroteThis citation pertains to Intake: MI00147492 Based on interview and record review, the facility failed to address an acute change of condition and notify the physician of symptoms of increased lethargy (abnormal drowsiness), right upper extremity weakness, asymmetry (unequal) on the right side of face, decreased grip strength, increased pain, warmth, and swelling in the right knee in 1 (Resident #101) of 3 residents reviewed for quality of care, resulting in the delay of treatment and interventions in the diagnosis of subacute cerebral vascular accident (CVA) (Stroke) and acute RLE (right lower extremity) DVT (deep vein thrombosis).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident safety with eating assistance for 1 (Resident #101) of 4 residents reviewed for accidents/hazards resulting in the potential for accidents and serious injury.

Inspectors wroteThis citation pertains to Intake #MI00146336. Based on interview, and record review, the facility failed to provide adequate supervision to prevent elopement and respond appropriately to the alarm system in 1 of 3 residents (Resident #103) reviewed for wandering/elopement, resulting in Resident #103 exiting the facility unbeknownst to staff and the potential for injury.

Inspectors wroteThis citation pertains to Intake # MI00146994. Based on observation, interview, and record review, the facility failed to maintain complete and accurate medical records in 1 of 4 residents (Resident #107) reviewed for accuracy of medical records, resulting in an inaccurate behavior record and the potential for providers to not have an accurate picture of resident status and condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement posted transmission-based precautions and don required Personal Protective Equipment (PPE) prior to entering COVID-19 positive resident rooms in 2 of 2 rooms reviewed for transmission-based precautions, resulting in the potential for cross-contamination and the development and spread of infection to a vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and ensure the right to safe self-administration of medication in 1 (Resident #105) of 3 residents reviewed for medication administration, resulting in the potential for unsafe self-administration of medication, medication errors, and medications not being stored in a secure manner.

Inspectors wroteThis citation pertains to intake: MI00143463. Based on interview and record review, the facility failed to respond timely to a request for medical records in 1 (Resident #105) of 6 residents reviewed for resident rights, resulting in delayed access to the resident's medical records and resident frustration.

Inspectors wroteThis citation pertains to intake: MI00143329. Based on interview and record review the facility failed to implement their Abuse and Neglect policy following an incident of visitor to resident verbal abuse in 1 (Resident #104) of 6 residents reviewed for abuse resulting in a delay in reporting the Facility Reported Incident (FRI) to the State Agency and a delay in the removal of the visitor pending an investigation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care planned interventions or document refusals of care planned interventions to prevent further skin breakdown for 1 (Resident #109) of 3 residents reviewed for pressure ulcer prevention, resulting in the potential for further skin breakdown, worsening of existing pressure ulcers, infection, and overall deterioration in health status.

Inspectors wroteThis citation pertains to intake: MI00142037. Based on interview and record review, the facility failed to ensure timely and consistent documented follow-up by a qualified nutrition professional following significant weight loss and skin breakdown in 1 (Resident #101) of 3 residents reviewed for nutritional care resulting in undocumented re-evaluation and assessment of resident nutritional needs and care and the potential for unmet nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to provide a written reason and/or give notifications of the transfer/discharge for 3 residents (#48, #72, & #115 ) reviewed for hospitalizations/transfers/discharges, resulting in the Long-Term Care Ombudsman not being notified of transfers/discharges and the potential for residents and/or family being un-informed of the reason for transfer/discharge.

Inspectors wroteBased on observation, interview and record review the facility failed to follow standards of practice and ensure 1.) proper hand hygiene was completed during meal services, as well as when staff entered and exited resident rooms which included Transmission Based Precaution (TBP) rooms for residents with infections including but not limited to Covid-19 2.) failed to ensure required PPE supplies/equipment were available to staff and visitors for use prior to entering TBP rooms, resulting in the potential for the introduction of infection, cross-contamination, and disease transmission.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were in reach for 1(Resident #105 ) of 2 residents reviewed for accommodation of needs resulting in the resident's inability to call for staff assistance with the potential for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to obtain a resident's advanced directive (Code status) for 1 resident (R228) of 25 residents reviewed for advanced directives resulting in the potential for failing to follow the resident's code status wishes.

Inspectors wroteBased on interview, and record review, the facility failed to notify the responsible party of a change in resident condition in 1 of 25 residents (R99) reviewed for notification of changes, resulting in the resident representative not being made aware of a dental abscess resulting in the lack of ability to participate in timely medical decision-making.

Inspectors wroteResident #76 Review of an admission Record revealed Resident #76 was a male, with pertinent diagnoses which included: mild cognitive impairment and psychotic disorder with delusions. On 1/10/24 at 1:08 PM, Resident #76's medical record was reviewed for evidence of facility coordination with OBRA (Omnibus Budget Reconciliation Act) for Preadmission Screening and Annual Review (PASARR) Level II screening. A review of a document dated 9/12/22 from State of Michigan Department of Health and Human Services for Resident #76 revealed, To Whom It May Concern: (OBRA Representative name omitted) completed an OBRA Level II Evaluation on the above-named individual and made the recommendation on placement and services. [...]

Inspectors wroteThis citation pertains to intake MI00141497. Based on interview, and record review, the facility failed to implement an effective discharge planning process and complete an accurate discharge plan of care in 1 of 2 residents (R128) reviewed for discharge, resulting in the resident being discharged without planned housing or medical care.

Inspectors wroteBased on observation, interview, and record review, the failed to 1.) perform neurological checks after falls for 2 (Resident #110 and #70) of 25 sampled residents, and 2.) ensure that a provider assessment was completed when requested by the Registered Dietician for 1 (Resident #70) of 25 sampled residents reviewed for quality of care resulting in the lack of assessment, monitoring, and documentation and the potential for the worsening of a medical condition and the delay in treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to clean and store BiPAP (bilevel positive airway pressure) equipment (a treatment used for sleep apnea - pressurized air is provided through a mask to prevent collapse of the airway) according to the physician's order for 1 resident (Resident #91) of 1 resident reviewed for respiratory care, resulting in an increased potential for respiratory infection and respiratory distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate pain monitoring and management for 1 resident (R99) of 25 residents reviewed for pain management, resulting in unrelieved dental pain that impacted the resident's eating and functional status of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate dental extraction services, for 1 resident (R99) of 1 resident reviewed for dental care, resulting in delayed dental services and treatment, on-going tooth pain, and an abscessed tooth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received food in an appropriate texture to optimize intake and meet individual needs for 1 resident (R99) of 25 residents reviewed for food and drink, resulting in food being difficult to chew and decreased food acceptance.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in 1 (Resident #24) of 25 residents reviewed for accuracy of medical records, resulting in the potential for providers to not have an accurate picture of resident status and condition.

Inspectors wroteThis citaiton pertains to intake number MI00134147. Based on interview and record review, the facility failed to monitor and treat pressure ulcers per nursing professional standards for 1 resident (R110) of 3 reviewed for pressure ulcers, resulting in the worsening of a pressure ulcer with the potential for infection and overall deterioration of health status.

Inspectors wroteThis citation pertains to MI00132640. Based on interview and record review, the facility failed to ensure post dialysis communication, assessment, and monitoring for 1 Resident (Resident #115) of 11 resident reviewed for quality of care, resulting in the potential for the resident to not meet her highest practicable physical, mental, and psychosocial well-being.