Optalis Health & Rehabilitation at Leonard

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure menus were consistently followed for 5 (Residents #26, 50, 55, 3, and 63) of 15 residents reviewed for dining and 9 of 11 residents from a confidential resident council meeting with the potential to affect all residents who consume food/beverages from the facility's kitchen resulting in dissatisfaction with meals, being provided incorrect foods, and/or being provided incorrect serving sizes with the potential for decreased oral intake and weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food preferences were consistently honored for 4 (Residents #26, 1, 24, and 50) of 15 residents reviewed for dining and 11 of 11 residents from a confidential resident council meeting resulting in dissatisfaction with meals and the potential for decreased oral intake and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure: 1.) facility staff's use of Personal Protective Equipment (PPE) for enhanced barrier and transmission based precautions, 2.) cleaning of shared resident equipment, and 3.) cleaning of respiratory equipment for 5 (Residents #17, #30, #50, #39 and #5 ) of 24 resident reviewed for infection control practices, 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 provide care and services to promote dignity and respect in 1(Resident #39) of 24 residents reviewed for reviewed for dignity and respect ; and 6 of 11 residents from the confidential group meeting resulting in unmet care needs and the potential for feelings of diminished self-worth, sadness, and frustration.

Inspectors wroteBased on observation, interview and record review, the facility failed to honor resident preferences for customary routines and activities for 1 (Resident #39) of 24 reviewed for self-determination resulting in feelings of frustration and the potential for diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident rooms were kept clean and in good repair for 3 (Resident #21, #22 and #30) of 24 Residents reviewed for home-like environment, resulting in emotional distress and a potential for increased risk of infection and/or injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper discharge notifications were completed in 1(Resident #39) of 2 residents reviewed for discharge process, resulting in Resident #39 not receiving written notice of bed hold when she was discharged from the facility to the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice for medication administration that included administration and monitoring of a narcotic medication by a licensed professional in 1 (Resident #20) of 5 residents reviewed for medication administration, resulting in the potential for narcotic diversion, unrelieved pain, and the worsening of medical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate Activities of Daily Living (ADL) care (provide showers and/or washing hair) for 2 (Residents #39 and Resident #21) of 4 residents reviewed for ADL care, resulting in the potential for avoidable negative physical and psychosocial outcomes for resident's who are dependent on staff for assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure implementation of resident-specific comprehensive care plans for 2 residents (R13 and R52), and prevent the development of a pressure ulcer for 1 resident (R13) of 4 residents reviewed for pressure ulcers, resulting in the development of a pressure ulcer for R13 and the potential for skin breakdown for R52.

Inspectors wroteThis citation pertains to intake #MI00151905 Based on interview, and record review, the facility failed to provide adequate supervision in 1 resident (Resident #101) of 3 residents, reviewed for elopement, when Resident #101, who was actively exit seeking and a high fall risk, exited the facility unattended on 3/27/25 and descended 16 concrete steps to a parking lot, resulting in the potential for serious injury and/or harm.

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 from the kitchen.

Inspectors wroteThis deficient practice has two DPS's: DPS A Based on observation, interview, and record review, the facility failed to implement posted Enhanced Barrier Precautions (EBP) and don required Personal Protective Equipment (PPE) prior to providing direct resident care in 4 of 5 residents (Resident #9, #35, #24, & #10) reviewed for Enhanced Barrier Precautions, resulting in the potential for cross-contamination and the development and/or spread of infection to a vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to update and revise the person centered care plan in a timely manner with appropriate interventions for 2 (Resident #3 and Resident #25) of 2 residents reviewed for comprehensive care plans, resulting in inaccurate reflection of the resident's status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistance with activities of daily living (ADL), specifically personal hygiene (shaving) and changing resident clothes daily were provided for 2 of 4 residents (Resident #13 and Resident #54) reviewed for ADL care, resulting in unmet care needs and the potential for avoidable declines in overall health and wellness.

Inspectors wroteThis citation pertains to Intake # MI00146840. Based on observation, interview, and record review, the facility failed to implement consistent venous ulcer interventions, monitoring, and treatments consistent with physician orders for 1 of 5 residents (Resident #34) reviewed for wounds, resulting in the potential for worsening of wounds and further skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plan interventions to prevent worsening of contractures for 1 (Resident #13) of 2 residents reviewed for range of motion resulting in the potential for worsening of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue often leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequate respiratory care in 1 (Resident #35) of 1 resident reviewed for tracheostomy (surgical opening in the neck to help with air passage) care, resulting in breathing complications and risk for infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide or use adaptive feeding equipment correctly for 1 residents (Resident #25) of 1 residents reviewed for adaptive equipment needs, resulting in the potential for decreased independence of consuming food and fluids and weight loss.

Inspectors wroteThis citation pertains to intake MI00144400 Based on observation, interview, and records review, the facility failed to safely transfer 1 of 3 residents (Resident #101) resulting in a fall and serious injury requiring a transfer to the hospital, and surgery to treat a distal left femoral (upper leg) fracture.

Inspectors wroteBased on observations, interview, and record review the facility failed to provide activities of daily living care, including bathing, grooming for 3 residents (Resident #11, Resident #41, and Resident #16) of 15 sampled residents resulting in feelings of frustration, anxiety and self-consciousness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff to meet resident needs in 4 of 9 residents (Resident #10, #11, #16, & #41) reviewed for sufficient staffing, resulting in long call light wait times, incontinence with feelings of embarrassment, missed showers/baths, and the potential for additional unmet needs.

Inspectors wroteBased on observation and interview the facility failed to employ either a full time Registered Dietitian or Certified Dietary Manager to provide oversight of kitchen and clinical nutritional services. This deficient practice has the increased potential to result in food service sanitation failures, food borne illness, or inadequate assessment of high-risk residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were followed to ensure adequate cleanliness of resident shared equipment (transfer lifts) which was reviewed for infection control resulting in the potential for bacterial harborage, cross contamination, and the spread of disease to a vulnerable population.

Inspectors wroteThis citation pertains to Intake # MI00139675. Based on interview, and record review, the facility failed to prevent misappropriation of a residents' narcotic (controlled substances) medications for 1 (Resident #163) of 4 residents reviewed for abuse/misappropriation resulting in missing pain medication, and the potential for uncontrolled pain and discomfort.

Inspectors wroteBased on interview, and record review, the facility failed to maintain complete and accurate medical records for 2 residents (Resident #16 and Resident #40) of a total sample of 15, resulting in a potential for delay in treatment or inappropriate treatment during an emergency.