Optalis Health and Rehabilitation at St. Francis

Inspectors wroteThis citation pertains to Intake Number 3027112. Based on interview and record review, the facility failed to ensure physician orders were followed for the timely testing and reporting results of residents' blood tests for three residents (#s 101, 106 and 107) of four residents reviewed for anticoagulant therapy (prevents blood from clotting) resulting in delays in evaluation and treatment for R101, R106 and R107 and the death of R101. Findings Include: A record review revealed Resident #101 who was receiving anticoagulant therapy did not receive the ordered timely testing and reporting of test results since admission into the facility. Additional record review indicated that Resident #101 was subsequently hospitalized and died due to a large brain bleed from decreased blood clotting. The Immediate Jeopardy (IJ) began on [DATE]. The Immediate Jeopardy (IJ) was identified on [DATE]. [...]

Inspectors wroteThis citation pertains to Intake Number 2997890. Based on observations, interview and record review, the facility failed to ensure that one resident (Resident #2) had an appropriate call light to meet his safety needs, and that one resident's (Resident #6) call light was within reach of two residents reviewed for accommodations of needs. Findings Include:Resident #2:On 5/6/2026 at approximately 2:15 PM, an audit of call light functionality was completed of resident rooms with Maintenance Staff C. It was found that room [ROOM NUMBER]-2 (Resident #2) did not have a call light and there was a black dowel in the call light panel on the wall (where the call light cord would connect into). Resident #2 was asked where his call light was and he stated he did not have one as the facility thought he was going to hang himself, so they (the facility) took it from him and never gave it back. [...]

Inspectors wroteBased on observation and interview, the facility failed to have results of the most recent survey readily accessible to facility residents, their families, and their legal representatives. Findings Include:On 5/7/2026 at approximately 11:00 AM, Family Member A shared that for the past two weeks they have been unable to locate the survey results book. They stated It is typically located in the lobby, underneath the bulletin board, on a brown high-top table. The area the family member referenced was observed and there was no book/binder with the survey results located. Receptionist B (located just inside the main office) was queried if she knew where the survey results binder was relocated too? She reported it was on the high-top table in the lobby. She was informed it was not there. She searched for the book in her area and could not locate it. [...]

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 who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have1) An active 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 waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. 2) Adequate staff hand hygiene during dining service,3) Nursing staff to clean glucose monitors and equipment after use, resulting in the potential for the spread of organisms and infection to all residents and staff.

Inspectors wroteBased on observation and record review, the facility failed to ensure that appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for contamination to the water supply, affecting all residents.

Inspectors wroteBased on interview and record review, the facility failed to provide nursing services for 9 residents (#19, #48, #42, #58, #93, #83, #84, #86, #89) residing on the [NAME] Nursing Unit, resulting in residents to missing medications, blood glucose monitoring, skilled charting assessments and vital signs.

Inspectors wroteBased on observation, interview and record review, the facility failed to label medications appropriately, dispose of expired medications, ensure the safe storage of medication and supplies, and ensure unlicensed staff did not have access to medication storage areas, for two of four medication carts and one of two medication rooms reviewed for medication storage and labeling.

Inspectors wroteBased on interview and record review, the facility failed to honor one resident's (Resident #25) wishes to discontinue a medication and obtain an informed consent for a dosage change of one resident reviewed for choices.

Inspectors wroteBased on observation, interview and record review the facility failed to timely refill one resident's (Resident #50) Sevelamer (medication used to control high blood levels of phosphorous) of five residents reviewed for dialysis, resulting in Resident #50 being without the medication since approximately January 17, 2026. Findings IncludeResident #50: On 2/10/2026 at approximately 9:15 AM, Resident #50 was observed in his room. He stated he was waiting to be transported to dialysis. Resident #50 was his own person and able to make his needs know to facility staff. Further review of his records yielded the following: [...]

Inspectors wroteThis citation pertains to Intake Number 2721708 and the recertification survey. Based on observation, interview and record review, the facility failed to provide adequate nursing staff to ensure that the needs of their residents were met for 7 residents (#16, #40, #41, #43, #51, #87, #88) and residents identified through confidential family interviews, resulting in insufficient and unmet resident care needs, feelings of frustration, and complaints about not enough staff.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures for antidepressant medication use for one resident (Resident #8) of 4 residents reviewed resulting in a lack of Gradual Dose Reduction (GDR), and the potential for ineffective and inappropriate treatment.

Inspectors wroteThis citation pertains to intake Numbers 2708679 & 2708703. Based on observation, interview, and record review, the facility failed to implement appropriate enhanced barrier precautions (EBP) for one resident (Resident #103), identified with an indwelling percutaneous endoscopic gastrostomy (PEG) tube, of three residents reviewed for infection prevention.

Inspectors wroteThis citation pertains to Complaint Number 2644043. Based on interview and record review, the facility failed to reimburse trust funds for one resident (Resident #1) of three residents reviewed for trust funds, resulting in trust funds not being reimbursed upon death.

Inspectors wroteThis citation pertains to Intake #1230868. Based on observation, interview and record review, the facility failed to 1) Ensure that nursing staff gave appropriate care for failure, 2) Ensure that nursing staff completed a respiratory assessment during a respiratory crisis, and 3) Ensure that nursing staff followed facility nursing care plan for 1 resident (Resident #105) of 3 residents reviewed for nursing care, resulting in pulmonary edema, HH (excessively high) CO2 (Carbon Dioxide-lab) blood level, hypoxia, pneumonia, acute respiratory distress, hospitalization, respiratory failure with the high likelihood of death. [...]

Inspectors wroteThis citation pertains to Intake Number MI00150995. Based on observation, interview and record review, the facility failed to ensure supervision for 1 resident (Resident #101) with a known history of falls prior to admission and after admission (who fell on 3/4/25, with a facial injury) of 3 resident's reviewed for falls, resulting in a contusion above the left eye, skin tear on bridge of nose, pain and hospitalization. Findings Include: Resident #101: [...]

Inspectors wroteThis Citation pertains to Intake Number MI00150622. Based on observation, interview and record review, the facility failed to ensure that medications were administered to 4 residents (#702, #703, #704, #705) of 5 sampled residents, and 10 unsampled residents, resulting in multiple residents not receiving their 5:00 PM medications on 02/25/2025.

Inspectors wroteThis Citation pertains to Intake Number MI00149640. Based on interview and record review the facility failed to address the disparities in one resident's (Resident #701) significant weight fluctuations over a short time period of one resident reviewed for weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent a Stage III coccyx pressure ulcer from developing for 1 resident (Resident #76), and failed to implement meaningful and planned interventions for 1 resident (Resident #332), of 2 residents reviewed for pressure ulcers, resulting in a Stage III infected pressure ulcer, IV antibiotic usage, and hospitalization with the potential for delayed healing of pressure ulcers. Findings Include: Review of hospital records dated 1/22/25, stated The patient had Covid and pneumonia in December (2024) and was admitted from 12/7/24 to 12/26/24 and has been in rehabilitation (living at the facility) until today. [...]

Inspectors wroteBased on interview, and record review, the facility failed to complete a performance review every 12 months for five Certified Nurse Aides (CNA's S, T, U, V, & X) of 5 reviewed for an annual performance review. This deficient practice resulted in the potential for inadequate and unmet resident care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for medication and medical supply labeling, storage, and disposal in one of one medication rooms and two of two medication carts reviewed, resulting in a medication cart being left unlocked and unattended, a lack of dating of medications with specified time frames for use after opening, expired medications, open and undated medications, and the potential for residents to receive medications with altered efficiency.

Inspectors wroteThis Citation Pertains to Intake Number MI00149278. Based on observation, interview and record review, the facility failed to ensure the provision of bathing and hygiene care for two residents (#7 and #59) of four residents reviewed, resulting in a lack of bathing/showers, nail care, and personal hygiene.

Inspectors wroteBased on observation and record review the facility failed to ensure nursing assessments were completed for two residents (#71 and #231) of three residents reviewed for assessment and monitoring, resulting in a delay in assessment and treatment for bowel management and skin/back rash of Residents #71 and #231. Findings Include: Resident #231: During initial tour on 1/21/2025, Resident #231 shared she developed a rash on her coccyx that extends to her back from the briefs used daily for incontinence care. She continued the rash is the shape of the brief and rom what staff from told her the rash is reddened with small bumps. She continued the rash was causing her great discomfort, but nursing staff mixed a cream to assist. On 1/2/2025 at 11:50 AM, Nurse P stated Resident #231's mid to lower back was reddened and it is in the same area where the brief would sit. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to implement and operationalize policies and procedures to ensure safe care and maintenance of PowerMidline (intravenous (IV) catheter inserted in the arm with the tip of the catheter positioned near the axillary for long term IV treatment) use and care per professional standards of practice and manufacturer's recommendations for one resident (Resident #61) of one resident reviewed, resulting in improper IV medication reconstitution, inappropriate PowerMidline flushing technique, lack of infection control standards, and the potential for infection, phlebitis (inflammation in vein), embolism (blockage in blood vessel), infiltration (medication administration into surrounding tissue), unnecessary pain and decline in overall health.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide behavioral health care and services for one resident (Resident #332) of one resident reviewed, resulting in a lack of timely and ongoing assessment of distress related to adjustment, timely evaluation for consent to receive behavioral health services, and expressions of emotional and psychosocial distress.

Inspectors wroteThis citation pertains to Intake Number MI00148817. Based on observation, interview and record review the facility failed to maintain sanitary conditions in the kitchen and nourishment rooms, resulting in improper kitchen sanitization of all kitchenware utilized to prepare and plate residents' meals, and soiled floors and ice machine for all residents who consume meals from the kitchen. Findings Include: On 12/23/2024 at 3:00 PM, the kitchen was toured in the presence of Dietary Manager N and the following was observed: -Used gloves on the ground behind the handwashing sink and stove. -Container of oats lid was not secured. -Floor by stove had multiple brown/orange dried substances stains scattered throughout the area. -Floors by three compartment sink was visibly soiled with dirt, debris and food particles. -Vents are soiled with thick dust particles on juice machine controller. [...]

Inspectors wroteThis citation pertains to Intake Numbers MI00148129 and MI00148412. Based on observation, interview and record review, the facility failed to ensure a clean environment for all residents who use the main dining room, the main activity room and eleven residents' rooms, resulting in dust-filled heater covers and ceiling vents, cobwebs and spiders, dirty floors/base boards and ceiling/roof leakage.

Inspectors wroteThis citation pertains to intakes MI00147160 and MI00148129. Based on observation, interview, and record review, the facility failed to ensure dignity and a clean urinal for one resident (Resident #9) out of twelve residents reviewed for dignity, resulting in the use of an old discolored and dirty urinal.

Inspectors wroteThis citation pertains to Intake Number MI00147389. Based on interview and record review, the facility failed to treat pain timely for one resident (Resident #4) of three residents reviewed for pain control, resulting in unwanted pain, crying and no pain medication offered for nearly 10 hours.

Inspectors wroteThis citation pertains to Intake Number MI00148129. Based on observation, interview and record review, the facility failed to ensure medication administration for one resident (Resident #14) out of three residents reviewed for medication administration, resulting in pills spilled onto the floor and a medication cup with pills at the bedside and not consumed.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent and document the occurrence of a skin abrasion and Deep Tissue Injury (DTI) for one resident (Resident #1) and the development of pressure ulcers for one resident (Resident #2), resulting in Resident #1 to be found with an abrasion to the left lateral hip and right heel deep tissue injury and Resident #2 developing a pressure ulcer to the left heel as a deep tissue injury and increased to a Stage III pressure ulcer and, also, the left foot 5th toe pressure ulcer to develop and increase in size to a Stage II pressure ulcer, resulting in skin breakdown, pain, the likelihood for infection and diminished overall health and wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide consistent incontinence care for two dependent residents (Resident #1, Resident #4), resulting in verbal complaints of incontinence care not received, frustration, embarrassment and the likelihood for skin breakdown.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to provide hand hygiene with meals for residents, 2) Failed to label open food items, clean dirty/unsanitary food surface, proper drying of dishware and no back flow protect on steam table, cover sliced cheese/clean mop bucket, and 3) Failed to ensure proper food storage of dairy products for cold food service and did not routinely check temperatures of cold food items for 79 of 83 residents who consume oral food items.

Inspectors wroteBased on observation, interview and record review, the facility 1) Failed to provide hand hygiene with meals for 79 of 83 residents who consume oral foods, and staff cross contamination with resident meals and 2) A Certified Nurses Aide failed to ensure appropriate PPE use, resulting in cross contamination of organisms.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure accuracy of a Minimum Data Set (MDS) assessment for one resident (Resident #5) reviewed for MDS assessments, resulting in Resident #5 being coded under Section I (Active Diagnoses) as being diagnosed with Schizophrenia when that was not one of his DSM diagnosis. Findings Include: Resident #5: During initial tour on 1/29/2024, Resident #5 was observed watching television in his room. As this writer spoke to him, he appeared to be somewhat guarded but communicated no concerns regarding his stay at the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to shave one resident (Resident #328) out of 21 residents reviewed for Activities of Daily Living (ADL) care, resulting in unwanted facial whiskers.

Inspectors wroteThis Citation pertains to Intake Number MI00137559 Based on interview and record review the facility failed to provide a comprehensive discharge for one resident (Resident #278) of five residents reviewed for discharge planning, resulting in, Resident #278 being discharged from the facility without prescribed pain medications as indicated in his discharge summary and appropriate referral to DME (Durable Medical Equipment) company for recommended therapy equipment. Findings Include: Resident #278: On 1/30/2024 at 8:15 AM, an interview was conducted with the complainant regarding Resident #278's discharge from the facility in May 2023. It was shared the resident admitted to the facility after a knee surgery for therapy and was discharged back to his Adult [NAME] Care (AFC) home, but the facility failed to send his prescriptions for pain medications. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow care plan interventions and document self-ambulation for one resident (Resident #24), resulting in a near fall, unassisted ambulation and Activities of Daily Living (ADL.).

Inspectors wroteBased on observation, interview and record review the facility failed to timely notify and obtain physician's consent prior to administration of a medication with the potential for a drug allergy for one resident (Resident #25) of three residents reviewed for antibiotic usage, resulting in Keflex being pulled from the facility's back up box and administered to Resident #25 prior to the physician's verification for contraindicated antibiotic therapy. Findings Include: Resident #25: During initial tour on 1/29/2024, Resident #25 was observed sleeping peacefully in bed. On 1/29/2024 at approximately 11:58 AM, a review was conducted of Resident #25's medical records and it revealed she admitted to the facility on [DATE] with diagnoses that included Heart Failure, Atrial Fibrillation, Cerebral Infarction and Peripheral Vascular Disease. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed properly administer medications to two residents (Resident #21, Resident #64), resulting in the wrong medications being administered.

Inspectors wroteBased on observation and interview, the facility failed to provide palatable timely meals, for Resident #16 and Resident Council members, resulting in breakfast meals served cold and not fully cooked and late cold dinners.