Optalis Health and Rehabilitation of Grand Rapids

Inspectors wroteThis citation pertains to intake 3001998. Based on observation, interview, and record review the facility failed to initiate emergency medical services (EMS) and start cardiopulmonary resuscitation (CPR; an emergency lifesaving procedure performed when a person's heartbeat or breathing has stopped) timely for 1 (Resident #302) of 5 residents reviewed for life sustaining measures, resulting in an Immediate Jeopardy when, on [DATE], Resident #302 who was a full code, was found unresponsive and staff delayed EMS initiation for approximately 34 minutes and provided limited life sustaining measures were attempted by facility staff prior to EMS arrival. Resident #302 was pronounced dead on [DATE] by EMS personnel. This deficient practice is likely to cause serious harm, injury and/or death for the additional 51 of a total of 98 residents who have been deemed to have full code status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate staffing to promote the physical, mental, and psychosocial well-being in 2 of 13 residents (Resident #306 and Resident #309) reviewed for staffing, resulting in unmet care needs and the potential for physical and psychosocial harm for all residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to implement its quality assurance and performance improvement policy with the potential to affect all residents of the census of 98 resulting in an adverse event not being thoroughly investigated and the potential for further repeat deficiencies and/or adverse events.

Inspectors wroteBased on interview and record review, the facility failed to maintain accurate medical records for 6 (Resident #301, #306, #309 #311, #312 and #313) residents out of a total of 13 residents reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to promote dignity and respect in 2 (Resident #306 and Resident #309) of 5 residents reviewed for dignity resulting in unmet care needs, feelings of diminished self-worth, sadness, and frustration.

Inspectors wroteThis citation pertains to intake 3026395. Based on interview and record review the facility failed to release medical records upon request for 1 (Resident #302) of 3 residents reviewed for access of resident records resulting in being unable to obtain and review requested records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for 1 (Resident #309) of 11 residents reviewed for abuse and neglect resulting in Resident #309 being left in a soiled brief for several hours, experiencing feelings of humiliation and dehumanization, and having his repeated verbal expressions for help go unanswered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement policies and procedures of reporting an allegation of neglect in 1 (Resident #309) of 11 residents reviewed for abuse and neglect timely to the State Agency resulting in the allegation not being thoroughly investigated and the potential of further occurrences of neglect to continue.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and thoroughly investigate an allegation of neglect for 1 (Resident #309) of 11 residents reviewed for abuse and neglect resulting in an allegation of neglect going unaddressed and the potential for ongoing neglect due to an incomplete investigation.

Inspectors wroteBased on observation and interview, the facility failed to properly secure medications in two of five medication carts resulting in the potential for the compromise of medications, accidental indigestion, and/or misappropriation of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during wound care dressing changes in 3 (Residents # 306, #311, and #312) of 3 residents reviewed for wound care resulting in the potential for the introduction of infection, cross-contamination, and disease transmission.

Inspectors wroteThis citation pertains to Intake # 2977605. Based on interview, and record review, the facility failed to follow professional standards of practice to ensure safety in 1 of 3 residents (Resident #102) reviewed for safety/supervision, resulting in the lack of a comprehensive assessment for injury by a licensed nurse post-fall and the potential for injury.

Inspectors wroteThis citation pertains to Intake # 2977605. Based on interview, and record review, the facility failed to ensure baths/showers were provided per resident preference and plan of care in 1 of 4 residents (Resident #102) reviewed for Activities of Daily Living (ADL) care, resulting in the potential for dissatisfaction with care, hygiene concerns, skin irritation, and low self-esteem.

Inspectors wroteThis citation pertains to intake 2990940 and 2970809. Based on interview and record review, the facility failed to maintain accurate medical records for 3 (Resident #101, #103 and #105) of 5 residents reviewed for complete and accurate medical record documentation, resulting in staff and providers mismanaging care for residents.

Inspectors wroteThis citation pertains to intake #2740840 and #2788540. Based on interview and record review, the facility failed to prevent the worsening of pressure injuries in 2 residents (Resident #104 & #101) of 5 residents reviewed for pressure ulcers, resulting in harm to Resident #104 when staff did not transcribe and enter hospital wound instructions, did not perform an initial wound assessment, and did not ensure measures were in place to promote healing of an Unstageable pressure injury (a full-thickness wound where the true depth and extent of tissue damage cannot be determined because the wound bed is covered by slough (moist dead tissue), eschar (crusty dead tissue), or both) on sacrum (tailbone) which led to hospitalization for sepsis (life threatening condition due to infection) due to wound infection. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a call light was within reach for 1 (Resident #110) of 3 residents reviewed for accommodation of needs, resulting in the potential for the resident to not meet their highest practicable level of well-being.

Inspectors wroteThis citation pertains to intake #2740840. Based on interview and record review, the facility failed to ensure medical records were complete and accurate for 1 resident (Resident #101) of 5 residents reviewed for skin and wound documentation, resulting in the potential for staff and providers mismanaging the necessary care and treatments of residents.

Inspectors wroteThis citation pertains to intakes: 2694470 and 2685061Based on interview and record review the facility failed to perform cardiopulmonary resuscitation (CPR) on [DATE] for 1 (Resident #13) of 1 resident reviewed for code status (medical orders that indicate a resident's preference for treatment in a medical emergency) orders, resulting in an immediate jeopardy when Resident #13 was found unresponsive and subsequently died.

Inspectors wroteThis citation pertains to Intakes: 2663490, 2673806. Based on interview and record review, the facility failed to protect the residents' right to be free from resident to resident and staff to resident physical abuse for 3 (Resident #1, Resident #2, and Resident #9) of 8 residents reviewed for abuse, resulting in Resident #1 being struck by Resident #2 and Resident #9 being struck by a staff member. Review of Incident Summary dated 10/16/25 at 9:47 PM, revealed, .CNA (Certified Nursing Assistant) heard resident (Resident #1) yelling No, No, no stop; CNA went to source of yelling and observed (Resident #2) smack (Resident #1) on the mouth. Both residents immediately separated. (CNA U) was interviewed and stated that she was rounding on her residents and when she arrived at the room of (Resident #1), she heard her state, No, No, No. [...]

Inspectors wroteThis citation pertains to intake 2615390Based on interview and record review the facility failed to prevent misappropriation of narcotic medications for 2 (Resident #7 and Resident #8) of 2 residents reviewed for misappropriation of personal property, resulting in the potential for ineffective pain management.

Inspectors wroteThis citation pertains to intake # 2673806Based on interview and record review, the facility failed to thoroughly investigate an allegation of staff-to-resident abuse for 1(Resident #9) of 8 residents reviewed for abuse, resulting in an incident of staff-to-resident physical abuse not being identified due to a lack of thorough investigation, and a potential for additional abuse to go unrecognized.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of nursing practice for medication administration for 1 of 1 residents (Resident #11) reviewed for medication administration resulting in the not following the physician's order for administration, administering a medication late and not contacting the provider and the potential for affected resident not maintaining or achieving their highest practical physical well-being.

Inspectors wroteThis citation pertains to Intake: 2611992 Based on observation, interview and record review, the facility failed to assess, monitor, document, and provide treatment per professional standards of practice for 1 resident (Resident #11) of 1 resident reviewed for quality of care, resulting in hospitalization for fecal impaction, potassium levels at a dangerous level, and implementation of treatment of weeping wounds with a potential for a decline in overall physical, mental, and psychosocial well-being.

Inspectors wroteThis citation pertains to Intake: 2611992 Based on observation, interview, and record review, the facility failed to ensure appropriate external catheter care, monitoring, and cleaning for 1 (Resident #11) of 1 resident reviewed for catheter care, resulting in the potential of a urinary tract infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents receives necessary respiratory care and services that is in accordance with professional standards of practice for 1 (Resident #104) of 1 resident reviewed for respiratory care resulting in the potential for respiratory distress and exacerbation of respiratory conditions.

Inspectors wroteBased on observation and interviews, the facility failed to ensure current daily facility staffing hours were posted in a prominent location readily accessible to residents, staff, and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident food choices were obtained and honored for 1 (Resident #11) of 1 resident reviewed for meal services, resulting in resident dissatisfaction with their meal experience and the potential for inadequate food/fluid intake.

Inspectors wroteThis citation pertains to intake 2648348 and 2640731. Based on interview and record review, the facility failed to ensure residents were free from significant medication errors in 1 of 6 residents (Resident #101) reviewed for medication administration resulting in an Immediate Jeopardy beginning on 10/9/25 at approximately 9:00 AM when Resident #101 received another resident's medications which were administered by an agency nurse and nursing student. Resident #101 was found approximately one hour later and was noted to be lethargic and was hospitalized from [DATE]-[DATE] where she was diagnosed with acute metabolic encephalopathy (significant decline in brain function due to an underlying metabolic disturbance) and iatrogenic polypharmacy (harm caused by the administration of multiple medications). [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure Certified Nursing Assistants (CNA's) yearly performance review was conducted resulting in the potential for CNA's to not be able to safely provide necessary care and services to residents, a lack of training, and the potential for unmet care needs.

Inspectors wroteThis citation pertains to intakes 2648348 and 2640731. Based on interview, and record review, the facility failed to administer the facility in a manner that ensures the highest practicable physical well-being of each resident by: [...]

Inspectors wroteBased on interview and record review, the facility failed to review and update the facility assessment after changes which would require substantial modification which includes an assessment of policies and procedures, training programs, education, training and competencies of direct care staff- both employees and those who provide services under contract, and contracts/memorandums of understanding or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies resulting in the potential for unidentified resources necessary to provide care and services to the resident populationFindings include: [...]

Inspectors wroteBased on interview, and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for Certified Nursing Assistants (CNA's) as determined by the yearly performance review, and ensure a total of 12 hours of yearly education, resulting in the potential for CNA's to not be able to safely provide necessary care and services to residents, a lack of training, and the potential for unmet care needs.

Inspectors wroteThis citation pertains to intake 2597303. Based on observation, interview, and record review the facility failed to ensure appropriate supervision and assistance was provided during toileting for 1 (Resident #503) of 3 residents reviewed for falls resulting in a head injury, fracture of a patella (kneecap), and pain.

Inspectors wroteThis citation pertains to intake 2602017Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 (Resident #504) of 3 residents reviewed for abuse resulting in an of injury of unknown origin not being reported to the state agency.

Inspectors wroteThis citation pertains to intake 2602017Based on interview and record review, the facility failed to identify and thoroughly investigate an injury of unknown origin for 1 (Resident #504) of 3 residents reviewed for abuse, resulting in the potential for ongoing injuries due to an incomplete investigation of an injury of unknown origin.

Inspectors wroteThis citation pertains to intake 2602017Based on interview and record review the facility failed to accurately and thoroughly assess, adequately monitor and provide quality care and treatment for pressure ulcers for 1 of 3 residents (Resident #504) reviewed for wound care resulting in the potential of worsening of a pressure wound.

Inspectors wroteThis citation pertains to intake 1214303, 1214279, and 2588205. Based on observation, interview and record review, the facility failed to provide sufficient nursing staff for 93 of 93 residents who reside in the facility, resulting in unmet care needs, as identified by the issues ascertained during the survey that included long call light wait times, residents left in soiled briefs for extended periods of time, residents missing showers and missing other activities of daily living (ADL) care, residents missing medications, treatments, and neurological assessments after falls, nursing staff feeling frustrated, overworked, exhausted, and management staff not available to assist direct care staff with Residents' care and needs, affecting the physical, mental, and psychosocial well-being of all 93 residents residing in the facility.

Inspectors wroteThis citation pertains to intake 2583410 and 1214279. Based on observation, interview, and record review, the facility failed to provide respectful and dignified personal care and services for 4 (Resident #102, #103, #106, and #107) of 6 residents reviewed for dignity, resulting in unmet care needs, and feelings of diminished self-worth, sadness, and frustration.

Inspectors wroteThis citation pertains to intake 1214304Based on interview and record review, the facility failed to maintain complete and accurate medical records for 4 of 9 residents (Resident #101, Resident #102, Resident #104, and Resident #108) reviewed for complete and accurate medical record documentation, resulting in the potential for staff and providers mismanaging care for residents.

Inspectors wroteThis citation pertains to intake 2564458Based on interview and record, review the facility failed to inform in advance and accommodate the residents' responsible party (RP) to participate in formulation of a care plans with relevant disciplines (nursing, dietary, social services, and activities) related to assessed healthcare needs for 1 (Resident #104) of 3 residents reviewed for notification for care planning resulting in ineffective communication and the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review the facility to failed to ensure call lights were within reach for 1 (Resident #108) of 9 residents (reviewed for accommodation of needs, resulting in resident's inability to call for staff assistance with the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent involuntary seclusion in one of 9 residents reviewed for abuse (Resident #109), resulting in the potential for residents to not meet their highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate Activities of Daily Living (ADL) care for 3 (Resident #102, #103 and #106) 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 interview and record review, the facility failed to ensure that residents received treatment in accordance with professional standards of practice for 2 (Resident #103 and Resident #108) of 9 residents reviewed for quality of care resulting in missed neurological (neuro) assessments after unwitnessed falls and missed medication doses resulting in the potential for a lack of monitoring, unnoticed adverse reactions, unnoticed injury, and the potential to negatively impact the resident's psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision to ensure resident safety for 2 (Resident #104 and Resident #109) of 9 residents reviewed for supervision resulting in the potential for resident-to-resident abuse.

Inspectors wroteThis citation contains two deficient practice statements, A & B. Deficient Practice Statement A Based on observation, interview, and record review, the facility failed to effectively implement Enhanced Barrier Precautions (EBP) per facility policy and Centers for Disease Control and Prevention (CDC) guidance, in 3 of 4 residents (Resident #2, #42, & #45) reviewed for EBP, 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 properly label, date, and store medications in 2 out of 6 medication carts resulting in the potential for decreased efficacy of medications and the exacerbation of medical conditions.

Inspectors wroteBased on interview, and record review, the facility failed to ensure COVID-19 vaccinations were offered to eligible residents in 3 of 5 residents (Resident #16, #18, & #60) reviewed for COVID-19 vaccinations, resulting in the potential for development and transmission of COVID-19 within a vulnerable population.

Inspectors wroteThis citation pertains to intake #MI00152454 Based on observation, interview and record review, the facility failed to ensure a functioning call light was in place for 4 residents (Resident #85, #63, #57 & #337) of 18 residents reviewed for supervision, and have a fully operational call system in place for all 89 residents residing in the facility resulting in the potential for unmet needs, harm or serious injury.

Inspectors wroteBased on interview, and record review, the facility failed to implement an effective training program in regard to infection prevention and control and Enhanced Barrier Precautions (EBP) in 4 of 5 staff members reviewed for infection control/EBP education, resulting in the potential for cross-contamination and the spread of infection to a vulnerable population.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were cared for with dignity and respect for 3 (Resident #14, #16 and #61) of 5 residents reviewed for dignity, resulting in the potential for feelings of embarrassment, frustration, depression, and loss of self-worth and an overall deterioration of psychological well-being.

Inspectors wroteBased on interview and record review the facility failed to obtain psychotropic medication consent prior to administration of psychotropic medication per facility policy for 1 resident (Resident #15) of 5 residents reviewed for unnecessary medications, resulting in the resident and/or representative not being fully informed and the potential for resident decision makers not having an accurate picture of resident condition.

Inspectors wroteThis citation pertains to intake #MI00152454 Based on interview and record review the facility failed to notify a resident durable power of attorney(DPOA)/emergency contact of a fall and transfer to hospital for 1 (Resident #337) of 2 residents reviewed for notification, resulting in the potential for a delay in required medical treatment.

Inspectors wroteBased on interview and record review, the facility failed to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) for non-covered services in 1 resident (Resident #188) of 3 residents reviewed for timely provision of notifications, resulting in the potential for unforeseen financial obligation and hardship.

Inspectors wroteBased on interview and record review, the facility failed to ensure proper discharge notifications were completed in 2 residents (Resident #85 & #337) of 2 residents reviewed for discharge process, resulting in the State Long-Term Care (LTC) Ombudsman not receiving notification of Resident #85's discharge to the hospital and DPOA (Durable Power of Attorney) not receiving written notice of bed hold for Resident #337.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care plan interventions for 1 (Resident #5) of 18 Residents reviewed for care planning, resulting in a potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received the necessary care and services, consistent with professional standards of practice to prevent and promote healing of pressure ulcers in 1 resident (Resident #45) of 3 residents reviewed for pressure ulcers, resulting in the development of an unstageable pressure injury to the right heel, and the potential for additional new, worsening and/or reoccurrence of pressure injuries due to the resident's bed being too short and his feet pressing against the footboard for extended periods.

Inspectors wroteBased on interview and record review, the facility failed to implement care planned interventions for bed mobility to to prevent a fall in 1 of 4 residents (Resident #45) reviewed for falls, resulting in a fall with injury.

Inspectors wroteBased on observation, interview, and record review the facility failed ensure post dialysis assessment and monitoring for 1 (Resident #42) of 1 resident reviewed for dialysis care, resulting in the potential for the resident to not meet his highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure a prompt response to the registered pharmacist's monthly medication regimen review (MRR) recommendations for 3 (Resident #40, #15, #35) of 5 residents reviewed for unnecessary medications, resulting in the registered pharmacist's recommendations not being addressed in a timely fashion and the potential for negative medication side effects as a result of unaddressed recommendations.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were screened for eligibility to receive pneumococcal vaccinations and receive the vaccination if eligible in 1 of 5 residents (Resident #60) reviewed for vaccinations, resulting in the potential of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia.

Inspectors wroteThis citation pertains to intake MI00150232. Based on interview and record review, the facility failed to ensure residents received quality care based on professional standards for 1 (Resident #103) of 3 residents reviewed for unwitnessed falls, resulting in a delay in identifying a change in condition and treatment for multicompartmental acute intracranial hemorrhage (brain bleed).

Inspectors wroteThis citation pertains to intake MI00150232. Based on interview and record review, the facility failed to 1.) Provide adequate supervision and assistance to prevent falls with injury for 2 (Resident #103 and Resident #101) of 3 residents; 2.) implement and revise care plan interventions to prevent falls for 2 (Resident #103 and #108) resulting in Resident #103 falling and sustaining a multicompartmental acute intracranial hemorrhage (brain bleed), Resident #101 falling and sustaining T3 and T8 (spine locations) fractures, and the potential for a fall with injury for Resident #108.

Inspectors wroteThis citation pertains to Intake: MI00150382 Based on observation, interview, and record review, the facility failed to provide an environment that promoted resident dignity in 1 (Resident #108) of 10 residents reviewed for dignity, resulting in the potential of feelings of frustration, embarrassment, and loss of self-worth, and a negative psychosocial outcome for the residents impacting their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to resolve resident concerns for 1 (Resident #107) of 1 sampled resident reviewed for resolution of concerns resulting in feelings of frustration and a potential decline in psychosocial and mental well-being.

Inspectors wroteThis citation pertains to intake MI00150229. Based on interview and record review, the facility failed to implement its policy and procedures on abuse and neglect by staff not reporting an allegation of abuse immediately to the abuse coordinator for 1 residents (Resident #105) of 5 residents reviewed, resulting in the potential for ongoing mistreatment, abuse or neglect.

Inspectors wroteThis citation pertains to intake MI00150232, MI00150229, MI00150376. Based on observation, interview, and record review, the facility failed to thoroughly investigate allegations of abuse and neglect in 4 (Resident #103, #104, #105, and #107 ) of 5 residents reviewed for abuse and neglect resulting in incomplete abuse investigations and the potential for future mistreatment and/or abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the further development of pressure ulcers for 1 (Resident #109) of 1 sampled resident reviewed for pressure ulcers, resulting in the development of 1 facility acquired pressure ulcer.

Inspectors wroteThis citation pertains to Intake # MI00147580, MI00147822, MI00147838, & MI00149046. This citation has two deficient practice statements, A & B. Deficient Practice Statement A Based on interview, and record review, the facility failed to protect the residents' right to be free from neglect in 7 of 15 residents (Resident #103, #104, #113, #120, #124, #125, #126) reviewed for neglect, resulting in an Immediate Jeopardy when on 10/12/24, 10/18/24, 10/19/24, and 10/26/24 licensed nursing staff did not accept responsibility for the care and supervision of residents on portions of the 300 and 400 Halls, which led to missed medications, significant medication errors (Resident #103 missed seizure medication on 10/18/24, Resident #113 missed insulin on 10/12/24, Resident #124 missed a blood thinner on 10/18/24, and Resident #125 missed insulin on 10/18/24 and 10/19/24), and a lack of overall [...]

Inspectors wroteThis citation pertains to intake #MI00149046 Based on interview and record review, the facility failed to implement their abuse policy and respond immediately to protect a resident from staff to resident abuse in 1 (Resident #114) of 15 residents reviewed for abuse, resulting in continued physical/verbal abuse when facility staff did not immediately identify abuse and remove the resident from contact with the alleged abuser.

Inspectors wroteThis citation pertains to Intake # MI00147580, MI00149295, & MI00149428. Based on interview, and record review, the facility failed to ensure residents are free from significant medication errors in 5 of 14 residents (Resident #118, #103, #113, #124, & #125) reviewed for medication administration, resulting in a significant change in condition and hospitalization for Resident #118, and the potential for adverse effects due to missed medications.

Inspectors wroteThis citation pertains to Intake # MI00147580. Based on interview, and record review, the facility failed to ensure it was administered in a manner that maintains the safety and care of residents, so residents may reach their highest practicable physical, mental, and psychosocial well-being, for all 92 residents who reside at the facility, resulting in quality care not being provided to residents, insufficient management of facility staffing, and a lack of follow-up in regard to concerns voiced by staff. For additional information see citations F600 and F725.

Inspectors wroteThis citation pertains to Intake # MI00147580, MI00147814, MI00147822, & MI00147838. Based on interview, and record review, the facility failed to report allegations of abuse and neglect to the State Agency in a timely manner in 11 of 15 residents (Resident #103, #104, #113, #120, #124, #125, #126, #105, #106, #108, & #109) reviewed for abuse and neglect, resulting in the potential for additional allegations of abuse and neglect to go unreported and delayed investigation.

Inspectors wroteThis citation pertains to Intake # MI00146268, MI00147061, MI00147580, MI00147744, MI00147821, MI00148620, & MI00148986. Based on interview, and record review, the facility failed to provide sufficient staff to meet resident needs in 9 of 11 residents (Resident #101, #107, #104, #103, #113, #120, #124, #125, & #126) reviewed for sufficient staffing, resulting in missed showers/baths, a lack of supervision of residents at risk for falls and elopement, long call light wait times, rushed staff, and missed medications. For additional information see citations F600, F677, F689, and F760.

Inspectors wroteThis citation pertains to Intake # MI00147061. Based on observation, interview, and record review, the facility failed to ensure effective hand hygiene and glove use during incontinence care in 1 of 4 residents (Resident #101) reviewed for infection control during incontinence care, resulting in the potential for cross-contamination and the development and spread of infection and disease.

Inspectors wroteThis citation pertains to Intake MI00148620 Based on observation, interview and record review, the facility failed to provide an environment that promoted a dignified dining experience for 1 (Resident #115) of 3 residents reviewed for dignity and respect, resulting in the potential for feelings of frustration, depression, loss of self-worth, and an overall deterioration of psychological well-being.

Inspectors wroteThis citation pertains to Intake # MI00149269, MI00149295, & MI00149428. Based on interview, and record review, the facility failed to prevent the misappropriation of resident medications in 3 of 15 residents (Resident #116, #118, & #119) reviewed for misappropriation of property, resulting in the unauthorized use of a resident's personal property, and the potential for missed medications and uncontrolled anxiety.

Inspectors wroteBased on interview, and record review, the facility failed to develop and/or implement a person centered, comprehensive care plans for 2 residents (Resident #120 and #200) of 4 residents reviewed for care planning, resulting in Resident #120 not receiving adequate supervision to prevent resident to resident abuse, and the potential for residents to not meet their highest practicable level of physical and psychosocial wellbeing.

Inspectors wroteThis citation pertains to Intake # MI00147061, MI00149269, MI00149295, & MI00149428. Based on interview, and record review, the facility failed to follow professional standards of practice for medication administration in 3 of 14 residents (Resident #101, #116, & #118) reviewed for medication administration, resulting in missed thyroid medication, inaccurate documentation of medication administration, and medications administered without a valid physician order.

Inspectors wroteThis citation pertains to Intake # MI00147061, MI00147744, & MI00148986. Based on observation, interview, and record review, the facility failed to ensure baths/showers and hygiene care were provided per resident preference and plan of care in 3 of 5 residents (Resident #101, #104, & #113) reviewed for Activities of Daily Living (ADL) care, resulting in the potential for dissatisfaction with care, hygiene concerns, skin irritation, and low self-esteem.

Inspectors wroteThis citation pertains to Intake # MI00147580. Based on interview, and record review, the facility failed to assess the resident and implement immediate interventions to ensure safety after an attempted elopement in 1 of 6 residents (Resident #103) reviewed for safety/supervision, resulting in the potential for additional elopement attempts and serious injury.

Inspectors wroteThis citation pertains to Intake # MI00147061 & MI00147821. Based on observation, interview, and record review, the facility failed to provide appropriate incontinence and catheter care in 2 of 4 residents (Resident #101 & #107) reviewed for incontinence/catheter care, resulting in cross-contamination, missed episodes of nephrostomy (a tube that drains urine from the kidney) care, and the potential for catheter related complications including the development of urinary tract infections.

Inspectors wroteBased on interview and record review, the facility failed to maintain a complete and accurate medical record related to Advance Directives / Code Status for 1 (Resident #111) of 1 sampled resident reviewed for Advance Directives / Code Status, resulting in an incongruent reflection of the resident records and the potential for the resident's care wishes not being honored as desired.

Inspectors wroteThis citation pertains to Intake # MI00147744 & MI00148620. Based on observation, interview, and record review, the facility failed to ensure a sanitary and comfortable environment in 2 of 5 residents (Resident #103 & #104) reviewed for a clean/homelike environment, resulting in noxious odors and the potential for decreased satisfaction with the living environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1.) properly label, date, and discard opened food products; 2.) securely cover opened food products before storage; 3.) clean food and non-food contact surfaces; 4.) thoroughly clean pans and cups before storage; and 5.) remove and discard rotten food items from among fresh items. These conditions resulted in an increased risk of food borne illness that affected all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility faciled to 1) discard expired medication and COVID-19 antigen test kits, 2) secure resident medications, and 3) separate medications stored in medication carts by route of administration, resulting in unsecured medication and the potential for cross contamination, decreased efficacy of medications, and the exacerbation of resident medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to ensure COVID-19 immunizations were offered to 6 of 6 residents (Resident #58, #46, #32, #52, #10 and #38) reviewed for COVID-19 immunizations, resulting in an increased risk for infection, and the potential spread of COVID-19 infection to other residents, staff, and visitors.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents are treated with dignity and respond to resident call lights timely in 3 of 3 residents (Residents # 23, #26 and #38) reviewed for dignity, resulting in episodes of incontinence and feelings of frustration and loss of self-worth with the potential for overall deterioration of psychological well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were in reach for 1 of 19 residents (Resident #5) reviewed for accommodation of needs, resulting in the inability to call for staff assistance and the potential for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 1 (Resident #28) of 19 sampled residents reviewed for MDS accuracy, resulting in an inaccurate reflection of the resident's health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement consistent pressure ulcer interventions, monitoring, and treatments consistent with physician orders and professional standards of care for 1 of 3 residents (Resident #32) reviewed for pressure injuries, resulting in the potential for worsening of facility acquired pressure ulcers and further skin breakdown.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that liquids were served according to Physician's Orders for 1 resident (Resident #35), of 3 residents reviewed for nutrition services, resulting in Resident #35 being served un-thickened (thin) liquid and liquid with a straw and the potential for Resident #35 to aspirate (accidentally breathe liquid into the lungs potentially resulting in aspiration pneumonia).

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were screened for eligibility to receive pneumococcal vaccinations and receive vaccination if eligible for 2 (Resident #32 and #10) of 5 residents reviewed for vaccinations, resulting in the potential of acquiring, transmitting, or experiencing complications from pneumococcal pneumonia.

Inspectors wroteThis citation pertains to Intake # MI00141034. Based on interview, and record review, the facility failed to perform Cardiopulmonary Resuscitation (CPR) on a resident with a Full Code status, in 1 of 5 residents (Resident #105) reviewed for code status/CPR, resulting in an Immediate Jeopardy when on [DATE] at approximately 9:00 AM Resident #105, who was designated as a Full Code, was found to be non-responsive (no respirations/heart beat). Licensed Nursing staff did not initiate CPR per physician order and facility policy, and Resident #105 passed away. This deficient practice placed all residents, who are designated as a Full Code and who suffer cardiac arrest, or are found non-responsive, at risk for serious harm and/or death.

Inspectors wroteThis citation pertains to Intake # MI00141034. Based on interview, and record review, the facility failed to honor an advance directive and the resident's right to refuse treatment in 1 of 5 residents (Resident #108) reviewed for code status/Cardiopulmonary Resuscitation (CPR), resulting in CPR being performed on a resident with a status of Do Not Resuscitate (DNR).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents consistently received treatment and services to prevent the worsening of a pressure ulcers for 3 residents (Resident #79, #39 and #28) of 3 residents reviewed for pressure ulcers, resulting in the worsening of a Stage 3 pressure ulcer for Resident #79 and a potential for worsening of facility acquired pressure ulcers for Resident #39 and #28.

Inspectors wroteBased on interviews and record review the facility failed to prevent falls for 1 (Resident #336) of 4 Residents reviewed for falls, resulting in a fall with fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Serve resident meals in a timely manner and per facility scheduled times and 2. Serve 2 of 2 residents (Resident #7 and #30) their meal timley, resulting in delayed meal service and the potential for resident dissatisfaction with the dining experience.

Inspectors wroteThis citation pertains to intake #MI00131204. Based on observation, interview, and record review the facility failed to: 1. Properly store raw animal product to minimize contamination; 2. Clean food and non-food contact surfaces to sight and touch; 3. Properly date mark potentially hazardous foods; and 4. Ensure proper installation of an air gap on an ice machine. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 85 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the facility, starting at 9:08 AM on 2/13/23, observation of the main walk-in cooler found a box of raw salmon stored on the second to top shelf over ready to eat slices of ham on a sheet tray. [...]

Inspectors wroteThis citation pertains to intake #MI00133647. Based on observation, interview and record review the facility failed to provide food at a palatable temperature for 2 of 16 residents (Resident #79 and #30) reviewed for food palatability, resulting in the potential for decreased food consumption and nutritional decline for all residents who consume food orally.

Inspectors wroteThis citation pertains to Intakes: MI00133647 and MI00131204 Based on observation and interview, the facility failed to effectively clean and maintain the physical plant resulting in the increased likelihood for cross-contamination, bacterial harborage, and possible decrease in the satisfaction of environment for residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely care and services to promote dignity in 1 of 5 residents (Resident #30) reviewed for dignity/respect, resulting in long call light wait times, episodes of incontinence and feelings of embarrassment, and the potential for feelings of diminished self-worth, sadness, and frustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure activities of daily living (ADL) cares and assistance were provided per resident preference for 1 (Resident #1) of 28 sampled residents reviewed for resident preferences, resulting in the potential for dissatisfaction with care and an overall decline in sense of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from physical restraints imposed for the purpose of convenience in 1 of 1 resident (Resident #81) reviewed for restraints, resulting in the restriction of mobility and a potential for decline in physical functioning, psychosocial wellbeing, and the development of skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident or resident representative was notified in writing of a transfer to an acute care hospital in 1 of 1 resident (Resident #73) reviewed for transfer notices.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident or resident representative was notified in writing of a transfer to an acute care hospital in 1 of 1 resident (Resident #73) reviewed for transfer notices.

Inspectors wroteThis citation pertains to Intake #MI00134395 Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 24 residents (Resident #79 ) reviewed for care planning, resulting in unmet incontinence care needs contributing to the worsening of a pressure ulcer for Resident #79.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services according to professional standards of practice for 1 (Resident #7) of 24 residents reviewed for provision of professional services, when licensed nursing staff failed to follow the physician orders for nutritional supplements, resulting in the potential for malnutrition.

Inspectors wroteThis citation pertains to Intake #MI00131204. Based on observation, interview, and record review, the facility failed to maintatin professional standards of care and provide adequate incontinence care in 1 of 3 residents (Resident #79) reviewed for bowel and bladder incontinence, resulting in an increased risk for UTI (urinary tract infection) and the potential for skin breakdown.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely and consistent nutrition/hydration and weight status follow-up of a resident deemed at Nutrition Risk in 1 (Resident #1) of 3 residents reviewed for nutritional care and services, resulting in inadequate monitoring and reassessment of a resident following a documented significant weight loss.

Inspectors wroteBased on observation and interview the facility failed to discard expired tube feeding supplements. These conditions resulted in an increased risk for contaminated foods and an increased risk of food borne illness for individuals who are prescribed these specific supplements.