Optalis Health and Rehabilitation of Kingsford

Inspectors wroteBased on interview and record review, the facility failed to ensure the timely acquisition, administration, and disposition of oral targeted cancer medication for 1 Resident (R1) of 1 resident reviewed for pharmacy services. This deficient practice resulted in missed doses of an oncologist (cancer physician) prescribed medication, the potential of reduced efficacy and progression of disease, and resident dissatisfaction with care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record contained accurate and complete information related to the facility's loss of oral chemotherapy medication for one Resident (#1) of one resident reviewed for a complete medical record

Inspectors wroteThis citation pertains to intake 2715858. Based on interview and record review, the facility failed to monitor urinary output for one Resident (#10) of three residents reviewed for standards of practice with indwelling catheters.

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision for one Resident #1 (R1) of three residents reviewed for elopement. This deficient practice resulted in R1 leaving the facility unattended and the potential for falls and injury. This citation pertains to intake 2600151Findings include:Resident #1 (R1)Review of Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 7/24/24, with active diagnoses that included anxiety disorder, depression and non-Alzheimer's dementia. R1 scored a 7 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment. Review of document titled Elopement dated 6/30/25, read in part .Resident was visualized by Admissions Director C ambulating towards [Name of business]. Resident entered the business. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement safety measures during transportation to an outside appointment for 1 Resident (#22) of 3 residents reviewed for accidents/hazards. This deficient practice resulted in harm for Resident #22 who sustained 4 fractures (both bones in lower legs broken), and a large laceration requiring sutures on right footAll times are in Eastern Daylight Time (EDT) unless otherwise notedFindings include:Resident #22 (R22)Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 3/15/18 with active diagnoses that included: dementia, depression, and type 2 diabetes mellitus. R22 scored 8 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to: effectively date mark potentially hazardous ready-to-eat food products, effectively clean food service equipment resulting in cross-contamination, bacterial harborage, and the increased potential for resident foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a clean, comfortable environment throughout the facility and maintain clean sanitary linens and shower rooms for shared resident use. This resulted in a potential decreased satisfaction of living conditions and an increased potential for a bacterial harborage for residents residing in the facility. All times are in Eastern Daylight Time (EDT) unless otherwise notedFindings include:In an observation on 6/24/25 at 12:15 PM., upon entering the facility for annual recertification it was noted walking through the main door into the main common area that a strong smell of urine and musty warm air was evident. There were multiple residents in the main common area watching TV. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to appropriately assess one (Resident #60) out of four residents reviewed for safe self-administration of medication clinically appropriate.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to ensure three Residents (#14, #18, & #57) of four residents reviewed for hospitalizations were provided with written notification of the bed hold policy when the residents were transferred to the hospital.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on observation, interview, and record review, the facility failed to provide grooming and hand hygiene to one Resident (R30) of two residents reviewed for Activities of Daily Living (ADL).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure intravenous (IV) site procedure was documented, dated when initiated and orders were in place to ensure the site was changed per standards of practice for one (Resident #18) of one resident reviewed for quality of care. All times are in Eastern Daylight Time (EDT) unless otherwise notedFindings include: Resident #18 (R18)Review of R18's electronic medical record (EMR) revealed initial admission to the facility on 4/30/25 with diagnoses including diabetes mellitus, dementia, urinary tract infection with indwelling urinary catheter, and heart failure. On 6/25/25 at 3:13 PM, an observation was made of R18 during medication pass. R18 was observed to have an IV site in their left lower extremity in their forearm that had a dressing that was not dated. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to appropriately maintain and store respiratory equipment in a sanitary manner for one (Resident #31) of one resident reviewed for respiratory care. All times are in Eastern Daylight Time (EDT) unless otherwise noted.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on observation, interview, and record review the facility failed to appropriately maintain and store respiratory equipment in a sanitary manner for one (Resident #31) of one resident reviewed for respiratory care. All times are in Eastern Daylight Time (EDT) unless otherwise notedFindings include:Based on observation, interview, and record review the facility failed to appropriately assess one (Resident #60) out of three residents reviewed for pain management.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted Based on observation, interview, and record review the facility failed to store medication in a secure and safe manner and ensure expired medication was disposed of in the active medication cart for three (Residents #33, Resident #57, and Resident #60) of 18 reviewed and one of two medication carts reviewed for medication storage.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were administered under nursing observation for one Resident (R6) of one resident reviewed for medication administration. This deficient practice resulted in the potential for delayed or non-administration of medications left unsupervised at bedside.

Inspectors wroteThis deficiency pertains to Intake MI00151603. Based on interview and record review, the facility failed to promptly resolve grievances for one Resident (R6) of three residents reviewed for grievances. This deficient practice resulted in resident frustration and dissatisfaction when missing personal items were not found or replaced.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a urinary nephrostomy drainage bag was maintained to prevent contact with contaminated surfaces or garbage for one Resident (R6) of one resident reviewed for catheter care. This deficient practice resulted in the increased risk of contamination of the urinary drainage bag and increased risk of urinary tract infection (UTI) for R6.

Inspectors wroteThis citation pertains to intake(s): MI00151324, MI00151372 Based on observation, interview and record review the facility failed to provide sufficient staffing to ensure resident needs were met timely for three Residents (#4, #5, & #3) of five residents reviewed for staffing concerns. This deficient practice resulted in Resident #4 being left wet and soiled for extended periods of time and unmet care needs including oral care, and grooming with the potential to affect all 75 residents.

Inspectors wroteThis citation pertains to Intakes: MI00151324, MI00151372. Based on observation, interview, and record review the facility failed to provide necessary care to assist two Residents (#3 & #4) of five residents reviewed for activities of daily living (ADLs)care. This deficient practice resulted in residents who appeared unkept, disheveled, and being left wet and soiled for extended periods of time and potential for embarrassment and humiliation based on the reasonable person comcept

Inspectors wroteIntake #MI00149612 Based on interview and record review the facility failed to ensure the accuracy and confidentiality of resident records for one Resident (#9) of two residents reviewed for confidentiality of medical records, resulting in the release of incorrect resident information accompanying a deceased resident's remains to the funeral home. All times are in Eastern Standard Time.

Inspectors wroteThis citation pertains to intake MI00149149. Based on observation, interview, and record review, the facility failed to ensure appropriate and consistent assessment of a penile tear for one Resident (#2) of three residents reviewed for wound care, resulting in the potential for unidentified worsening of the wound and delay in treatment.

Inspectors wroteThis citation pertains to intake MI00148886. Based on interview and record review, the facility failed to ensure consistent skin and risk assessments were completed according to professional standards of practice and facility policy, for one Resident (#7) at risk for pressure injuries of three resident reviewed, resulting in the potential for unidentified wounds and delay in treatment.

Inspectors wroteThis deficiency pertains to intake MI00148886. All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on observation, interview, and record review, the facility failed to ensure a urinary catheter securement device was utilized, proper placement of a urinary collection bag, and timely drainage of urine from a urinary catheter collection bag for two Residents (R2 and R4) of three residents reviewed for catheters.

Inspectors wroteThis deficiency pertains to Intake #MI00147846. Based on interview and record review, the facility failed to timely obtain and process physician orders for respiratory assessment, treatment, and radiology diagnostics for one Resident (R1) of three residents reviewed for quality of care. This deficient practice resulted in harm when R1 was hospitalized related to severe respiratory distress and fluid volume overload.

Inspectors wroteThis citation pertains to intake MI00147496. Based on observation, interview and record review, the facility failed to ensure appropriate transfer using a mechanical lift for one Resident (#1) of three residents reviewed for accidents, resulting in Resident #1 sustaining a fall with subsequent left knee pain and the potential for serious injury.

Inspectors wroteThis citation pertains to intake MI00 147221. Based on observation, interview and record review, the facility failed to ensure use of Enhanced Barrier Precautions (EBP, gown and glove use) during high-contact resident care activities, according to physician order and current professional guidelines, for one Resident (#2) of three residents reviewed for infection control, resulting in the potential for spread of multidrug-resistant organisms (MDROs) and infection.

Inspectors wroteThis citation pertains to intake MI00147078. Based on observation, interview and record review, the facility failed to provide a meal and assistance for one resident (R13) of three residents reviewed for meal delivery and feeding assistance. This deficient practice resulted in the potential for clinical/nutritional compromise.

Inspectors wroteThis citation pertains to intake MI00147078. Based on interview and record review the facility failed to provide timely pharmaceutical services, for one resident (R15) of three sampled residents reviewed for pharmacy services. This deficient practice resulted in missed doses of a prescribed medication with symptoms of sweating and shaking and the potential for worsened medical conditions.

Inspectors wroteThis intake pertains to MI00145231: Based on interview and record review, the facility failed to inform the Resident Representative of the grievance policy and procedure and promptly address all grievances for one Resident (R1) out of three residents reviewed for Resident Rights. This deficient practice resulted in grievances submitted by email, without inclusion in the facility grievance log, and a delay or omission of grievance response(s).

Inspectors wroteThis intake pertains to MI00145231: Based on interview and record review, the facility failed to provide the appropriate treatment and services to maintain the ability to carry out activities of daily living for one Resident (R1) out of three residents reviewed for ADL care. This deficient practice resulted in inadequate grooming, dressing, personal hygiene, and toileting for R1.

Inspectors wroteResident #38 (R38) A review of R38's medical records revealed admission to the facility on [DATE] with diagnoses including non-displaced intertrochanteric fracture of right femur (fracture of long bone leg between the greater and lesser trochanter), dementia, hypertension, congestive heart failure, osteoarthritis, sarcopenia (age related progressive loss of muscle mass and strength), difficulty in walking, transient ischemic attack, and cerebral infarction without residual deficits. R38's Brief Interview for Mental Status (BIMS) from 4/11/24 indicated a score of 0/15, indicating R38 had severe cognitive impairment. A physician's order dated 12/12/23 at 4:17 PM revealed the following: Cleanse R38's right hip incision site with normal saline and apply band-aids to area every dayshift. Monitor surgical incision to right hip area every shift for signs and symptoms of infection, bleeding. [...]

Inspectors wroteThis citation pertains to intakes MI00141835, MI00142802, and MI00142093. Based on observation, interview, and record review, the facility failed to provide adequate nursing staff to provide quality care and services. This deficient practice resulted in extended call light wait times with the potential for lack of care to meet resident's needs amongst any/all 73 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure the dietary department was provided with sufficient and properly trained staff to carry out the functions and duties of the nutritional services department. This deficient practice has the potential to result in inadequate nutrition for all 73 residents.

Inspectors wroteOn 5/20/24 at 12:48 PM, the lunch meals were observed to include mostaccioli, garlic bread, green beans, and fruited jello. The mostaccioli appeared to have no meat and had cottage cheese or ricotta cheese, but only four to five pearls of cottage cheese per serving visible. The recipe for the mostaccioli was requested to investigate the protein content of the mostaccioli entree. During the initial tour on 5/19/24 at 2:54 PM, Resident # 22 (R22) stated she had a healing below the knee amputation, and she needed to be fitted for a prosthesis. She said she knew she needed protein to continue with the healing process. However, she said, There is bad food here with very little protein. I have gained weight by eating crap here. She showed me protein supplements that she had ordered because the facility was not serving enough protein. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to follow menu recipes to ensure that the nutritional value of the items was met. This deficient practice has the potential to result in nutritional deficiencies to all 73 residents of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received diets as prescribed by a physician for one of three residents reviewed for therapeutic diets (Resident #25) in a sample of 18 Residents. This deficient practice resulted in the potential for health complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 73 residents.

Inspectors wroteDuring this annual survey process the survey team identified an immediate jeopardy for pressure ulcers due to the facility's failure to identify, completely and accurately assess, appropriately treat and implement interventions to prevent facility-acquired pressure injuries and promote healing and prevent worsening of existing pressure injuries. When the NHA was asked if the QAPI committee had addressed skin and wound issues, she could not show any evidence of documentation demonstrating performance improvement activities in this area. The NHA reviewed the QAPI committee minutes and could only find a mention of Other injuries which she thought could include pressure ulcers. [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct and document an annual facility wide assessment resulting in the potential for inadequate knowledge of the facility population's needs and potential for inadequate resources to care for any and all 73 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement and maintain an effective, comprehensive, data-driven Quality Assurance & Performance Improvement (QAPI) program to develop and implement appropriate plans of action to correct identified quality deficiencies. This deficient practice resulted in a system failure in the skin and wound program for prevention and healing of pressure ulcers, which had the potential to affect all 73 residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Quality Assurance and Performance Improvement (QAPI) program committee was composed of the required committee members. This deficient practice resulted in the potential for ineffective coordination of medical care and delayed resolution of facility issues placing all 73 residents of the facility at risk for quality care concerns.

Inspectors wroteBased on observation and interview, the facility failed to maintain or ensure proper maintenance was provided on essential equipment in the kitchen. This deficient practice had the potential to result in equipment not being operational and contributing to unnecessary risks to staff and residents.

Inspectors wroteThis citation pertains to Intake MI000142093. Based on observation, interview, and record review, the facility failed to follow through with the grievance process initiated by resident representatives regarding resident care and by the resident council (10 members in attendance) related to snacks not being provided in the evenings. This deficient practice resulted in the residents and their representatives' grievances not being resolved or followed up on for those who filed grievances, with the potential for other grievances to go unanswered for any of the other residents at the facility.

Inspectors wroteBased on interview and record review the facility failed to include mandatory training outlining and informing their staff of the elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program for 4 staff (identified as Staff N, P, R and Q) out of seven in-service training files reviewed for QAPI training. This deficient practice resulted in the potential for unmet resident care needs due to an ineffective performance improvement program.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the appropriate care of indwelling, urinary catheter equipment for one Resident (R19) of three residents reviewed for catheter care, resulting in the potential for contamination of the equipment with infectious organisms and urinary tract infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess respiratory status for residents receiving as needed respiratory medications and supplemental oxygen according to professional standards of practice for one Resident (R168) of one resident reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the administration of an incorrect dose of insulin was documented and the attending physician notified for one Resident (R18) of two residents reviewed for insulin administration, resulting in the potential for uncontrolled glucose levels and future orders for insulin dosages adjusted based on incorrect documentation.

Inspectors wroteThis citation pertains to intakes MI00141709 and MI00142802. Based on observation, interview, and record review, the facility failed to ensure a medication error rate of 5% or less, with 3 medication errors observed of 35 opportunities, resulting in a medication error rate of 8.57%.

Inspectors wroteThis citation pertains to intakes: MI00140557 and MI00140628 This requirement is not met as evidenced by: All times are reported in Eastern Standard time (EST) unless otherwise indicated. Based on observation, interview, and record review, the facility failed to provide properly sized incontinence briefs for four residents (R6, R7, R8, and R10 ) of four residents reviewed for adequate supplies. This deficient practice resulted in the potential for embarrassment, brief leakage, discomfort, and skin breakdown from residents wearing incorrectly sized briefs.

Inspectors wroteThis deficiency pertains to MI00140557 and MI00140628. Based on interview and record review, the facility failed to ensure prompt resolution of grievances for seven Residents (R3, R6, R11, R12, R13, R14, and R15) of 15 samples residents reviewed. This deficient practice resulted in unaddressed resident grievances.

Inspectors wroteBased on interview and record review, the facility failed to provide dignified care for five Residents (Resident [R14] and four confidential group Residents [C2, C3, C4, and C6]), of seven residents reviewed for dignity. This deficient practice resulted in feelings of sadness and discouragement for R14, and feelings of frustration, unease, and anger for confidential group residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain informed consent for psychotropic medications for four Residents (#11, #18, #25, and #37) out of five residents reviewed for psychotropic medications. This deficient practice resulted in the lack of documentation for evaluation regarding use, and lack of communication/education to the resident/resident representatives for initiation and/or dose changes of psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and secure storage of medications in one of two medication rooms reviewed during the medication storage task. This deficient practice resulted in the potential for medication diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, obtain orders for treatment, and provide wound care according to professional standards of practice for one Resident (R267) of 17 residents reviewed for quality of care. This deficient practice had the potential for delayed or worsening of wound healing and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent an avoidable accidental shoulder injury for one Resident (#60) of thirteen residents reviewed for accidents. This deficient practice resulted in Resident #60 reporting increased right shoulder pain, and feelings of frustration and unease related to the incident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate nutrition and monitoring of nutritional status for two Residents (#11 & #59) of three residents reviewed for nutritional status. This deficient practice resulted in wrong diets being provided and lack of appropriate monitoring and/or follow-up with significant weight changes.

Inspectors wroteThis citation pertains to Intake #MI00136290. Based on observation, interview, and record review, the facility physician failed to review the total program of care, including skin/wound care treatments for one Resident (R33) of one resident reviewed for a facility acquired burn and subsequent wound. This deficient practice resulted in poor continuity of care, and the potential for inconsistent skin/wound care treatments for R33's.

Inspectors wroteThis deficient pertains to Intake #MI00131468. Based on interview and record review the facility failed to maintain a complete and accurate medical record for one Resident (R217) out of 15 sample residents reviewed. This deficient practice resulted in the failure to document a potential resident elopement from the facility.