Optalis Health and Rehabilitation of Sterling Heig

Inspectors wroteThis citation pertains to intake: 2719896Based on observation, interview, and record review, the facility failed to provide two-person assistance with bed mobility for one resident (R701) out of three reviewed for falls, resulting in a right leg femur fracture requiring surgery.

Inspectors wroteThis citation pertains to intake: 2716778Based on interview and record review, the facility failed to initiate psychiatry services for one resident (R700) out of one reviewed for behaviors.

Inspectors wroteThis citation pertains to Intake: 2574739Based on observation, interview, record review facility failed to implement interventions (alternating pressure mattress) as ordered to prevent worsening of pressure ulcer for one (R901) of two residents reviewed for pressure ulcer prevention/management.

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

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the exterior trash refuse area in a clean manner. This deficient practice had the potential to affect all residents, staff, and visitors.

Inspectors wroteThis citation has two deficient practice statements. Deficient Practice #1 Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among any or all the residents in the facility.

Inspectors wroteOn 6/24/25 at 2:12 PM, five of the 14 residents that attended the group reported the food did not taste good. They went on to say the food is sometimes cold when it reaches them. A review of the facility's policy titled Food Palatability dated 4/4/25 noted, Food is prepared by methods that conserve nutritive values, flavor, and appearance. Food and drink should be palatable, attractive, and at a safe and appetizing temperature for the general population This citation pertains to Intake: MI00153364 Based on observation, interview, and record review, the facility failed to ensure that food was served in a palatable manner and at the preferred temperature for four residents (R31, R33, R51, R95) and five confidential group residents of twenty reviewed for food palatability.

Inspectors wroteA review of the record for R152 revealed R152 was admitted into the facility on [DATE]. Diagnoses included Non traumatic Brain Dysfunction, Stroke and High Blood Pressure. The Minimum Data Set (MDS) assessment dated [DATE], indicated severely impaired cognition, impaired range of motion of the extremities, and R152 was dependent on staff for all activities of daily living including bed mobility, bathing and personal hygiene. A review of the policy, Care Plan - Comprehensive and Revision, revised 8/25/2023, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident .Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. [...]

Inspectors wroteA review of the record for R152 revealed R152 was admitted into the facility on [DATE]. Diagnoses included Non traumatic Brain Dysfunction, Stroke and High Blood Pressure. The Minimum Data Set (MDS) assessment dated [DATE], indicated severely impaired cognition, impaired range of motion of the extremities, and R152 was dependent on staff for all activities of daily living including bed mobility, bathing and personal hygiene. Resident #57 On 06/23/25 at 9:01 AM, R57 was observed to be supine in bed, with their heels on the bed, and and dressed in a hospital style gown. R57's breakfast tray was observed on the over bed table which was over the waist area of R57. R57 had not eaten or drank any items. The mighty shake (for calorie/nutrition assistance) was not opened. The call light was in the top drawer of the night stand away from R57. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate and meaningful activities for two (R57 and R152) of three residents reviewed for activites.

Inspectors wroteBased on interview and record review, the facility failed to provide gynecological care in a timely manner for one resident (R25) of one reviewed for a delay in treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent a fall for one resident (R143) of four residents reviewed for falls resulting in pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to label, date, and provide tube feeding (nutrition infused directly into the stomach via a tube) as ordered for one resident (R152) of three residents reviewed for tube feeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident medications were not left at the bedside for one resident (R74) of one resident reviewed for medication storage.

Inspectors wroteBased on interview and record review, the facility failed to ensure the completion of 12-hours of annual in-service trainings of two Certified Nursing Assistants (CNA O and CNA P), of five reviewed for the completion of 12-hours of annual in-service training.

Inspectors wroteThis citation pertains to Intake MI00151526 Based on interview and record review, the facility failed ensure timely assess a pressure ulcer for one resident (R703) out of two reviewed for pressure ulcers.

Inspectors wroteThis citation pertains to Intake: MI00147942. Based on interview and record review, the facility failed to provide timely incontinence care for one resident (R702) of two residents reviewed for Activities of Daily Living (ADL) care.

Inspectors wroteThis citation pertains to Intake: MI00147856. Based on interview and record review the facility failed to timely implement preventative and effective interventions to prevent the development of a pressure ulcer (wound caused by pressure) for one resident (R701) of two residents reviewed for pressure ulcers.

Inspectors wroteThis citation pertains in part to intakes: MI00146160, MI00146194, MI00146496. Based on observation, interview and record review the facility failed to document and provide Activities of Daily Living for two dependent residents (R902 and R903) of five residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was safely stored and failed to maintain sanitary conditions in the kitchen. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label/date and remove a peripheral intravenous line (PIV) for one resident (R95) out of one reviewed for PIV's.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and document targeted behaviors, non-pharmacological interventions for behaviors, and monitor side effects of a prescribed psychotropic for one resident (R9) of six residents reviewed for unnecessary medications.

Inspectors wroteDeficient Practice Statement #2 Based on observation, interview, and record review, the facility failed to monitor the temperatures of one of one medication refrigerator that stored drugs and biologicals.

Inspectors wroteThis citation pertains to Intake MI00142524. Based on interview and record review, the facility failed to involve the guardian in the plan of care for one resident (R807) out of one reviewed for resident/representative rights. Findings Include: A review of an Intake called inot the State Agency revealed the following, [Guardians] have given [facility] their guardianship court papers twice but they have not returned any calls. [Facility] also made a doctor appointment and transported [R807] to the appointment without the guardian's permission. [R807] is supposed to be discharged on 2/2/2023 and will be taken home but [guardian] has yet to hear from [facility] about this upcoming discharge. A review of the medical record revealed that R807 admitted into the facility on [DATE] with the following diagnoses, Acute Osteomyelitis, Right Ankle and Foot, and Dysphagia. [...]

Inspectors wroteThis citation pertains to Intake MI00142524. Based on interview and record review, the facility failed to properly provide a Notice of Medicare Non-Coverage (NOMNC) to the guardian of one resident (R807) out of one reviewed for NOMNC's. Findings Include: A review of an intake called inot the State Agency revealed the following, [R807] is supposed to be discharged on 2/2/2023 and will be taken home but [guardian] has yet to hear from [facility] about this upcoming discharge. A review of the medical record revealed that R807 admitted into the facility on [DATE] with the following diagnoses, Acute Osteomyelitis, Right Ankle and Foot, and Dysphagia. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status (BIMS) score of 14/15 indicating an intact cognition. R807 also required assistance with bed mobility and transfers. [...]

Inspectors wroteThis citation pertains to Intakes MI00141267, MI00142762, and MI00143006. Based on interview and record review, the facility failed to complete wound care treatments for one resident (R801) out of three reviewed for wound care.

Inspectors wroteThis citation pertains to Intake MI00142280. Based on interview and record review the facility failed to ensure a resident was weighed and documented weekly for one resident (R901) of three whose weights were reviewed resulting in dietitian recommendations and physician orders not followed.

Inspectors wroteThis citation pertains to Intake MI00142280. Based on interview and record review the facility failed to ensure physical rehabilitation services were provided as ordered and scheduled for one resident (R901) of three whose rehab services were reviewed.

Inspectors wroteThis citation pertains to Intakes MI00140458 and MI00141009. Based on observation, interview, and record review, the facility failed to assist with care in a timely manner for two residents (R702 and R704) out of four reviewed for call light response, resulting in feelings of frustration and delay in care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow recommendations of no straws, for two residents (R702 and R703) out of two reviewed for person-centered care. Findings Include: R702 On 11/27/2023 at 10:08 AM, R702 was observed in their room sitting up in their wheelchair. Observed on a white board in R702's room there was, No Straws written on it. R702 was observed with a white Styrofoam cup with a straw in it. R702 stated that there was water in the cup. A review of the medical record revealed that R702 admitted into the facility on [DATE] with the following diagnoses, Fracture of Left Femur and Fall. A review of the Minimum Data Set assessment revealed a Brief Interview for Mental Status score of 12/15 indicating a moderately impaired cognition. R702 also required two-person extensive assist with bed mobility and transfers. [...]

Inspectors wroteThis citation pertains to Intake: MI00140118. Based on interview and record review, the facility failed to notify the resident's representative of a change in condition for one resident (R901) of one reviewed for notification of changes, resulting in the resident's representative being unaware of significant medical changes, and inability to participate in medical decisions regarding care and treatment.

Inspectors wroteThis citation pertains to Intake: MI00139787 Based on interview and record review the facility failed to administer medications as ordered by the physician for one resident (R909) reviewed for medication administration resulting in medication not given as prescribed, with the potential for adverse side effects.

Inspectors wroteThis citation has two deficient practices. Deficient practice #1. This citation pertains to Intake MI00134465. Based on interview and record review, the facility failed to adequately assess and monitor a skin alteration for one resident (R283) of two reviewed for quality of care, resulting in an unmonitored infection, gangrene, and ultimately, amputation of the right great toe.

Inspectors wroteBased on interview and record review, the facility failed accurately document the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, resulting in the potential for inadequate coordination of care and negative clinical outcomes, potentially affecting all 107 residents currently residing in the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to display current nurse staffing information daily, and failed to maintain 18 months of daily staff postings, affecting all 107 facility residents, resulting in the likelihood of necessary staffing information not being available to residents and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were dated, failed to ensure staff with facial hair donned beard restraints, and failed to maintain kitchen equipment in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the kitchen to eliminate the harborage of gnats. This deficient practice had the potential to affect all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident personal belongings were accounted for, affecting one sampled Resident (R121), resulting in missing personal items, the potential for further missing/unaccounted for items, and resident/family dissatisfaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to pass medications in a timely manner and per physician's orders and standards of practice affecting two residents (R41 and R40), resulting in resident dissatisfaction, and the potential for adverse effects.

Inspectors wroteThis citation pertains to Intake: MI00134600 and MI00134043. Based on observation, interview, and record review, the facility failed to provide showers as scheduled for two residents (R40, and R75) and a bed pan for one resident (R24) out of ten reviewed for Activities of Daily Living (ADL's), resulting in dissatisfaction with care and fustration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to apply a splint to one resident (R75) out of one reviewed for limited range of motion, resulting in the potential for the worsening of a contracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications per professional standards during medication administration, and failed to label/date insulin pens in two of four medication carts, resulting in the potential for medication error.

Inspectors wroteBased on interview and record review, the facility failed to completely and accurately document current COVID-19 vaccination status and offer the vaccine/booster if eligible for four residents (R28, R38, R51, R114) of nine reviewed for immunizations, resulting in the potential for miscommunication and misunderstanding of resident immunization preferences, and the potential for the development of severe disease if infected with COVID-19 (highly contagious respiratory virus).