Optalis Health and Rehabilitation of Troy

Inspectors wroteThis citation pertains to intake: 3040204. Based on observation, interview and record review the facility failed to ensure adequate supervision for a resident with dementia, failed to timely implement adequate elopement interventions and failed to ensure all staff received adequate elopement training for residents that wear a monitoring device, for one (R307) of three residents reviewed for elopements, resulting in an Immediate Jeopardy (IJ). The facility failed to ensure the safety of R307 when the resident was allowed to leave the facility unnoticed wearing a monitoring alarm device, without staff knowledge of the elopement, until notified by the family. The resident entered into the car of a stranger and was transported approximately 11 miles away from the facility placing the resident at risk for serious harm, injury, and/or death. The IJ was identified on 6/16/26. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement an effective infection control surveillance program, including transmission-based precautions (for R146), and to maintain an active water management program which had the ability to affect all 112 residents who resided in the facility.

Inspectors wroteThis citation relates to Intake 2718224. Based on observation, interview, and record review, the facility failed to provide a safe, home-like environment by ensuring comfortable water temperatures for residents who used the central shower rooms (including R79) for showers.

Inspectors wroteThis citation relates to Intake 2718224. Based on observation, interview, and record review, the facility failed to ensure consistent activity programming with meaningful individualized activities to promote domains of wellness for five Residents (R79, R60, R29, R97, and R42) of five residents reviewed for activities.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure proper storage and supervision was provided for medications left at bedside for four (R93,102,146, and 147) of five residents reviewed for medication storage.

Inspectors wroteBased on interview and record review the facility failed to maintain an effective antibiotic stewardship program to ensure appropriate infection criteria was met for five (R17, R38, R95, R116 and R153) residents identified which had the ability to affect multiple residents who were prescribed antibiotics while residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure appropriate cross-connection prevention resulting in the potential for contamination of ice in the ice machine, affecting all residents.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure two of two nurses reviewed for the medication administration observation followed the protocol for the administration of controlled medications for two (R's 10 & 119) of two residents observed for the medication administration task.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper storage of smoking paraphernalia for one (R71) of two residents reviewed for smoking/accidents.

Inspectors wroteThis citation pertains to Intake: 2746350. Based on observation, interview and record reviews the facility failed to protect Residents' (R's 64 & 65) right to be free from sexual abuse by another resident (R66) for three of three residents reviewed for abuse, resulting in inappropriate and unwanted sexual contact that would cause the reasonable person severe psychosocial harm (feelings of being violated, embarrassment, humiliation, fear & worthlessness) as a result of the sexual abuse.

Inspectors wroteThis citation pertains to complaint 2689220 Based on interview record review, the facility failed to provide timely on-going assessment and intervention for one resident (R401) of one reviewed for change of condition resulting in a hospitalization to rule out stroke (CVA).

Inspectors wroteThis citation relates to Intake 2655900. Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical and sexual abuse by one Resident, R108, towards two residents, R103 and R104, and by R106, towards two residents, R109 and R110, of six residents reviewed for abuse.

Inspectors wroteThis citation relates to Intake 2655900. Based on interview and record review, the facility failed to report a physical and sexual abuse incident for three residents (R103, R104, and R108) of six residents reviewed for abuse.

Inspectors wroteThis citation is based on complaint: 2655900. Based on observation, interview and record reviews the facility failed to provide adequate supervision for a resident with medical issues and physical limitations which makes client unsafe to leave the facility alone and cognitive function and awareness concerns, for one (R105) of four residents reviewed for supervision/accidents. This resulted in the facility's failure to ensure the necessary supervision for R105 was provided.

Inspectors wroteThis citation pertains to Complaint #2596436Based on interview and record review the facility failed to ensure timely medical appointments and debridement treatments were implemented to prevent the worsening of a wound for one (R302) out of two residents reviewed for pressure ulcers/wounds resulting in R302 being hospitalized for additional care.

Inspectors wroteThis citation pertains to Intake 2597366Based on interview and record review, the facility failed to ensure appropriate supervision was provided to a resident for one (R303) of two residents reviewed for transportation resulting in R303 being sent multiple times to medical appointments with no staff supervision.

Inspectors wroteR303 Review of the medical record revealed R303 was admitted to the facility on [DATE], with a primary diagnosis of displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture, pulmonary hypertension and heart failure. A Minimum Data Set (MDS) assessment dated [DATE], noted a Brief Interview for Mental Status (BIMS) score of 15 (which indicated intact cognition). A review of a Nursing note dated 1/8/25 at 9:00 PM, documented in part . Patient observed sleeping in chair when writer attempted wake patient, she had a delayed response which was different from our morning interactions. Writer checked her BP (blood pressure) it was 90/44, writer then checked her blood sugar it was 49 (normal is above 70). Writer assisted CNA (certified nursing assistant) to help patient into bed and elevated her feet. [...]

Inspectors wroteThis citation pertains to intake: MI00151683. Based on interviews and record reviews the facility failed to ensure consistency with the timely identification and reporting in changes in condition, ensuring accurate assessments and monitoring for a resident with an identified change of condition, ensure professional nursing standards of practice were consistently followed for medication administration, failed to ensure the implementation of a physician order for oxygen administration and intravenous therapy was administered, failed to ensure accurate and complete documentation of nursing skilled notes and failed to timely transfer to a higher level of care, for one R402 of four residents reviewed for a change of condition and resulting in multiple hospitalizations.

Inspectors wroteThis citation pertains to intake: MI00151683. Based on interview and record reviews several failures were identified regarding the facility's nutritional management and oversight that included- a delayed gastroenterology referral/follow up, delayed nutritional assessment/lack of oversight/monitoring, untimely implementation of nutritional interventions and a communication break down with the facility's Interdisciplinary team to ensure a collaborative approach for one R402 of four residents reviewed for Nutrition and Hydration, resulting in a severe weight loss of 13.27% within two months, hospitalization and the contribution to R402's death.

Inspectors wroteThis citation pertains to intake # MI00150676. Based on interview, and record review, the facility failed the appropriate level of assistance per plan of care to prevent serious injury (acute appearing distal tibia fracture) for one (R406) of four residents reviewed for quality of care.

Inspectors wroteThis citation pertains to intake #MI00151683 Based on observation, interview and record review, the facility failed to ensure consistent implementation and documentation of a DNR (Do Not Resuscitate) order for one resident (R408) of four residents reviewed for resident rights.

Inspectors wroteThis citation pertains to intake #MI00150318 Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a staff member for one resident (R404) of four residents reviewed for abuse/neglect/mistreatment.

Inspectors wroteThis citation pertains to intake # MI00150676. Based on interview, and record review, the facility failed to report an allegation of abuse to the State Agency and Administrator (Abuse Coordinator) within the required time frame for one (R406) of four residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake # MI00150676 and MI00150318. Based on interview and record review, the facility failed to complete a thorough investigation into an initial injury of unknown origin and allegation of mistreatment for one resident (R406) and ensure protection/prevention of further access with an employee (alleged perpetrator) with confirmed abuse findings from having continued access to one resident (R404) out of four residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly respond, provide timely assistance and proper positioning in bed for one (R410) of four residents reviewed for quality of care.

Inspectors wroteThis citation pertains to intake: MI00151683. Based on interview and record reviews the facility staff failed to follow the facility policy on capacity decision making for one (R402) of four residents reviewed for the accuracy of medical records.

Inspectors wroteThis intake pertains to MI00149760. Based on observation, interview, and record review, the facility failed to provide safe, operational mechanical lifts for three Residents (R502, R503, R504) of four residents reviewed for safe transfers and equipment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that grievances were promptly documented, investigated, tracked and resolved for four residents (R24, R30, R37, R40) of five residents that participate in the resident council (RC) meetings.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure services provided met professional standards of practice for four (R2, R45, R13, and R308) of four residents reviewed for professional standards.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate documentation of controlled substances for one (R258) of one resident reviewed for controlled medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were appropriately stored and in a safe/sanitary manner in three of four medication carts and one treatment cart reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate infection control practices related to transmission-based precautions (TBP) for two (R159 and R6) of three residents reviewed for infection control, resulting in the potential for the spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment that promoted and enhanced resident's dignity for multiple residents, including two (R50 and R259) of two residents reviewed for dignity and anonymous residents attending resident council.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident's right to personal privacy during treatment (lab draw) for one (R6) of one resident reviewed for privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure necessary documentation was completed, provide evidence of communication to the receiving facility, and completing the discharge process for one (R2) of one resident reviewed for hospitalization.

Inspectors wroteBased on record review and interview, the facility failed to ensure an admission medication order was followed for one (R38) of one resident reviewed for admission orders.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess and implement treatment orders, and identify skin changes and/or the worsening of pressure ulcers for two (R38 and R39) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to ensure two (Certified Nurse Aides - CNA 'L' and CNA 'P') of five CNAs reviewed for competency was evaluated for skills and techniques necessary to care for the needs of the residents.

Inspectors wroteBased on interview and record review the facility failed to ensure a Physician ordered laboratory (lab) diagnostic was completed for two residents (R47 and R52) of two residents reviewed for diagnostics.

Inspectors wroteBased on interview and record review, the facility failed to ensure collaboration with hospice representatives with one (R32) of one resident reviewed for hospice services, resulting in hospice not informed of clinical and intervention changes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure nurse staffing information was readily accessible for all 79 residents and/or families/visitors in the facility, resulting in necessary staffing information not being available.

Inspectors wroteThis citation pertains to Intake MI00147673 Based on observation, interview and record review facility failed to follow-up and resolve grievances for one (R503) of three residents reviewed for grievances.

Inspectors wroteThis citation pertains to intake #MI00147673. Based on interview and record review, the facility failed to ensure an allegation of abuse/neglect/mistreatment was reported to the State Agency (SA) for one resident (R501) of three residents reviewed for abuse/neglect/mistreatment.

Inspectors wroteThis citation pertains to intake #MI00147673. Based on interview and record review, the facility failed to ensure bed mobility was completed according to the plan of care for one resident (R501) of three residents reviewed for abuse/neglect/mistreatment.

Inspectors wroteThis citation pertains to intake #MI00147673. Based on interview and record review, the facility failed to ensure a Certified Nursing Assistant (CNA) was provided required training on abuse policies/procedures prior to working with residents in the facility for one resident (R501) of three residents reviewed for abuse/neglect/mistreatment.

Inspectors wroteThis citation pertains to intake #'s MI00146745, MI00147112, MI00147118. Based on observation, interview and record review, the facility failed to document follow-up and resolve grievances/concerns for one resident (R901) of two residents reviewed for dignity/respect.

Inspectors wroteThis citation pertains to intake: MI00146135. Based on interview and record reviews the facility failed to develop and implement a comprehensive person-centered care plan to address the urinary diagnoses for one (R303) of four residents reviewed for quality of care.

Inspectors wroteThis citation pertains to Intake #MI00145683 and MI00145247 Based on interview and record review, the facility failed to ensure timely showers were provided for one (R302) of two residents reviewed for Activities of Daily Living (ADL).

Inspectors wroteThis citation pertains to intake: MI00146135. Based on interview and record reviews the facility failed to obtain an adequate assessment, notify the physician of the change in condition and ensure the timely transfer to a higher level of care, for one (R303) of four residents reviewed for quality of care.

Inspectors wroteThis citation pertains to intake: MI00146135. Based on interview and record reviews, the facility failed to ensure an order for oxygen was continuously administered as prescribed by the physician, for one (R303) of two residents reviewed for oxygen administration.

Inspectors wroteThis citation pertains to Intake: MI00145107. Based on interview and record reviews the facility failed to implement an effective baseline care plan to ensure the necessary care was provided to one R402 of three residents (including R405) reviewed for a change of condition.

Inspectors wroteThis citation pertains to intake: MI00144714. Based on interview and record review the facility failed to ensure a change of condition was timely addressed and accurately reported for one (R403) of three residents reviewed for a change of condition.

Inspectors wroteThis citation pertains to intake: MI00144428. Based on interviews and record reviews the facility failed to accurately document and address the concerns verbalized for one (R402) of two residents reviewed for quality of care.

Inspectors wroteThis citation pertains to intake: MI00144428. Based on interviews and record reviews the facility failed to ensure consistent physician monitoring and follow-up of vaginal/urinary concerns for one R402 of two residents reviewed for quality of care.

Inspectors wroteThis citation pertains to intake: MI00144428. Based on interviews and record reviews the facility failed to ensure laboratory services for a urinalysis and culture/sensitivity test were completed as ordered and ensured the timeliness of a urinalysis results were processed, obtained, and reported to the physician for follow-up for one (R402) of two residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store/label food items, and 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 observations, interviews and record reviews, the facility failed to complete a resident self-administration of medication assessment for four (R's 5, 17, 35 & 52) of four residents reviewed for medications observed at the bed side.

Inspectors wroteThis citation contains two Deficient Practice Statements (DPS). DPS# 1 Based on interview and record review the facility failed to ensure a dementia medication was continued for one (R69) of one resident reviewed for a death closed record review.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure coordination of behavioral health services for three (R2, R43, and R58) of five residents reviewed for behavioral care, resulting in delayed and/or unmet mental and psychosocial care needs, staff to be unaware of individualized approaches or targeted behaviors, and the inability to monitor the effectiveness of the prescribed treatment due to lack of documented supporting evidence.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that medically-related social services were adequately provided to four (R2, R37, R43, and R58) of five residents reviewed for social services, resulting in insufficient/ineffective mood and behavior monitoring, inaccurate social service assessments to effectively monitor and/or address changes in mental and psychosocial health needs, patient advocacy, and coordination with behavioral care.

Inspectors wroteR41 On 10/24/23 at 10:32 AM, R41 was observed in their room walking from bathroom to the side of bedroom and sat in chair. R41 sat down and crossed legs and asked what did I need. R41 was interviewed and asked about the care, R41 shrugged their shoulders and stated ok. Record review revealed that R41 was admitted to the facility on [DATE] with Brief Interview for Mental Status(BIMs) of 5 with the medical diagnosis of Parkinson's Diseases, Sarcopenia and Major depressive disorder, recurrent sever with psychotic symptoms. Upon a record review of R41's medication, R41 was prescribed Olanzapine 10milgram(mg) one time a day at bedtime for bipolar initiated for 8/1/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for two (R2 and R37) of five residents reviewed for mood/behavioral care plans, resulting in the potential for unmet care needs.

Inspectors wroteBased on observation, interview and record review the facility failed to address recommendations from Physical Therapy (PT) to ensure restorative care was provided to maintain functional mobility status for one resident (R53) of two residents reviewed for Range of Motion (ROM)/Physical Therapy.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to implement adequate and resident specific interventions to prevent further falls for a resident with a history of falls, one (R62) of one resident reviewed for falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper management of tube feeding including labeling on the formula to ensure appropriate administration in accordance with physician orders for one(R39) for tube feeding, resulting in the potential for inaccurate tube feeding administration.

Inspectors wroteThis citation pertains to Intake #MI00137799 Based on interview and record review the facility failed to thoroughly assess and ensure professional standards of care were followed for a resident expressing concerns of pain and change in condition for one (R904) of three residents reviewed for pain, resulting in R904 calling 911 on their own to ensure hospitalization, arriving at the emergency department tachycardic (rapid heart rate) and hypotensive (blood pressure 77/62) and continued hospitalization following a surgical procedure for a left groin hematoma. Findings Include: A complaint was filed with the State Agency (SA) that alleged R904 made concerns to nursing staff that noted they were not doing well and had terrible leg pain. Nursing staff did not take them seriously and they had to call 911 on their own to ensure they were taken to the Hospital. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure consistent and comprehensive skin assessments and implement interventions for one (R912) resident reviewed for pressure ulcers (PU), resulting in R912 developing an unstageable PU(Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar).

Inspectors wroteThis citation pertains to intake #MI00139048 Based on observation, interview and record review, the facility failed to ensure medications were available for administration and the Physician was notified of missed doses of medication for one resident (R908) of one resident reviewed for Nursing standards of practice.