Optalis Health & Rehabilitation of Whitehall

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect the resident's (R6, R7, R9, R15, R26, R34, R35, R58 and F60) right to be free from mental abuse and verbal abuse by R52 resulting in fear and physical anguish in the resident's home.

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor weights in a CHF resident and drug allergies in one (R89) and failed to implement and monitor ace wrap orders for one (R40) of two residents reviewed for change in condition, contributing to R89's death in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent further pressure ulcer development for 1 resident (R7) out of 2 residents reviewed for pressure ulcers resulting in 3 facility acquired pressure ulcers for R7.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure sufficient staff were available to provide care and services for dependent resident's and meet resident needs including (R40 and R45) out of 87 residents who live the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the Director of Nursing (DON) from working as a nurse on the floor. This deficient practice affects all 89 residents who resided at the facility.

Inspectors wroteBased on interview and record review, the facility failed to implement policies and procedures to ensure an effective Compliance and Ethics program.

Inspectors wroteBased on interview and record review, the facility failed to document in the medical record in a complete, accurate, and timely fashion for 4 residents (R7, R52, R58 and R60) out of 19 sampled residents.

Inspectors wroteBased on observation and interview, the facility failed to maintain general cleanliness and repair of facility. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living of residents. Findings Include:On 03/03/2026 at 9:13AM, observed on wall near the nurses' station on 200 hall, a wall mounted mini-split unit had grey and green crusted material on the unit. This crusted material was observed both on interior of the mini-split and the face of the unit. On 03/03/2026 at 3:00PM during tour of facility with Maintenance Director (MD) R, MD R confirmed observation of crusted material on the mini-split and stated the mini -splits in the facility are not in use during the winter and were scheduled to be professionally cleaned before starting them up for the year. [...]

Inspectors wroteBased on interview and record review, the facility failed to honor the resident's right to set their own schedule for 1 resident (R24) out of 2 residents reviewed for dignified care.

Inspectors wroteBased on interview and record review, the facility failed to evaluate 1 resident (R6) out of 4 residents reviewed every 14 days before as needed benzodiazepine (psychotropic) medication was renewed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement and update individualized care plans for 3 residents (R6, R7, and R52) of 12 residents reviewed.

Inspectors wroteBased on interview and record review the facility failed to ensure medication was administered according to professional standards for 5 residents (R3, R24, R38, R93, R94) out of 19 residents reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide showers for 1 (R45) of 1 resident reviewed for showers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent falls and injuries for 1 Resident (R52) contributing to increase and likelihood of further injuries and potential for harm.

Inspectors wroteThis citation pertains to intake # 2695940 and 2690356Based on interview and record review, the facility failed to ensure that weights were obtained, and medications were administered in accordance with physician orders for 5 out of 7 residents (Resident #4, #8, #9, #10, and #11), reviewed for the provision of nursing services.

Inspectors wroteBased on observations, interviews and record review the facility failed to resolve grievances in a timely manner for 2 residents (R1 and R5) of 3 residents reviewed for grievances.

Inspectors wroteBased on observation, interviews and record review the facility failed to safely transfer with an electronic lift 2 of 2 residents (R5 and R6) reviewed for lift transfers.

Inspectors wroteThis citation pertains to intake 2590962. Based on observations, interviews and record review the facility failed to provide proper infection control for 1 Resident (R1) of 3 residents sampled for infection control.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sufficient staff to meet the needs of seven Residents on the 100 hall (R202, R207, R210, R212, R215, R216 and R207) and five residents on the 200 hall (R204, R206, R208, R211, and R214). Findings Include: Review of the staff schedules provided by the facility for 8/12/25 through 8/14/25 reflected that one Certified Nurse aide (CNA) was scheduled for the 100 hall and one CNA was scheduled for the 200 hall for each day, afternoon, and night shifts. A review of documentation provided by the facility reflected fourteen residents resided on the 100 hall and eight residents on the 200 hall. R202 - 100 HallR202 was admitted to the facility 7/10/2025 with diagnoses that include Muscular Dystrophy and Chronic Obstructive Pulmonary Disease. [...]

Inspectors wroteThis citation pertains to intake #MI00152587 Based on interview and record review the facility failed to follow professional standards for three of three residents (Resident #100, Resident #109, and Resident #113) reviewed for medication administration.

Inspectors wroteThis citation is related to intakes MI00152587, MI00152791, and MI00152955. Based on observation, interview, and record review, the facility failed to provide meal assistance to one of four residents (Resident #116) reviewed for accommodation of needs.

Inspectors wroteBased on interview and record review, the facility failed to 1.) provide care following professional standards of practice and facility policy to prevent the development of a pressure injury, 2.) promptly notify the provider of a new pressure injury, 3.) promptly notify the DPOA (Durable Power of Attorney) of a new pressure injury and subsequent treatment changes, and 4.) ensure ordered treatments were completed for 1 of 4 residents (Resident #106) reviewed for pressure injury prevention/management.

Inspectors wroteThis citation pertains to intake # MI00149091 and MI00150877 Based on observation, interview and record review, the facility failed to follow physician ordered wound care and provide care to prevent the development of skin breakdown/pressure injuries for 6 residents (Resident #302, #303, #311, #316, #317, and #318) out of 9 reviewed for alterations in skin integrity.

Inspectors wroteThis citation pertains to intake # MI00150877 Based on interview and record review, the facility failed to 1.) ensure residents received care and services following provider orders, 2.) identify and notify the physician a change in condition, and 3.) ensure complete and accurate medical records, for 1 resident (Resident #302) out of 3 residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively clean and maintain food service equipment, and date mark potentially hazardous food item potentially affecting 68 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage.

Inspectors wroteBased on interview and record review, the facility failed to implement a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, and visitors to prevent the spread of an illness/outbreak.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide for the needs of four of four residents (Resident #45, Resident #67, Resident #62, and Resident #7) reviewed for accommodation of needs.

Inspectors wroteThis citation refers to MI00147849 and MI00148347. Based on interview and record review, the facility failed to protect the residents' right to be free from verbal and mental abuse by staff for 5 of 24 residents (R8, R12, R35, R53, and R68), resulting in residents being verbally abused.

Inspectors wroteThis citation refers to MI00147849 and MI00148347. Based on interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act and report within a timely manner to facility management and the State Survey Agency allegations of verbal and/or mental abuse by staff for three of 24 residents (R12, R35, and R53), resulting in a delay in investigating allegations of abuse and the potential for residents to not be protected from abusive individuals

Inspectors wroteBased on interview and record review, the facility failed to 1.) administer controlled medications following professional standards of practice, 2.) ensure medications were administered following the physician ordered parameters, and 3.) accurately transcribe/order a newly admitted resident's antipsychotic medication, for six of 12 residents (Resident #5, #46, #7, #2, #24, and #68) reviewed for medication administration, resulting in missed doses of medication, medication administration errors, and the inaccurate documentation of the administration of controlled drugs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quality care to three of three residents reviewed (Resident #14, Resident #3, and Resident #19) resulting in untreated significant swelling in the feet for R14, an order to change tube feed guidelines for R3 to be missed, and a delay in treating a urinary tract infection for R19.

Inspectors wroteThis citation is related to intake # MI00148049 Based on interview and record review, the facility failed to prevent the misappropriation of controlled substances for three (Resident #35, Resident #5, and Resident #174) of three residents reviewed.

Inspectors wroteBased on observation and record review, the facility failed to utilize foot rests on a wheelchair for two of four residents (Resident #44 and Resident #62) reviewed for accidents and hazards.

Inspectors wroteBased on interview and record review, the facility failed to ensure that pharmacy recommendations are received by the facility and reviewed by the physician for 1 of 5 residents (R53) reviewed for monthly pharmacy medication regimen reviews, resulting in the facility and physician not being aware of a pharmacy recommendation for R53 and the potential for an adverse outcome from medications and/or lack of assessment and monitoring of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure unattended medication carts for three of five carts reviewed and failed to label opened medications according to industry standards.

Inspectors wroteBased on interview and record review, the facility failed to 1.) implement an antibiotic stewardship program and 2.) ensure accurate monitoring and antibiotic use for two of 5 residents (Resident #45 and #5) reviewed for antibiotic use, resulting in inappropriate antibiotic utilization and the potential for antibiotic resistance.

Inspectors wroteBased on interview and record review, the facility failed to provide the pneumococcal immunization per consent and the recommendation by the Centers for Disease Control and Prevention (CDC) for three (Resident #18, #4, and #56) out of 5 reviewed for immunizations, resulting in residents not receiving the pneumococcal immunization.

Inspectors wroteThis citation pertains to intake #: MI00146305 and MI00146949 Based on interview and record review, the facility failed to 1.) assess and monitor pressure injuries/wounds, 2.) ensure pressure injury/wound assessments were complete, accurate, and documented in the resident record, 3.) notify the provider and the DPOA (Durable Power of Attorney) of new pressure injuries/wounds, and 4.) provide physician ordered treatments/assessments and ensure treatments were in place for pressure injuries/wounds for 4 of 4 residents (Resident #7, #8, #1, and #9) reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to: 1) develop and utilize an effective antibiotic stewardship program to ensure an accurate and effective program for tracking and monitoring antibiotic use potentially affecting all 79 residents who reside at the facility, 2) follow through with laboratory orders and implement antibiotic stewardship for 1 (Resident #8) of 2 residents reviewed for antibiotics/unnecessary medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure acceptable standards of practice were observed during medication administration on the 400 Hall.

Inspectors wroteThis citation pertains to intake M100140413 Based on observation, interview and record review, the facility failed to properly assess, document, monitor changes in condition, provide medication timely and accurately, and per standards of practice accurately document medication administration, and provide resident incontinence care for 5 residents (R39, R49, R11, R281, R8) of 5 residents reviewed for quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standards of practice for 1 of 1 resident ( R400) reviewed for tube feeding, resulting in the potential for contaminated equipment introducing pathogens into the resident, and the potential for choking or aspiration and the resident unable to call for help.

Inspectors wroteBased on interview and record review, the facility failed to assure that a Registered Nurse was on duty for eight consecutive hours a day, seven days a week.

Inspectors wroteBased on observation and interview, the facility failed to secure controlled substances in one of two medication storage refrigerators.

Inspectors wroteR66 Review of the medical record reflected R66 was admitted to the facility 1/31/24 with diagnoses that included Left Below the Knee Amputation, Wound Infection, and Morbid Obesity. On 2/27/24 at 11:06 AM, R66 was observed laying in bed on sheets stained with what appeared to be drainage from a dressed wound on the right lower extremity. On the opposite side of the bed the sheet was also stained from drainage that appeared to be from the wound of the left leg stump. The sheet had holes in the upper half of the sheet toward the head of the bed. On 2/28/24 at 12:20 PM, R66 was observed lying in bed on the sheet with holes but the wound drainage stains previously noted covered a greater areas. It was observed that the dressing on the right lower extremity appeared fresh and was dated 2/28/24. Also observed was a wet, brown-tinged, dated dressing was on the floor next to the bed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Annual forms were fully completed for 1 resident (R44) out of 3 residents reviewed for Advance Directives and for their ability to participate in decision making.

Inspectors wroteBased on interview and record review, the facility failed to report timely an allegation of abuse for one Resident (Resident#180).

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain basic personal hygiene for one Resident (Resident #66).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement positioning supportive care for 1 (Resident #48) of 3 residents reviewed for position and mobility.

Inspectors wroteBased on observation, interview and record review, the facility failed follow physician orders to provide the necessary respiratory care and services for 1 residents (R21) of 3 residents reviewed for utilizing the use of oxygen equipment.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess, monitor, and provide pain management for 1 (Resident #39), resulting in not following physician orders and not accurately documenting in the medical record.

Inspectors wroteBased on interview and record review, the facility failed to ensure Doctor Ordered medications were obtained from the Pharmacy and available to be administered to one Resident (Resident #27).

Inspectors wroteBased on observation, interview, and record review, the facility failed to safeguard the confidentiality of medical records for 2 of 79 facility residents (R36 and R69), resulting in the potential for unauthorized access to the medical records, and the potential for the loss of resident privacy and confidentiality of their personal health information.

Inspectors wroteBased on interview and record review, the facility failed to give the appropriate notice of termination of Medicare Part A coverage to the resident/responsible party for 3 of 3 residents (R10, R49, and R285) reviewed and potentially affecting an additional 16 of 79 current facility residents who were given notice of termination of Medicare Part A coverage in the last six months.