The 300 Hall sat unattended from 6:30 PM to 11:00 PM while managers refused to come to the facility or answer emergency calls from staff, according to federal inspection records. Multiple residents missed critical medications during the crisis.
"We were always short," said RN LLL, who was assigned to the 400 Hall that night. "Staffing was definitely an issue that night." The nurse recalled that management was "fully aware" of the staffing crisis but would not assist when the facility was short-staffed.
Agency LPN JJJ, working the 100 Hall, confirmed no nurse was assigned to the 300 Hall for the four-hour period. "I canceled all my shifts after that," the nurse told inspectors. "I did not feel safe working there."
The crisis repeated itself the following day. On October 19, RN PPP arrived to find the 300 Hall again without nursing coverage. "It was horrible because a lot of people did not get their medications," the nurse reported. The previous night's nurse had locked keys in the medication cart and left without giving verbal report.
LPN OOO described working one shift with 56 residents under her care. "They were telling me I had to work like that. I told them there are people who are a fall risk, people with mental health issues. I told them it's not safe. I am not going to put these people's lives in jeopardy."
The nurse called that shift "the most nerve-wracking night of my life." She discovered the assignment only when a nursing assistant asked for pain medication for a resident. The previous nurses had locked keys in the medication cart and left without report.
"I never got report or nothing about that hall or any of those patients," LPN OOO said.
Former Assistant Director of Nursing MMM claimed the facility was "at State minimums" for staffing on October 18, despite acknowledging that multiple residents missed medications that evening.
The pattern continued beyond October. LPN QQ reported the same scenario on October 26, when no nurse took responsibility for the 300 Hall, resulting in missed medications. On October 12, an agency nurse arrived but "refused the assignment, saying she wasn't going to put her license at risk."
Staff attempts to reach management proved futile. "To call them was a waste of time. They wouldn't do anything," LPN QQ told inspectors. The nurse tried contacting the on-call manager, scheduler, and regional manager with no response.
"This is why it didn't matter if you called the on-call because nothing would be done," LPN QQ said.
The facility also failed to maintain accurate medical records for residents' end-of-life wishes. Resident #111 had a signed do-not-resuscitate order, but the facility's electronic system showed him as "Full CPR." Assistant Director of Nursing C confirmed the records "did not match" and said the order was entered incorrectly when the resident returned from the hospital.
Inspectors observed serious infection control violations during incontinence care. Two nursing assistants cleaned bowel movement from a female resident's body, then handled her pillows and personal items with the same soiled gloves. One assistant wiped from back to front during cleaning and applied protective cream with contaminated gloves.
The resident, who had an indwelling catheter and frequent urinary tract infections, told inspectors that staff "generally do not change their gloves during incontinence care." Both nursing assistants confirmed they "typically don't" or "not usually" change gloves during such care.
Bathrooms in residents' rooms remained unsanitary for days. Inspectors found unflushed toilets with visible urine and feces, soiled briefs on floors, and brown splattered substances on toilet surfaces. One resident's family member reported the room "is unsanitary and smells of urine."
The inspection found Resident #103's toilet riser detached and lying on the bathroom floor with brown substance smeared on the bottom. Multiple observations over several days showed persistent urine odors and debris scattered across bathroom floors.
One bathroom floor was so dirty it felt "tacky when walked on," inspectors noted.
The violations affected dozens of residents across multiple areas of care, from life-threatening medication gaps to basic hygiene failures, while management remained unresponsive to staff pleas for help.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Optalis Health and Rehabilitation of Grand Rapids from 2025-01-14 including all violations, facility responses, and corrective action plans.
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