Optalis Health & Rehabilitation Of Bloomfield Hill

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the right to examine or obtain the patient's Health Record. Health Information Management/Medical Record Department will .Make the Health Record available for inspection or copying, or both, at the facility's business location during regular business hours or provide a copy of all or part of the Health Record, as requested by the resident or his or her authorized representative .Per Federal regulations, residents will have access to their Health Records within 24 hours of request, during normal business hours .On 9/17/25 at 9:10 AM, an interview was conducted with Administrator 'I'. When queried about what was going on with Resident R705's medical records being provided to RR 'J', Administrator 'I' reported she was required to sign a form and refused to do so, per the grievance form from 5/20/25. Administrator 'I' reported RR 'J' did eventually receive the medical records she requested. When queried about the time frame between when RR 'J' first requested the medical records and when she actually received them, Administrator 'I' did not know. On 9/17/25 at 9:49 AM, an interview was conducted with Medical Records Staff (MR 'E'). MR 'E' reported she had not received any requests to provide medical records to RR 'J' regarding Resident R705. On 9/17/25 at 10:59 AM, it was confirmed via email with RR 'J' that the facility provided on 6/5/25. RR 'J' reported they asked for Resident R705's medication list on 3/7/25. RR 'J' was told by Administrator 'H' that MR 'E' was out on 3/7/25 but would be back that Monday (3/10/25) and would ensure they received a copy of the most recent medication list. RR 'J' said that did not happen. Nothing was received until 6/5/25. On 9/17/25 at 3:03 PM, Administrator 'I' reported she spoke with RR 'J' on that day and was informed she received Resident R705's medical records in June 2025.

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health & Rehabilitation of Bloomfield Hill

2975 N Adams Road Bloomfield Hills, MI 48304

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

of opened disposable bathing wipes. When asked, CNA C could not confirm whether the bagged linen was clean or dirty and was observed removing from the room. The entire floor of the shower room was observed with dark soiled matter throughout. The drain located under the shower bed was observed with two large piles of human hair, broken plastic razor caps, and small antlike insects actively crawling under shower bed.

The shower bed middle wheel was observed tangled with large amounts of human hair. The pink and white shower chair was observed storing 6 bottles of half used shower gels. The pink bathing seat was observed with black film discoloration in the creases and seams of the seat.On 9/17/25 around 9:45 AM, the community room on the first floor where the vending machines are stored, was confirmed by the NHA as a room open to the residents, staff, and visitors, revealed unlocked cabinets storing Personal Protective Equipment (PPE), including boxes of facemasks and gowns. A full box of opened 3-millimeter (ml) hypodermic syringes were also observed under the kitchen cabinets. One coffee end table was opened and contained an empty used juice bottle and storing electrical equipment. A second coffee end table was opened and revealed moderate amounts of orange cracker crumbs and a white toothbrush. Food crumbs and debris were noted amongst the entire carpeted room including the entire perimeter of floor, under tables and chairs, windows, and cabinets.On 9/17/25 around 10:00 AM, The Administrator and Housekeeping Director D were requested and toured the facility areas and acknowledged the areas in question were unkempt.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health & Rehabilitation of Bloomfield Hill

2975 N Adams Road Bloomfield Hills, MI 48304

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684

7/29/2025 at 23:07-Gabapentin Oral Solution 250 MG/5ML-Awaiting pharmacy.

Level of Harm - Minimal harm or potential for actual harm

7/30/20250 at 6:51-Gabapentin Oral Solution 250 MG/5ML-Awaiting pharmacy.

Residents Affected - Few

8/16/20250 at 6:40-Dicyclomine HCl Oral Solution 20 MG/10ML-Awaiting Pharmacy. 8/16/2025 at 12:20-Dicyclomine HCl Oral Solution 20 MG/10ML-On order. 8/22/2025 at 06:56-Gabapentin Oral Solution 250 MG/5ML-medication not available, Pharmacy stated medication is not due for refill until tomorrow. Will notify MD (medical doctor). 8/22/2025 at 13:19-on order.

A review of Resident R703's June 2025 MAR (Medication Administration Record) revealed the following medications that were not administered: Lovenox Injection Solution Prefilled Syringe 120 MG/0.8ML (Enoxaparin Sodium)-Inject 0.74 ml subcutaneously one time a day related to PERSONAL HISTORY OFPULMONARY EMBOLISM-6/24 (1000) dose, cloBAZam Oral Suspension 2.5 MG/ML (Clobazam) Give 8 ml via J-Tube every 12 hours for seizure-6/23 (2100) dose. Lacosamide Oral Solution 10 MG/ML (Lacosamide) Give 5 ml by mouth every 12 hours for seizure-6/23 (2100) dose. LaMICtal Tablet 100 MG (LamoTRIgine) Give 1 tablet by mouth two times a day related to CONVERSION DISORDER WITH SEIZURES OR CONVULSIONS-6/24 (0600) dose. PriLOSEC OTC Oral Tablet Delayed Release 20 MG (Omeprazole Magnesium) Give 1 tablet via PEG-Tube two times a day related to GASTRO ESOPHAGEAL REFLUX DISEASE WITHOUT ESOPHAGITIS-6/25 (1700) dose. busPIRone HCl Oral Tablet 10 MG (Buspirone HCl) Give 1 tablet via J-Tube every 8 hours related to ATTENTION-DEFICIT HYPERACTIVITY DISORDER, UNSPECIFIED TYPE-6/24 (2200) dose, 6/25 (0600) dose, (1400) dose, (2200) dose. Dantrolene Sodium Oral Capsule 25 MG (Dantrolene Sodium) Give 1 capsule via J-Tube every 8 hours related to EPILEPSY, UNSPECIFIED,NOT INTRACTABLE, WITHOUT STATUS EPILEPTICUS-6/24 (2200) dose, 6/25 (0600) dose, (1400) dose, (2200) dose. Gabapentin Oral Solution 250 MG/5ML (Gabapentin) Give 2 ml via PEG-Tube every 8 hours for pain-6/24 (0600) dose. Neomy-Bacit-Polymyx-Pramoxine External Ointment 1 % (Neomycin-Bacitracin-Polymyxin-Pramoxine) Apply to peg site topically three times a day for rash-6/24 (0600) dose, (1300) dose, (1700) dose, 6/25 (0600) dose, (1700) dose, 6/26 (0600) dose, (1300) dose, (1700) dose, 6/28 (0600) dose, (1300) dose, (1700) dose, 6/29 (0600) dose, (1300) dose, Dicyclomine HCl Oral Solution 10MG/5ML (Dicyclomine HCl) Give 10 ml via PEG-Tube every 6 hours related to GASTROPARESIS-6/24 (0600) dose. Zinc Oxide External Paste 40 % (ZincOxide (Topical)) Apply to peg site topically four times a day for rash-6/24 (0600) dose, (1300) dose, 6/25 (1700) dose.

On 9/17/25 at approximately 10:13 a.m., during a conversation with the Director of Nursing (DON), The DON was queried regarding Resident R703's not receiving their medications for multiple days after they were readmitted from the hospital on 6/23/25. The DON reported the Nursing staff have a process that should be followed to ensure medications are available for the next ordered administration times including utilizing the backup supply, and the drop ship method (a faster option to get medications delivered). The DON was queried regarding regular supply reordering of medications and they reported that the Nursing staff should be reordering medications two-three days before a resident runs out to ensure an uninterrupted supply is maintained. The DON was queried if residents should have their medications administered as ordered and

they indicated that they should. The DON reported the facility had recently switched to a new pharmacy to try to ensure medications were available to be administered.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health & Rehabilitation of Bloomfield Hill

2975 N Adams Road Bloomfield Hills, MI 48304

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

practitioner after readmission. A review of a Physician progress note dated 8/27/25 revealed, .Spoke with

the patient's daughter yesterday considering .his agitation while being on Seroquel 12.5 (MG). Currently his Seroquel is 25 MG, psychiatry not on the case anymore. Today I discussed with social worker as well as nursing manager concerning patient's behaviors .we will continue 25 MG .On 9/17/25 at approximately 12:40 PM, an interview was conducted with the DON and the Administrator. When queried about the process for monitoring residents on psychotropic medications, the DON reported residents on psychotropic medications were referred to the psychiatrist. The DON reported the resident, or the resident representative gave consent for the mental health services and the behavioral health team or nursing was required to update and obtain consent from the resident representatives if changes were made or behaviors increased.

When queried about why Resident R705 was not seen by a psychiatry practitioner since 12/5/24, the DON reported RR 'J' refused services with Physician 'K' who was the facility's contracted psychiatrist. The DON further explained there is a psychiatric NP who came on Mondays, but Resident R705 was at dialysis during the time she came so he was not seen. When queried about what was done to try to accommodate Resident R705's schedule and the wishes for Physician 'K' not to see Resident R705, the DON reported the social services department was responsible to coordinate that. When queried about what the family's concern was regarding the Seroquel dose adjustment on 8/7/25, the DON reported family was upset about the adjustment and social services was told to follow up with psychiatry services.On 9/17/25 at 12:52 PM, an interview was conducted with Social [NAME] Director, Social Worker (SW) 'L'. When queried about why Resident R705 had not been seen by a psychiatry practitioner since 12/5/24, SW 'L' reported family did not want Physician 'K' to see him and the Psychiatric NP came on a day Resident R705 was at dialysis, so he was always missed. SW 'L' reported they just put virtual visits in place. When queried about when those occurred, SW 'L' reported they had not yet happened. When queried about why Resident R705's Seroquel dose was reduced on 8/7/25 to 12.5 MG at bedtime, who changed the order, and whether consent was obtained from RR 'J', SW 'L' reported she would look into it.On 9/17/25 at 3:10 PM, SW 'L' followed up and reported Physician 'K' saw Resident R705 on 8/6/25 and provided a printed-out consultation. SW 'L' reported the facility did not have the consultation on file in the medication record and that they just obtained it from Physician 'K'. SW 'L' reported it was not until 8/25/25 that RR 'J' requested that Physician 'K' did not see Resident R705 any longer. SW 'L' did not provide an explanation of why Resident R705 was not seen by a psychiatry practitioner between 12/5/24 and 8/6/25 and confirmed no conversation was had with RR 'J' regarding the reduction in dose of Seroquel on 8/7/25 and consent was not given. A review of the consultation provided indicated Physician 'K' signed the document on 9/17/25 at 3:04 PM, six minutes prior to SW 'L' providing the document. A review of a facility policy titled, Psychotropic Medication Use, revised 4/18/25, revealed, in part, the following, .Informed consent .For any resident taking

a psychotropic mediation, The Social Service employee .will obtain informed consent from the resident and/or authorized representative .The Social Service employee .will review the medication prescribed, dosage, side effects, and risks versus benefits of the medication .A review of a facility policy titled, Social Services, revised 3/10/25, revealed, in part, the following, .The social worker .tasks include but are not limited to .Providing or arranging psychiatric or counseling services .

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health & Rehabilitation of Bloomfield Hill

2975 N Adams Road Bloomfield Hills, MI 48304

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0791

Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or potential for actual harm

This citation pertains to Intake 1191435Based on interview and record review the facility failed to obtain requested and ordered services to be seen by an Oral Surgeon for two surgical teeth extractions to meet a needed escalation of dental care for one resident (Resident R701) of one reviewed for dental services. Findings include:Clinical record review revealed Resident R701 had a medical diagnosis including diabetes, morbid obesity, heart disease, seborrheic dermatitis (chronic inflammatory skin condition), and schizoaffective disorder, bipolar type (bouts of hypomania, mania, and depression)On 9/16/25 at 9:30 AM, during an interview , Resident R701 stated they had two molars that need to be removed but the facility never followed through setting up

an appointment.Requested medical records for Resident R701 from March 2025 were reviewed and revealed on 3/5/2025 Resident R701 was seen at bedside by a Dentist related to tooth pain in their lower right side. Treatment notes documented Resident R701 had severely decayed teeth #30, #31 (Tooth number 30 is the lower right first molar; Tooth number 31 is the lower right second molar.) and Resident R701 would need surgical extractions with sedation due to their agitation.Action Required by Nursing Home Staff.Refer to oral surgeon for extraction #30, #31. The Dental Provider further documented rewrote orders today (3/5/2025), spoke to the floor Nurse, and gave prescription for Clindamycin (antibiotic).Further record review revealed the Nurse who ordered the Clindamycin on 3/5/25 was the current Director of Nursing (DON) and on 9/17/25 around 3:00 PM was questioned why Resident R701 was not referred to an Oral Surgeon as ordered. The DON recalled Resident R701 being sent to the hospital on 3/6/25 and could not confirm nor deny why the orders were not followed through or documentation of not being sent upon his readmission to the facility on 3/20/2025.Review of the facility policy titled Dental Services dated 4/2019 documented.Referrals to dietician, speech therapist, physician, or dental provider shall be made as appropriate.The facility will, if necessary or requested, assist

the resident with making dental appointments and arranging transportation to and from the dental services location.All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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