Optalis Health And Rehabilitation Of Grand Rapids

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

procedures that include: Reporting any allegations of abuse, neglect, mistreatment, exploitation, and misappropriation or resident property including reporting a reasonable suspicion of a crime to the State Survey Agency and other officials in accordance with state law . The facility will ensure that all allegations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, and crimes are reported immediately to the Administrator and: Reported to the State Survey Agency immediately but not later than two hours after the allegation is made if the allegation involves abuse or results in serious bodily injury and to other officials (including adult protective services and/or law enforcement, when applicable) OR Reported to the State Survey Agency no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury to the State Survey Agency and to other officials (including adult protective services and/or law enforcement, when applicable) .

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids

1950 32nd Street SE Grand Rapids, MI 49508

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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

did not have concerns that Resident #504 had a fracture. On 9/3/25 at 2:45 PM and 9/4/25 at 7:45 AM, this writer attempted to contact MD E via telephone. This writer was not able to speak to MD E prior to survey exit. Review of the facility's Abuse policy dated 4/13/22 revealed, Policy Overview: Residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. This includes, but is not limited to, freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint that is not required to treat the patient/resident's medical symptoms. The facility will develop and implement written policies and procedures that include: Screening potential employees and prospective residents . Investigating allegations of abuse, neglect, misappropriation, mistreatment, and exploitation to include protecting residents during the investigation, and taking necessary actions as a result of the investigation . Investigation: Key to investigating abuse allegations is an environment that facilitates the reporting of such allegations. Once reported, the center conducts a timely, thorough, and objective investigation of any allegation of abuse. It is the Center's policy to investigate all alleged violations involving Abuse, Neglect, Misappropriation of Resident Property, Exploitation or Mistreatment, including Injuries of Unknown Source to ensure that all individuals who report such incidents and allegations are free from retaliation or reprisal for reporting the incident. Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. Report the results of all investigations to the administrator or designee and to the State Agency in accordance with State law. The investigation process includes: Identifying staff responsible for the investigation, Determining the purpose of the investigation and issue(s) to be investigated, whether or not the alleged violation has occurred, the extent, and cause, Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations (such as other residents, family members, staff who worked closely with the alleged perpetrator and/or alleged victim), Conducting

observations of the alleged victim, including identification of any injuries as appropriate, the location where

the alleged situation occurred, interactions and relationships between staff and the alleged victim and/or other residents, and interactions/relationships between resident to other residents as applicable, Identifying and reviewing all relevant medical records and facility documentation as applicable, If the alleged perpetrator is a staff member, review their employment records, Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence), Providing complete and thorough documentation of the investigation, After completion of the investigation, the evidence should be analyzed, and the Administrator or designee will make a determination regarding whether the allegation is substantiated or unsubstantiated. The Administrator will determine if modifications to existing policies and procedures (or new policies and procedures) are needed to prevent similar incidents or injuries from occurring in the future in accordance with its QAPI Plan. The quality assurance investigative materials will be reviewed by the quality assurance committee in accordance with the facility QAPI Plan.

The quality assurance committee will take all actions deemed necessary based upon their review

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids

1950 32nd Street SE Grand Rapids, MI 49508

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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

ADON M confirmed that the facility missed obtaining treatment orders for Resident #504's wound. In an

interview on 9/4/25 at 11:23 AM, Director of Nursing (DON) B reported that she thought that Resident #504 was being followed by the wound care team. DON B was not able to report what treatment orders were in place for Resident #504's wound. In an interview on 9/4/24 at 10:38 AM, Wound Care Provider (WCP) AA reported that she had not assessed Resident #504's wound, and she did not see Resident #504. WCP AA confirmed that Resident #504 was at high risk for pressure ulcer development, and that he did have a skin integrity plan in place from his previous admission to the facility. It was noted that Resident #504's Care Plan was not updated when he was re-admitted to the facility on [DATE REDACTED]. Review of the facility's Skin and Wound Guidelines policy dated 3/5/24 revealed, Policy Overview: To describe the process steps required for identification of residents at risk for the development of pressure injuries, identify prevention techniques and interventions to assist with the management of pressure injuries and skin alterations . Treatments: treatment options are selected based upon the type of wound, tissue type, exudate, condition of the peri wound, pain, the need for protection of the wound bed, the goal of treatment, and manufacturer's recommendations for product utilization. Treatments are ordered by the medical practitioner. A complete treatment order consists of the following: Site of application, type of skin alteration or treatment needed, cleaning agent, if indicated. Frequency, including end date orders if applicable. Directions for use, if applicable. Primary and secondary dressing, if applicable. Type of securement, if applicable .

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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids

1950 32nd Street SE Grand Rapids, MI 49508

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 0689 Level of Harm - Actual harm Residents Affected - Few

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

time.Routinely incontinent (bowel and/or bladder).Moderate/severe unsteadiness - requires physical assist.Safety Awareness: .Lack of understanding of physical and cognitive limitations.Review of Resident #503's cognition care plan, revised 07/02/2025, stated, The resident (Resident #503) has impaired cognitive function/dementia or impaired thought process r/t (related to) Alzheimer's, Dementia.Staff to anticipate her (Resident #503) needs aeb (as evidenced by) non-verbal communication, provide safety and comfort. Review of the facility's Activities of Daily Living (ADL) policy, revised 12/7/2023, stated, Appropriate care and services will be provided for residents who are unable to carry out ADL independently.including appropriate support and assistance with.Elimination (toileting).

Event ID:

Facility ID:

If continuation sheet