Optalis Health And Rehabilitation Of Grand Rapids

F 0730

Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or potential for actual harm

Based on interview, and record review, the facility failed to ensure Certified Nursing Assistants (CNA's) yearly performance review was conducted resulting in the potential for CNA's to not be able to safely provide necessary care and services to residents, a lack of training, and the potential for unmet care needs.Findings include: On 10/23/25 at 12:48 PM, this writer requested verification of annual performance reviews for five sampled CNA files: (CNA H, M, OO, PP, and QQ). The facility was unable to provide the requested information. In an interview on 10/23/25 at 1:06 PM, Nursing Home Administrator (NHA) A reported that the facility had not completed annual performance reviews for the CNA staff.

Residents Affected - Many

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

11/24/2025

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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

nurses and (Nursing College) student nurses for Rotation 1 (October 6th, 7th, 9th, and 10th) in attendance were re-educated on October 9, 2025, by the DON and/or Designee on: Medication Administration policy.and Verification of resident identity prior to medication administration utilizing name verification and/or resident photo.12. Medication Skills Checklists were completed with all licensed nurses, including agency nurses. 13. Education was started with all licensed nurses were educated on BSN436: Concepts of Nursing III on October 21, 2025. No licensed nurse will work without completion of this education. 14. Attendance was documented via an in-service log. An audit was conducted of all licensed nurses to verify completion of education. 15. New hires will receive the same education prior to assuming independent medication administration responsibilities. Agency nurses booking future shifts with the facility will be educated on the facility's Medication Administration policy and BSN436: Concepts of Nursing III. Per interviews on 10/22/25,

the facility has been completing this. B. Plan of Correction1. The Director of Nursing and/or Designee will conduct direct observation of medication passes for 5 nurses weekly for four weeks then monthly until substantial compliance is met. 2. Daily audits of MAR documentation will be completed by the DON and/or Designee for thirty days. 3. All medication errors will be reviewed in daily clinical stand-up and QAPI meetings to identify patterns and prevent recurrence.4. (Nursing College) nursing students who attended Rotation 2 (October 20th, 21st, 23rd, and 24th) were educated on the facility's Medication Administration policy on October 20, 2025. 5. Inter-Disciplinary Team met for an ad-HOC QAPI to review the facility's Intern and Student Nurse policy as well as BSN436: Concepts of Nursing III and Medication Rights weekly audits completed between October 12, 2025, through October 17, 2025, and October 20, 2025, through October 22, 2025. Physicians with (name redacted- local group) also reviewed the facility's Intern and Student Nurse policy as well as BSN436: Concepts of Nursing III. 6. Additional communication was completed with (Facility Nursing College) representatives (name redacted), Strategic Engagement Liaison III, Partnerships, and (name redacted), (Nursing College) Placement Coordinator. Review of the facility's Medication Administration policy dated, 8/7/23 revealed, General Instructions: Medications are administered in accordance with the following rights of medication administration. Right resident, right medication, right dose, right route, right time and frequency, right documentation, right of resident to refuse, and right clinical indication . Prepare medications for administration. Administer medication: Knock on door and request entrance. Introduce self, explain medication administration need, and provide privacy. Identify resident by calling name and referring to photo .

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

11/24/2025

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 0835

F-F760 and F-F838 for additional information.

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

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

11/24/2025

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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to review and update the facility assessment after changes which would require substantial modification which includes an assessment of policies and procedures, training programs, education, training and competencies of direct care staff- both employees and those who provide services under contract, and contracts/memorandums of understanding or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies resulting in the potential for unidentified resources necessary to provide care and services to the resident populationFindings include: Review of the Facility assessment dated [DATE REDACTED]- 6/31/25 indicated that the facility assessment which was documented as reviewed on 6/3/25 did not include a facility nursing assistant, resident, or resident representative as part of the assessment review. The assessment did review staffing needs but had not been updated or reviewed after 6/2025. It was noted that the facility had been cited for staffing in August 2025. The facility assessment did not include the staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population. The facility assessment did not include services provided, such as physical therapy, pharmacy, behavioral health, and specific rehabilitation therapies. The facility assessment did not include all personnel, including managers, nursing and other direct care staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care or contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies. During the survey, the writer identified that the facility had not completed annual performance reviews for Certified Nursing Assistants (CNA's) or ensured that the CNA's were completing the 12-hour in-service education based on the annual performance review. The writer also identified that the facility had a nursing school to conduct clinical rotations at the facility without an active contract, and without determining what training and any competencies related to resident care the students had completed prior to providing resident care. In

an interview on 10/23/25 at 1:06 PM, Nursing Home Administrator (NHA) A reported the facility was purchased in August 2024. NHA A reported that she had completed the first assessment for the facility in June 2025, and that she had completed the facility assessment as a look back period from 7/2024-6/2025.

NHA A confirmed that the facility assessment had not been reviewed and updated after June 2025. Please see F-F760, F-F835, F-F730 and F-F947 for additional information.

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

11/24/2025

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 0947 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Based on interview, and record review, the facility failed to develop, implement, and permanently maintain

an in-service training program for Certified Nursing Assistants (CNA's) as determined by the yearly performance review, and ensure a total of 12 hours of yearly education, resulting in the potential for CNA's to not be able to safely provide necessary care and services to residents, a lack of training, and the potential for unmet care needs.Findings include: On 10/23/25 at 12:48 PM, this writer requested verification of annual in-service education for five sampled CNA files: (CNA H, M, OO, PP, and QQ. The facility was unable to provide the requested information. In an interview on 10/23/25 at 1:06 PM, Nursing Home Administrator (NHA) A reported that the facility had not completed annual reviews for the CNA staff, and therefore, the facility was not ensuring that the CNA's at the facility had completed the 12 hours of in-service education based on the annual performance reviews.

Event ID:

Facility ID:

If continuation sheet