Optalis Health And Rehabilitation Of Grand Rapids

F 0600

LPN SS appeared angry and used a loud tone of voice which he directed at Resident #9.

Level of Harm - Minimal harm or potential for actual harm

In an interview on 12/29/25 at 2:51pm, CNA I reported she was standing near the nurse's station on 11/15/25 when she heard 2 voices yelling near Resident #9's room. CNA I reported she ran to Resident #9's room and found the resident on the floor on his knees, holding onto his wheelchair. CNA I reported she saw blood on Resident #9's lip. CNA I reported Resident #9 told her he hit LPN SS, and the nurse hit him back. CNA I reported she provided a verbal statement and text to interim Director of Nursing (DON) VV which included what she saw and heard that day.

Residents Affected - Few

In an interview on 12/22/25 at 3:44pm, FM RR reported he was visiting a relative on Resident #9's hall on 11/15/25 when he heard loud, 2 male voices yelling and swearing. FM RR reported he became concerned that other residents were upset by the loud yelling and responded to the situation that was occurring in the hallway. FM RR reported Resident #9 and LPN SS were in the hallway yelling and swearing at each other with several other staff member's trying to intervene. FM RR reported Resident #9 stated You hit me! to LPN SS. FM RR reported he heard LPN SS respond to Resident #9 and say, You hit me first!. FM RR reported he got in between Resident #9 and LPN SS, told LPN SS to walk away, which he did. FM RR reported no one from the facility interviewed him about what he saw or heard that day.

In an interview on 12/29/25 at 10:34am, LPN SS reported he approached Resident #9 while he was in the dining room on 11/15/25 and asked the resident to come to his room for an insulin injection. LPN SS reported Resident #9 was frustrated and stated he wanted to receive his injection in the dining room. LPN SS reported he was not comfortable doing that, so he left and reapproached Resident #9 approximately an hour and half later in his room. LPN SS reported Resident #9 voiced frustration with the situation and poked LPN SS in the chest with 2 fingers. LPN SS reported in response, he pushed Resident #9's hands away and the resident stumbled. When queried, LPN SS denied Resident #9 fell or was on the floor on his knees at any time. LPN SS reported he was concerned he was going to get in trouble and refused to answer additional questions.

In an interview on 12/29/25 at 1:54pm, Nursing Home Administrator (NHA) A reported interim DON VV conducted the investigation for the incident involving LPN SS and Resident #9. NHA A confirmed the only written witness statement taken was that of CNA N. When further queried, NHA A reported it was her understanding that none of the other staff working witnessed any of the interactions between Resident #9 and LPN SS. NHA A confirmed to her knowledge, no other staff or guests were interviewed.

Attempts to interview interim DON VV were unsuccessful prior to the conclusion of the survey.

Review of a police department Incident Report Form with a reference date of 11/15/25 at 7:13pm revealed Offense Descriptions: 1. A&B/SIMPLE ASSAULT.Suspect Interview . (LPN SS) explained he was attempting to administer medication and (Resident #9) needed his blood sugar checked and his dose of insulin. (Resident #9) refused to leave the dining room.approximately an hour later (LPN SS) found (Resident #9) in his room and asked if he wanted his medication. (Resident #9) began swearing and argued.poked (LPN SS) in the chest with a single finger. (LPN SS) reacted the (sic) slapped (Resident #9's) hand away.

Review of an Abuse policy with a reference date of 4/13/22 revealed POLICY OVERVIEW: Residents have

the right to be free from abuse.DEFINITIONS: Physical Abuse.Includes, but not limited to hitting, slapping.

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

12/29/2025

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 0602 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Former DON TT reported she interviewed RN M and Agency RN BBB, and her investigation determined

the cards went missing during the shift that started on 8/30/25 and ended on 8/31/25 when Agency RN BBB was assigned to Resident #7. Former DON TT reported the narcotic medications, cards, and count sheets were never located.Resident #8 Review of an admission Record revealed Resident #8 was originally admitted to the facility on [DATE REDACTED] and had pertinent diagnoses which included: burn of multiple sites of left lower limb, burn of abdominal wall, fracture of part of scapula, right shoulder, and fracture of fifth lower lumbar vertebra.Review of Order Summary for Resident #8 revealed .Oxycodone HCl oral tablet 10 mg give 1 tablet by mouth every 4 hours as needed for pain with a start date of 8/20/25.Review of Packing Slip from (Name Omitted) pharmacy service dated 8/26/25 revealed . Rx (prescription) Resident #8, Quantity 29.0, Medication Oxycodone 10 mg and Rx- Resident #8, Quantity 29.0, Medication Oxycodone 10 mg . The packing slip was noted to be initialed by receiving staff next to each prescription listed and signed by the same receiving staff member on 8/21/25.Review of MAR for Resident #8 revealed .documented administration of 14 scheduled Oxycodone 10 mg tablets and 4 as needed Oxycodone 10 mg tablets between the dates of 8/20/25 and 8/27/2025. No other documentation was noted as indicating the administration of additional tablets to Resident #8.Review of Witness Statement completed by Former DON TT on 8/31/25 at 14:30 (2:30 PM) revealed The writer (Former DON TT) . (RN M) Resident #8 has some pink pills missing also. RN M spoke with Agency RN BBB on 8/30 on who would be discharged . 2 people

this week. Resident #8, and both those residents' medications are missing. The witness statement was noted to be signed and dated for 8/31/25 by RN M and Former DON TT. In an interview on 12/29/25 at 10:45 AM, Licensed Practical Nurse (LPN) DD reported the nurses should sign the controlled substance shift inventory at shift change when they count together. LPN DD was observed completing the controlled substance shift inventory and it was noted that the off going nurse did not sign the shift-to-shift count sheet,

the boxes were blank.In an interview on 12/29/25 at 10:53 AM, Director of Nursing (DON) B reported her expectations were that the nurses signed the shift-to-shift controlled substance shift inventory sheet when

they count at shift change.In an interview on 12/29/25 at 11:04 AM, Nursing Home Administrator (NHA) A reported Former DON TT had informed her Resident #7 and Resident #8 were missing narcotic medications. NHA A reported the medications were never located.Review of facility policy Controlled Medication Guidelines with a revision date of 3/20/24 revealed .A physical inventory of all controlled medications is completed by two licensed nurses and is documented on the Shift-to-shift form at shift change.verify the count of medication packages listed on the Shift-to-shift form matches the number in the lock box.unresolved discrepancies must be reported immediately as follows: notify the DON, charge nurse, or designee and the pharmacy.

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

12/29/2025

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

needed his blood sugar checked and his dose of insulin. (Resident #9) refused to leave the dining room.approximately an hour later (LPN SS) found (Resident #9) in his room and asked if he wanted his medication. (Resident #9) began swearing and argued.poked (LPN SS) in the chest with a single finger. (LPN SS) reacted the (sic) slapped (Resident #9's) hand away.Review of an Abuse policy with a reference date of 4/13/22 revealed .INVESTIGATION: . Once reported, the center conducts a.thorough investigation.

The investigation process includes: .Identifying and interviewing all involved persons.witnesses.and others who might have knowledge of the allegations (such as.family members.) .Providing complete and thorough documentation of the investigation.

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

12/29/2025

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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

as they can have opposing effects on the heart and blood pressure, which may cause a dangerously slow heart rate (bradycardia).Metoprolol works by slowing the heart rate and reducing blood pressure.Midodrine used to treat severe low blood pressure by narrowing blood vessels and increasing blood pressure.When combined, the opposing actions can interfere with each other and potentially lead to a medical emergency.

The primary concern is that Midodrine may cause slow heart rate when taken with Metoprolol that also reduces heart rate. https://www.drugs.com/drug-interactions/metoprolol-with-midodrine-1615-0-1629-0.htmlReview of Fundamentals of Nursing ([NAME] and [NAME]] revealed, Professional standards such as Nursing: Scope and Standards of Practice [ANA, 2010) .apply to the activity of medication administration. To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6.

The right documentation. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]: Hall, [NAME].

Fundamentals of Nursing - E-Book (Kindle Locations 39307-393131. Elsevier Health Sciences. Kindle Edition.

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

12/29/2025

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 0678 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

preference in resident records, and review of facility cardiac arrest emergency management policy.4. The Director of Nursing will ensure that all staff received in-service education and completed education was documented prior to working their next assigned shift.5. The Director of Nursing/Designee will monitor all booked shifts for Agency licensed staff for completion of assigned required in-service education and completed education was documented prior to working the scheduled shift.6. The medical director was notified on [DATE REDACTED]. The Director of Nursing held mock CPR drills with nursing staff on each shift starting on [DATE REDACTED]. Director of Nursing will conduct mock CPR drills monthly on each shift.8. Information from the drills will be reviewed for recommendations at QA&A committee meetings monthly.9. An Ad-Hoc (unscheduled) QAPI (quality assurance performance improvement) meeting was held on [DATE REDACTED] to review findings and action plan.

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

12/29/2025

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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

a quantity of 30 for QD (every day) change frequency. During an observation and an interview on 12/29/25 at 11:15 AM, Resident #11 was lying in her bed and she had three blue absorbent pads on right and left lateral thigh areas with dated bandages, as well as other spotted open areas on both thighs not currently weeping. On her left lateral thigh, she had a dark brown scab about the size of a quarter midway up on her left lateral thigh. The bandages were dated 12/29/25. Resident #11 reported she saw the wound nurse today. In an interview on 12/29/25 at 11:50 AM, UM AAA reported the nurses could have used the ABD pads for Resident #11 if the other pads had run out. UM AAA reported she would provide education to the nursing staff in regard to using the briefs instead of using the dressings or ABD pads. In an interview on 12/29/25 at 2:41 PM, Director of Nursing (DON) B reported there was a bowel protocol for Resident #11 as

she had a complicated bowel history the typical bowel protocol would not be applied to her and DON B reported she would check with the nurse practitioner as the facility would be cautious. DON B reported if

the resident refused treatment, it would be documented in the administration record, and a progress note would be entered in the medical record to allow for communication with other staff. DON B reported any time a resident's bowel appear to be abnormal it should be communicated. DON B reported if resident refused the application of the compression stockings and the lymphedema boots, she would have the staff document it as behaviors based on the refusals. DON B reported the wound nurse sees patients on Monday and Wednesdays and Resident #11 would be seen weekly by the wound nurse and as she was aware she was seen weekly for her wounds. DON B reported staff should follow the care plan as ordered but with Resident #11 asking to have the lymphedema boots and then requesting they were removed. This writer informed the DON the boots were ordered to be worn for an hour a day.

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

12/29/2025

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 0690 Level of Harm - Minimal harm or potential for actual harm

of degradation are noted.The female external catheter urine collection system and accessories should be cleaned and disinfected at the time of each use, or at a minimum, daily, as per the manufacturer's instructions.

Residents Affected - Few

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

12/29/2025

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 0732

Post nurse staffing information every day.

Level of Harm - Minimal harm or potential for actual harm

Based on observation and interviews, the facility failed to ensure current daily facility staffing hours were posted in a prominent location readily accessible to residents, staff, and visitors.Findings include:On 12/22/25 at 11:20 AM, staffing hours dated 12/09/25 were observed posted on a bulletin board in a glass enclosed case in the hallway directly behind the entry way and reception of the building.On 12/22/25 at 2:52 PM, staffing hours dated 12/22/25 were observed taped to the glass enclosure of the bulletin board in

the hallway directly behind the entry way and reception of the building.On 12/23/25 at 11:02 AM, staffing hours dated 12/22/25 were observed taped to the glass enclosure of the bulletin board in the hallway directly behind the entry way and reception of the building.On 12/29/25 at 8:42 AM, 10:40 AM, and 11:23 AM staffing hours dated 12/22/25 were observed taped to the glass enclosure of the bulletin board in the hallway directly behind the entry way and reception of the building.In an interview on 12/29/25 at 11:24 AM Scheduler (S) K reported it was her responsibility to post the staffing hours. S K reported she had taken over the role of staffing coordinator from Staffing Coordinator (SC) X on 12/29/25, and she knew posting hours was part of her responsibilities. S K reported the hours did not get posted on a regular basis like they should; and that she had not yet posted todays staffing hours.In an observation and interview on 12/29/25 at 11:33 AM, Nursing Home Administrator (NHA) A reported staffing hours were to be posted daily. NHA A escorted this surveyor to the glass enclosure of the bulletin board in the hallway directly behind the entry way and reception of the building and stated, staffing hours are posted here while she gestured to the two pieces of paper taped to the glass. NHA A reported the key to the glass enclosure of the bulletin board was missing and the staffing hours had to be taped to the front of it. NHA A was observed reading and then removed the papers from the glass and stated, I will get the updated one right now. On 12/29/2025 at 3:22 PM, NHA A was observed unlocking the glass enclosure, removing the staffing hours postings from the bulletin board, and giving verbal instructions to S K regarding her role in posting staffing hours on the bulletin board.

Residents Affected - Few

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

12/29/2025

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 0803 Level of Harm - Minimal harm or potential for actual harm

lentil meatloaf did not get made for Resident #11 over the weekend, but she was unsure why and she would have a talk with the cook. RD DDD reported that was unacceptable and the lentil meatloaf should have been made for Resident #11 as that was what was on the menu.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet