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Complaint Investigation

Optalis Health And Rehabilitation Of Grand Rapids

April 30, 2026 · Grand Rapids, MI · 1950 32nd Street Se
Citations 3
CMS Rating 1/5
Beds 120
Provider ID 235458
Healthcare Facility
Optalis Health And Rehabilitation Of Grand Rapids
Grand Rapids, MI  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

Optalis Health and Rehabilitation of Grand Rapids in Grand Rapids, MI — inspection on April 30, 2026.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0658
Resident Assessment and Care Planning Deficiencies

resident call out from the bathroom to notify her that he had fallen. CNA CC reported Resident #102

have any injuries, so she helped the resident get up off the floor and assisted him back to bed before

comfortably before I left to get his nurse . CNA CC reported the nurse came and assessed the resident in bed and did not identify any injuries. CNA CC reported she would normally not move a resident from the floor prior to notifying the nurse and having the nurse complete an assessment.In an interview on 4/30/26 at 12:27 PM, CNA V reported if a resident falls, the nurse should be notified immediately to complete an assessment of the resident for injury before moving the resident or providing transfer assistance.In an interview on 4/30/26 at 1:11 PM, DON B reported Resident #102's fall on 4/5/26 was reviewed after the incident. DON B reported she was not aware that the CNA had moved the resident up from the floor prior to the completion of an assessment by the nurse. DON B reported when a resident falls, staff should notify the nurse immediately and an assessment of the resident should be completed .from the floor . DON B reported once the resident has been assessed by the nurse, the resident can then be transferred from the floor if it is safe to do so.In an interview on 4/30/26 at 1:34 PM, Assistant Director of Nursing (ADON) I reported if a resident falls, they should not be moved prior to being assessed for injury by the nurse.

Review of the policy/procedure Fall Management Guidelines, dated 2/3/26, revealed .The purpose of this policy is to provide guidelines to assist with fall risk identification and fall management of residents in the facility .POST-FALL EVALUATION .If a resident has just fallen or is observed on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities prior to moving the resident .

235458 04/30/2026

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd Street SE Grand Rapids, MI 49508

ensure baths/showers were provided per resident preference and plan of care in 1 of 4 residents

dissatisfaction with care, hygiene concerns, skin irritation, and low self-esteem.Findings include:According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME].

Fundamentals of Nursing - E-Book (Kindle Locations 50742-50744).

Elsevier Health Sciences.

Kindle Edition.Personal hygiene affects patients' comfort, safety, and well-being.

Hygiene care includes cleaning and grooming activities that maintain personal body cleanliness and appearance.

Personal hygiene activities such as taking a bath or shower and brushing and flossing the teeth also promote comfort and relaxation, foster a positive self-image, promote healthy skin, and help prevent infection and disease .Resident #102In an interview on 4/29/26 at 11:12 AM, Family Member DD reported concerns with provision of scheduled showers/baths at the facility.

Family Member DD reported Resident #102 was supposed to receive showers on Mondays, Wednesdays, and Fridays, but those were not always completed as scheduled.Review of a Face Sheet revealed Resident #102 was a male, with pertinent diagnoses which included right-sided hemiplegia/hemiparesis (paralysis/weakness) following a stroke, abnormal gait/mobility, depression, and dementia.Review of a Minimum Data Set (MDS) assessment for Resident #102, with a reference date of 3/20/26, revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, indicating moderate cognitive impairment.Review of a Nursing - Progress Note for Resident #102, dated 3/18/26, revealed .Showers dates updated per resident request to Mondays, Wednesday and Friday's (sic) evenings .Review of a current Care Plan for Resident #102 revealed the focus .ADL (Activities of Daily Living) Self-care deficit related to CVA (stroke) with right sided weakness, cognitive impairment, history of failure to thrive . revised 9/26/25, with interventions which included .Assist to bathe/shower as preferred per shower schedule and as needed . initiated 3/18/25, and .Resident prefers showers on evening shift, scheduled Monday, Wednesday and Fridays . revised 3/18/26.Review of a Kardex (a concise, frequently updated document of essential resident information used for quick reference by nursing staff to guide resident care) for Resident #102, dated 4/29/26, revealed .Resident prefers showers on evening shift, scheduled Monday, Wednesday and Fridays .

Review of the shower/bath documentation for Resident #102, from 4/1/26 through 4/30/26 revealed a total of three missed showers (no documentation on Friday 4/3/26, Monday 4/20/26, and Monday 4/27/26) from a total of 13 scheduled showers.In an interview on 4/30/26 at 1:11 PM, Director of Nursing (DON) B reported Resident #102's shower schedule was changed to three times per week, on Mondays, Wednesdays, and Fridays, per family request.

Requested documentation for any showers/baths offered/completed for Resident #102 on 4/3/26, 4/20/26, and 4/27/26. No documentation provided for those dates prior to survey exit.

Review of the policy/procedure Activities of Daily Living (ADL), dated 2/2/26, revealed .Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).

Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal, and oral hygiene .Appropriate care and services will be provided for residents who are unable to carry out ADL(s) independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with .Hygiene (bathing, dressing, grooming, and oral care) .The amount of assistance the resident needs to complete their ADL care will be documented in the resident's care plan and on the resident's Kardex .

235458 04/30/2026

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd Street SE Grand Rapids, MI 49508

During an interview on 4/30/26 at 11:34 AM, LPN D reported that she had documented 07-Other/See Progress Notes on 4/15/25 and 4/16/26 for Resident #105's albuterol treatment because the facility did not have a nebulizer for her, and she had to call and get it ordered. LPN D was unable to report why other nurses had administered the treatment as complete in between the dates that she had documented 07-Other/See Progress Notes on 4/15/25 and 4/16/26 as Resident #105 did not have a nebulizer for the medication to be administered. On 4/20/26 at 1:08 PM and 1:11PM, this writer attempted to contact the two other nurses (LPN HH and LPN II) that had documented Resident #105's albuterol treatments as administered. LPN HH and LPN II did not return this writer's call prior to survey exit.

During an interview on 4/30/26 at 11:42 AM, DON B reported that the facility had a delay in getting Resident #105 a nebulizer, which caused a delay in Resident #105 receiving her ordered albuterol treatments.

DON B was unable to report why nursing staff had documented that Resident #105 had the albuterol treatments administered when the facility had not yet received a nebulizer to administer the treatments.

Review of the facility's Documentation in the Medical Record Policy last reviewed 2/3/26 revealed, Policy Overview: The purpose of this policy is to provide guidelines for documentation in the medical record.

Guidelines: Principles of documentation include, but are not limited to: Documentation should be factual, objective, and resident centered.False information will not be documented.

Record descriptive and objective information based on knowledge of the assessment, observation, or service provided .Documentation should be accurate, relevant, and complete .

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Grand Rapids, MI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Optalis Health and Rehabilitation of Grand Rapids or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.