Samaritas Senior Living Grand Rapids Lodge

F-F725.

Findings include:

Review of the policy/procedure Staffing, dated 11/3/23, revealed .The facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for the residents in accordance with the residents plan of care .Licensed nurses and nursing assistants are available 24 hours a day, 7 days

a week to provide direct resident care services .Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on their plan of care .Inquiries or concerns related to the facility's staffing should be directed to the Administrator or their designee .

Review of the policy/procedure Staffing (Department: Nursing), dated 4/13/22, revealed .There will be a designated staff member listed at the front desk who is responsible to ensure appropriate staffing at all times . Designated staff member will ensure that there is staff appropriate to care for all residents in the facility .

In an interview on 1/8/25 at 9:15 AM, RN LLL reported they were assigned the 400 Hall on 10/18/24 from 6:30 PM-7:00 AM. RN LLL reported they could not recall who was responsible for the 300 Hall that night (10/18/24 between 6:30 PM-11:00 PM). RN LLL recalled a resident on the 300 Hall attempted to elope from

the facility between 7:00 PM-11:00 PM. RN LLL stated in regard to staffing .We were always short. (Staffing) was definitely an issue that night . RN LLL reported management was .fully aware . of the staffing concerns but would not come into the facility to assist when short-staffed.

In an interview on 1/8/25 at 9:52 AM, Former Assistant Director of Nursing (ADON) MMM reported no issues with staffing the evening of 10/18/24 between 6:30 PM-11:00 PM and stated .we were at State minimums . Former ADON MMM reported they were aware that multiple residents missed medications the evening of 10/18/24 and stated .we did look into that .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 In an interview on 1/8/25 at 10:07 AM, Agency Licensed Practical Nurse (LPN) JJJ reported they worked on

the 100 Hall the evening of 10/18/24. Agency LPN JJJ reported that evening there was no nurse assigned to Level of Harm - Minimal harm or the 300 Hall between 6:30 PM-11:00 PM. Agency LPN JJJ reported there was only a nurse on the 400 Hall. potential for actual harm Agency LPN JJJ reported they took over some of the rooms on the 300 Hall after 11:00 PM, but from 6:30 PM-11:00 PM on 10/18/24 there was no nurse assigned to the residents on the 300 Hall. Agency LPN JJJ Residents Affected - Many reported the evening of 10/18/24 was not the first time where no nurse was assigned to a section of residents, and stated .I canceled all my shifts after that. (I) did not feel safe working there . Agency LPN JJJ reported they spoke with the on-call manager that evening (Former ADON MMM) about the staffing concerns, and reported there were only three nurses in the building when there should have been four.

In an interview on 1/8/25 at 10:44 AM, LPN OOO reported concerns with staffing at the facility. LPN OOO reported at times there would be one nurse assigned to over 50 residents. LPN OOO stated .They were telling me I had to work like that. I told them there are people who are a fall risk, people with mental health issues .I told them it's not safe .I am not going to put these people's lives in jeopardy . LPN OOO reported

they worked one shift with a 56 resident assignment and stated .it was too dangerous .It was the most nerve-wracking night of my life . LPN OOO reported they spoke with Former Assistant Director of Nursing (ADON) MMM at the time about the staffing concerns and no assistance/guidance or direction was provided. LPN OOO reported former ADON MMM often did not answer the phone and stated .if you had an issue at night that was your issue .(Former ADON MMM) wouldn't come in and get on a cart or help at all . LPN OOO reported the evening when she worked with a 56 resident assignment, she was not aware until a CNA came and asked her to get a pain medication for a resident. LPN OOO reported the offgoing nurses that night had locked the keys in the medication cart and left at the end of their shift. LPN OOO stated .I never got report or nothing about that hall or any of those patients .

In an interview on 1/8/25 at 11:49 AM, RN PPP reported they worked at the facility on 10/19/24 and stated .

they were short on nurses that morning . RN PPP recalled going over to the 300 Hall to assist with passing morning medications. RN PPP reported there was no nurse assigned to the 300 Hall that day. RN PPP stated .It was horrible because a lot of people did not get their medications . on 10/18/24 and 10/19/24. RN PPP reported in each instance, the offgoing nurse locked the keys in the medication cart and left the facility without giving verbal report. RN PPP reported the nurse on the 400 Hall that day had been calling management for help, and no plan was in place to assist staff when there was a shortage of nurses. RN PPP reported the on-call nurse manager at the time stopped responding to phone calls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 In an interview on 1/8/25 at 3:40 PM, LPN QQ reported at shift change the evening of 10/18/24, no nurse showed up for the 300 Hall. LPN QQ reported they counted the controlled substances with the other day shift Level of Harm - Minimal harm or nurse and locked the keys in the medication cart before leaving the facility. LPN QQ reported they wrote a potential for actual harm shift-to-shift report on a piece of paper and left it at the desk. LPN QQ stated .(With Agency staff) you don't know who will show up . LPN QQ reported RN LLL was on the 400 Hall that night and refused to take Residents Affected - Many responsibility for the 300 hall because .it was too many people . LPN QQ reported the same thing happened

on 10/26/24 on day shift, where no nurse took responsibility for the 300 Hall resulting in residents not receiving their ordered medications. LPN QQ stated calling management or the on-call nurse was .a waste of your time . LPN QQ reported there were multiple days with missed medications and management .didn't do anything . LPN QQ reported residents on the 400 Hall missed medications and had no nurse the evening of 10/12/24. LPN QQ reported that night (10/12/24) the Agency nurse on the schedule arrived and refused the assignment, saying she wasn't going to put her license at risk.

In an interview on 1/9/25 at 3:09 PM, LPN QQ reported they attempted to notify the on-call manager on 10/12/24 when the Agency nurse arrived refused the assignment. LPN QQ reported the on-call manager did not answer the phone. LPN QQ reported they also attempted to contact the scheduler and the Regional Manager with no answer. LPN QQ stated .to call them was a waste of time. They wouldn't do anything . LPN QQ stated .This is why it didn't matter if you called the on-call because nothing would be done .

The executive's position within an organization is critical in uniting the strategic direction of an organization with the philosophical values and goals of nursing. The nurse executive is a clinical and business leader who is concerned with maximizing quality of care and cost-effectiveness while maintaining relationships and professional satisfaction of the staff. Perhaps the most important responsibility of the nurse executive is to establish a philosophy for nursing that enables managers and staff to provide quality nursing care. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 18631-18634). Elsevier Health Sciences. Kindle Edition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41982

Residents Affected - Few Based on interview and record review, the facility failed to maintain a complete and accurate medical record related to Advance Directives / Code Status for 1 (Resident #111) of 1 sampled resident reviewed for Advance Directives / Code Status, resulting in an incongruent reflection of the resident records and the potential for the resident's care wishes not being honored as desired.

Findings include:

According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing.High-quality documentation is necessary to enhance efficient, individualized patient care. Quality documentation has five important characteristics: it is factual, accurate, complete, current, and organized . Accessed from: Kindle Locations ,d+[DATE REDACTED]). Elsevier Health Sciences. Kindle Edition.

Resident #111

Review of an Admission Record revealed Resident #111 was a male.

Review of Resident #111's DO-NOT-RESUSCITATE ORDER signed by Resident #111's Responsible Party (Family Member FM TT), 2 physicians (names omitted), and 2 witnesses (names omitted) on [DATE REDACTED] revealed, .PATIENT ADVOCATE CONSENT I authorize that in the event the declarant's heart and breathing should stop, no person shall attempt to resuscitate the declarant. I understand the full import of this order and assume responsibility for its execution. This order will remain in effect until it is revoked as provided by law .

Review of Resident #111's current Care Plan revealed the focus of .Request to limit treatment form filled out indicating residents wishes . with care planned interventions which included, Follow the limited treatment sheet and advanced directives as written per residents wishes with Date Initiated of [DATE REDACTED].

Review of Resident #111's Order Summary as of [DATE REDACTED] revealed an active order of, Adv (advance) Directive: Full Cardiopulmonary Resuscitation (CPR) .Order Status Active Order Date [DATE REDACTED]

Review of Resident #111's Electronic Medical Record Dashboard (home screen) on [DATE REDACTED] at 10:54 AM revealed, Code Status (Advance Directives) Adv Directive: Full Cardiopulmonary Resuscitation (CPR)

In an interview on [DATE REDACTED] beginning at 10:54 AM, Assistant Director of Nursing (ADON) C reviewed Resident #111's DO-NOT-RESUSCITATE ORDER document as well as Resident #111's Adv (advance) Directive: Full Cardiopulmonary Resuscitation (CPR) .Order Status Active Order Date [DATE REDACTED] and Resident #111's Electronic Medical Record Dashboard (home screen) with this surveyor and confirmed they did not match. ADON C reported it looked like when Resident #111 returned to the facility from the hospital, he was entered as a Full Code. ADON C reported the order was entered incorrectly, and that it should have been entered as

a DNR (do not resuscitate) to match Resident #111's DNR paperwork.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 36221 potential for actual harm

This citation pertains to Intake # MI00147061. Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure effective hand hygiene and glove use during incontinence care in 1 of 4 residents (Resident #101) reviewed for infection control during incontinence care, resulting in the potential for cross-contamination and the development and spread of infection and disease.

Findings include:

Resident #101

Review of an Admission Record revealed Resident #101 was a female, with pertinent diagnoses which included bladder dysfunction, depression, anxiety, and muscle weakness.

Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 12/13/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated she was cognitively intact.

In an observation and interview on 1/2/25 at 1:47 PM, Resident #101 was noted in bed in her room. Resident #101 reported she had an indwelling catheter and has had issues with frequent Urinary Tract Infections (UTIs) while at the facility. Observed Certified Nursing Assistant (CNA) AA and CNA BB assist Resident #101 with incontinence care due to a bowel movement. Noted CNA AA and CNA BB donned gowns and gloves prior to entering Resident #101's room. CNA AA and CNA BB lowered the head of Resident #101's bed and opened Resident #101's soiled brief to begin incontinence care. CNA AA and CNA BB rolled Resident #101 onto her left side and used washcloths/soap to perform incontinence care. Observed CNA AA clean bowel movement from Resident #101's buttocks, and then immediately handle Resident #101's pillows and place a new pad below Resident #101 with no glove change or hand hygiene performed. Resident #101 was then assisted onto her right side. Observed CNA BB clean bowel movement from Resident #101's buttocks and thighs, wiping from back to front with the washcloth. After drying Resident #101's buttocks, CNA BB applied protective cream to Resident #101's buttocks using the same soiled gloves, and then wiped

the excess cream from the soiled gloves with a towel and continued with care. CNA AA and CNA BB assisted Resident #101 to a laying position to complete incontinence care, and wash Resident #101's vaginal/perineal area. Noted both CNA AA and CNA BB continued to wear the same soiled gloves originally donned upon entering Resident #101's room. CNA AA dampened the corner of a large towel (since no washcloths were left in the room) and washed Resident #101's vaginal/perineal area. After incontinence care was completed, both CNA AA and CNA BB handled Resident #101's pillows/linens and personal items using

the same soiled gloves originally donned upon entering Resident #101's room.

In an observation on 1/2/25 at 2:37 PM, CNA AA returned to Resident #101's room wearing a gown and gloves to empty the catheter bag. Once care was complete, observed CNA AA remove their gloves and perform hand washing at the sink in Resident #101's room for approximately five seconds.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 0880 In an interview on 1/2/25 at 2:37 PM, Resident #101 reported staff generally do not change their gloves

during incontinence care. Level of Harm - Minimal harm or potential for actual harm In an interview on 1/2/25 at 2:57 PM, CNA BB stated gloves are .not usually . changed with incontinence care. Residents Affected - Few

In an interview on 1/2/25 at 3:02 PM, CNA AA reported staff typically don't change gloves during incontinence care.

Review of the policy/procedure Hand Hygiene, dated 4/14/23, revealed .To provide guidelines to staff for proper hand hygiene techniques that will aid in the prevention and transmission of infections .SITUATIONS

IN WHICH USING SOAP AND WATER OR ALCOHOL BASED HAND RUB CAN BE USED .Before and

after handling clean or soiled dressings, linens, etc .Before moving from a contaminated body site to a clean body site during resident care .After handling contaminated objects, equipment, dressings, etc .HAND HYGIENE TECHNIQUE WHEN USING SOAP AND WATER .Wet hands with water .Apply soap .Rub hands together vigorously for at least 20 seconds, covering all surfaces of the hands and fingers .Rinse hands with water .Dry thoroughly with a paper towel .Use clean paper towel to turn off the faucet .

Review of the CDC (U.S. Centers for Disease Control and Prevention) Guidance Clinical Safety: Hand Hygiene for Healthcare Workers, last updated 2/27/24, revealed .Gloves are not a substitute for hand hygiene .When to change gloves and clean hands .If gloves become soiled with blood or body fluids after a task .If moving from work on a soiled body site to a clean body site on the same patient or if a clinical indication for hand hygiene occurs .If they look dirty or have blood or body fluids on them after completing a task . Retrieved from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm 36221

Residents Affected - Few This citation pertains to Intake # MI00147744 & MI00148620.

Based on observation, interview, and record review, the facility failed to ensure a sanitary and comfortable environment in 2 of 5 residents (Resident #103 & #104) reviewed for a clean/homelike environment, resulting

in noxious odors and the potential for decreased satisfaction with the living environment.

Findings include:

Resident #103

Review of an Admission Record revealed Resident #103 was a male, with pertinent diagnoses which included stroke, muscle weakness, anxiety, and depression.

Review of a Minimum Data Set (MDS) assessment for Resident #103, with a reference date of 10/16/24, revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated moderate cognitive impairment.

In an observation on 1/6/25 at 3:09 PM, noted a strong urine smell in Resident #103's bathroom. Observed that Resident #103's toilet seat was up, and the toilet bowl was unflushed with yellow urine and toilet paper visible in the bowl. Noted a splattered brown substance on the back surface of the toilet bowl. Observed a toilet riser, detached from Resident #103's toilet and laying on the floor, with a smeared brown substance on

the bottom surface of the riser.

In an observation on 1/7/25 at 2:24 PM, noted a splattered brown substance on the back surface of the toilet bowl in Resident #103's bathroom.

Resident #104

Review of an Admission Record revealed Resident #104 was a female, with pertinent diagnoses which included dementia, Alzheimer's disease, depression, and anxiety.

Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 11/4/24, revealed a Brief Interview for Mental Status (BIMS) score of 1, out of a total possible score of 15, which indicated she had severe cognitive impairment.

In an interview on 1/2/25 at 11:04 AM, Family Member VV reported Resident #104's room is unsanitary and smells of urine.

In an observation on 1/2/25 at 11:30 AM, noted Resident #104's bathroom door was ajar with visible toilet paper debris on the bathroom floor. Observed a toilet brush laying on the floor beside the toilet, not in a holder. Noted a strong urine smell in Resident #104's bathroom.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 0921 In an observation on 1/6/25 at 1:23 PM, noted a strong urine smell in Resident #104's bathroom. Observed a soiled brief on the floor in Resident #104's bathroom, to the left of the toilet along the wall, along with multiple Level of Harm - Minimal harm or small pieces of toilet paper. potential for actual harm

In an observation on 1/7/25 at 2:11 PM, noted a strong urine smell in Resident #104's bathroom. Observed Residents Affected - Few multiple bits of trash/debris on Resident #104's bathroom floor including two wadded up, soiled briefs. Observed Resident #104's toilet bowl was unflushed with yellow urine and toilet paper visible in the bowl. Noted Resident #104's bathroom floor was tacky when walked on.

In an observation on 1/8/25 at 12:23 PM, noted a slight urine smell in Resident #104's bathroom. Observed multiple sugar packs and bits of trash/paper on the floor of Resident #104's bathroom. Observed a brown, splattered substance on the back of the toilet bowl and toilet seat.

In an observation on 1/13/25 at 11:44 AM, noted a strong urine smell in Resident #104's room and bathroom. Observed multiple small bits of paper trash on the floor of the bathroom, along the wall behind the toilet. Noted Resident #104's toilet bowl was unflushed with yellow urine, stool, and toilet paper visible in the bowl.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 68 235458

F-F760.

Findings include:

According to [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 1589-1592). Elsevier Health Sciences. Kindle Edition.Time management, therapeutic communication, patient education, and compassionate implementation of bedside skills are just a few of the essential skills you need. It is important for your patients to leave the health care setting with a positive image of nursing and a feeling that they received quality care. Your patients should never feel rushed. They need to feel that they are important and are involved in decisions and that their needs are met .

Review of the policy/procedure Staffing, dated 11/3/23, revealed .The facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for the residents in accordance with the residents plan of care .Licensed nurses and nursing assistants are available 24 hours a day, 7 days

a week to provide direct resident care services .Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on their plan of care .

Review of the policy/procedure Staffing (Department: Nursing), dated 4/13/22, revealed .All employees of the facility are responsible for Residents and required to report to work when scheduled and to remain at work until replaced by someone else .

In an interview on 1/2/25 at 11:33 AM, Licensed Practical Nurse (LPN) Q reported there were currently three nurses and six Certified Nursing Assistants (CNAs) on the 300 and 400 Halls. LPN Q reported five CNAs is more typical for day shift staffing. LPN Q reported the facility uses a significant number of Agency staff, for both nurses and CNAs. LPN Q reported there are a lot of issues with call-ins and no-shows, and reported if

an Agency nurse/CNA cancels a scheduled shift, the floor staff working that day have no idea until .no one shows up for the shift .

In an interview on 1/6/25 at 12:23 PM, Agency LPN DDD reported issues with staffing at the facility. Agency LPN DDD reported sometimes the schedule will say three nurses (on the 300 and 400 Hall) but only two will show up. Agency LPN DDD reported three nurses on the 300/400 Hall is ideal, and reported more care/treatments can be completed. Agency LPN DDD stated when only two nurses are on the 300/400 Hall it .gets very time sensitive . regarding care. Agency LPN DDD reported staffing constraints result in medications/treatments being administered outside of designated time frames.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 0725 In an interview on 1/6/25 at 3:48 PM, LPN QQ reported staffing was a major issue in September/October 2024 after the change in facility ownership. LPN QQ reported at times they were the only nurse on the Level of Harm - Minimal harm or 300/400 Hall, or there was no oncoming nurse at the end of their shift. LPN QQ stated .I was exhausted . potential for actual harm LPN QQ reported on 10/18/24 the Agency nurse scheduled to relieve them at 6:30 PM on the 300 Hall did not show up for the shift. LPN QQ reported that evening there was only one nurse on the 400 Hall, and no Residents Affected - Some nurse on the 300 Hall. LPN QQ reported the evening of 10/18/24 on the 300 Hall, no residents received scheduled medications. LPN QQ reported on 10/18/24 between 7:00 PM-11:00 PM one resident from the 300 Hall attempted to elope from the facility and was found in the parking lot after setting off a door alarm. LPN QQ reported with Agency staff, the nurses working have no notification when a scheduled Agency staff member calls in or cancels a shift, and stated .we have no idea if they will show up or not . LPN QQ reported

after the change in ownership, only two nurses were scheduled on the 300/400 Halls, when previously they had three, and stated .that is how we ended up with this mess . LPN QQ reported when short-staffed, they are unable to pass medications timely or provide quality care.

In an interview on 1/7/25 at 10:18 AM, LPN FF reported staffing at the facility .varies . and reported the number of CNAs on the 300/400 hall for day shift fluctuates between four and seven. LPN FF stated .it depends on who shows up for work . LPN FF reported management posts the open shifts for other staff to pick up, and stated .(If) they don't pick (the open shift) up, we work with what we get . LPN FF reported when short-staffed, it can be difficult to ensure medications are administered timely. LPN FF stated .we try our best but there (are) a number of residents that require more care than others . LPN FF reported when short-staffed, they try to prioritize who needs a shower .the most . and complete bed baths on other residents .to save time .

In an interview on 1/7/25 at 1:22 PM, Registered Nurse RN KK reported after the change in facility ownership, the staffing levels were adjusted and stated it was a .very heavy, heavy workload .it was very hard . RN KK reported medications were .barely . administered on time. RN KK stated when the facility is short-staffed they .have to work with what we have .

In an interview on 1/8/25 at 9:15 AM, RN LLL reported they were assigned the 400 Hall on 10/18/24 from 6:30 PM-7:00 AM. RN LLL reported they could not recall who was responsible for the 300 Hall that night (10/18/24 between 6:30 PM-11:00 PM). RN LLL recalled a resident on the 300 Hall attempted to elope from

the facility between 7:00 PM-11:00 PM. RN LLL stated in regard to staffing .We were always short. (Staffing) was definitely an issue that night . RN LLL reported they had issues getting medications administered timely when short-staffed. RN LLL reported they stopped working at the facility shortly after that night, and stated . That was one of the reasons I left .safety .

In an interview on 1/8/25 at 10:07 AM, Agency Licensed Practical Nurse (LPN) JJJ reported they worked on

the 100 Hall the evening of 10/18/24. Agency LPN JJJ reported that evening there was no nurse assigned to

the 300 Hall between 6:30 PM-11:00 PM. Agency LPN JJJ reported there was only a nurse on the 400 Hall. Agency LPN JJJ reported they took over some of the rooms on the 300 Hall after 11:00 PM, but from 6:30 PM-11:00 PM on 10/18/24 there was no nurse assigned to the residents on the 300 Hall. Agency LPN JJJ reported the evening of 10/18/24 was not the first time where no nurse was assigned to a section of residents, and stated .I canceled all my shifts after that. (I) did not feel safe working there . Agency LPN JJJ reported they spoke with the on-call manager that evening about the staffing concerns, and reported there were only three nurses in the building when there should have been four.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 0725 In an interview on 1/8/25 at 10:44 AM, LPN OOO reported concerns with staffing at the facility. LPN OOO reported at times there would be one nurse assigned to over 50 residents. LPN OOO stated .They were Level of Harm - Minimal harm or telling me I had to work like that. I told them there are people who are a fall risk, people with mental health potential for actual harm issues .I told them it's not safe .I am not going to put these people's lives in jeopardy . LPN OOO reported

they worked one shift with a 56 resident assignment and stated .it was too dangerous .It was the most Residents Affected - Some nerve-wracking night of my life . LPN OOO reported they spoke with former Assistant Director of Nursing (ADON) MMM at the time about the staffing concerns and no assistance/guidance or direction was provided. LPN OOO reported former ADON MMM often did not answer the phone and stated .if you had an issue at night that was your issue .(Former ADON MMM) wouldn't come in and get on a cart or help at all . LPN OOO reported the evening when she worked with a 56 resident assignment, she was not aware until a CNA came and asked her to get a pain medication for a resident. LPN OOO reported the offgoing nurses that night had locked the keys in the medication cart and left at the end of their shift. LPN OOO stated .I never got report or nothing about that hall or any of those patients .

In an interview on 1/8/25 at 12:40 PM, Agency CNA QQQ reported they responded to a door alarm the evening of 10/18/24 and found Resident #103 outside the facility in the parking lot. Agency CNA QQQ reported they redirected Resident #103 back into the facility and brought him back to his room on the 300 Hall. Agency CNA QQQ could not recall which nurse was assigned to Resident #103 at the time of his attempted elopement, and stated .they were short-staffed that whole day .It was so busy. They had days with no nurse on the hall . Agency CNA QQQ reported when there was no nurse assigned to a hall, there would be an additional CNA added to help monitor until a nurse could come in and take the assignment.

In an interview on 1/14/25 at 12:36 PM, CNA RRR reported they were assigned to Resident #103 the evening of his attempted elopement on 10/18/24. CNA RRR reported that evening, the facility was short-staffed and there was no nurse caring for the residents on the 300 Hall. CNA RRR reported at the time of Resident #103's attempted elopement, they were in a room caring for a different resident. CNA RRR reported there was a nurse on the 400 Hall, but when they asked the 400 Hall nurse for assistance they would say they were busy. CNA RRR stated .I was like, then who should I ask? CNA RRR reported they were unsure if any residents received their evening medications on 10/18/24.

Resident #101

Review of an Admission Record revealed Resident #101 was a female, with pertinent diagnoses which included bladder dysfunction, depression, anxiety, and muscle weakness.

Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 12/13/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated she was cognitively intact.

Review of a current Care Plan for Resident #101 revealed the focus .ADL (Activities of Daily Living) Self care deficit as evidenced by weakness . initiated 9/6/24, with interventions which included .Assist to bathe/shower as preferred per shower schedule and as needed . initiated 12/11/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 0725 In an interview on 1/2/25 at 2:37 PM, Resident #101 reported concerns with staffing and long call light wait times. Resident #101 reported she has experienced long wait times while waiting for incontinence care after Level of Harm - Minimal harm or a bowel movement, typically around an hour. Resident #101 reported missed bed baths, and stated she went potential for actual harm almost two weeks between bed baths recently. Resident #101 reported staff do not offer to wash her hair, and stated .only once or twice has someone taken my compression socks off to wash my feet and lower legs Residents Affected - Some . Resident #101 reported she will often wash her hair herself and just have the staff setup tubs of water within reach for her to use. Resident #101 stated .yesterday (the CNA) was so busy. You get the feeling that

they are in a hurry . so she did not ask for help to wash her hair.

Review of the Shower/Bath documentation for Resident #101, from 12/3/24 to 1/2/25, revealed only five showers/baths documented as given within that time frame, on 12/5/24, 12/12/24, 12/19/24, 12/23/24, and 12/27/24. Noted Shower/Bath was documented as Resident Refused on 12/16/24, 12/26/24, and 12/30/24, with no supporting documentation in the electronic medical record regarding the refusals, or any education provided to the resident or follow-up completed on those dates. Noted Shower/Bath was documented as Not Applicable on 12/9/24.

Resident #107

Review of an Admission Record revealed Resident #107 was a female, with pertinent diagnoses which included diabetes, anxiety, and depression.

Review of a Minimum Data Set (MDS) assessment for Resident #107, with a reference date of 12/5/24, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated she was cognitively intact.

In an interview on 1/2/25 at 11:49 AM, Resident #107 reported concerns with facility staffing and long call light wait times. Resident #107 reported at times she has waited up to two hours for a brief change after a bowel movement. Resident #107 reported there is not enough staff to meet resident needs and provide timely care.

Resident #104

Review of an Admission Record revealed Resident #104 was a female, with pertinent diagnoses which included dementia, Alzheimer's disease, depression, anxiety, insomnia (difficulty sleeping), chronic pain, and high blood pressure.

Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 11/4/24, revealed a Brief Interview for Mental Status (BIMS) score of 1, out of a total possible score of 15, which indicated she had severe cognitive impairment.

In an interview on 1/2/25 at 11:04 AM, Family Member VV reported Resident #104 does not receive adequate showers or hygiene care, and stated .She just [NAME] of urine .

Review of a current Care Plan for Resident #104 revealed the focus .ADL (Activities of Daily Living) Self Care Deficit r/t (related to) cognitive deficit . with interventions which included .BATHING/SHOWERING: 1 person assist . both initiated 8/13/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 0725 Review of the Shower/Bath documentation for Resident #104, from 12/7/24 to 1/6/25, revealed only three showers/baths documented as given within that time frame, on 12/24/24, 12/31/24, and 1/3/25. Noted Level of Harm - Minimal harm or Shower/Bath was documented as Resident Refused on 12/13/24, 12/20/24, and 12/27/24 with no supporting potential for actual harm documentation in the electronic medical record regarding the refusals, or follow-up completed on those dates.

Residents Affected - Some Review of the October 2024 Medication Administration Record (MAR) for Resident #104 revealed no documentation (missed medications) on 10/18/24 in the evening for the following physician orders:

-Melatonin Oral Tablet 3 MG (Melatonin) Give 2 tablet by mouth one time a day for Sleep

Review of the October 2024 Medication Administration Record (MAR) for Resident #104 revealed no documentation (missed medications) on 10/26/24 in the morning for the following physician orders:

-Aspirin Oral Tablet Chewable 81 MG (Aspirin) Give 1 tablet by mouth one time a day for blood thinner

-Cyanocobalamin Oral Tablet 100 MCG (Cyanocobalamin) Give 1 tablet by mouth one time a day for supplement

-Lisinopril Oral Tablet 5 MG (Lisinopril) Give 1 tablet by mouth one time a day for HTN (hypertension - high blood pressure)

-Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350) Give 17 gram by mouth one time a day for Constipation

-clonazePAM Oral Tablet 0.5 MG (Clonazepam) Give 1 tablet by mouth two times a day related to anxiety

Resident #103

Review of an Admission Record revealed Resident #103 was a male, with pertinent diagnoses which included stroke, anxiety, muscle weakness, depression, high blood pressure, and a history of falls.

Review of the October 2024 Medication Administration Record (MAR) for Resident #103 revealed no documentation (missed medications) on 10/18/24 in the evening for the following physician orders:

-Latanoprost Ophthalmic Solution 0.005 % (Latanoprost) Instill 1 drop in both eyes one time a day for Glaucoma

-Losartan Potassium Oral Tablet 25 MG (Losartan Potassium) Give 1 tablet by mouth one time a day for HTN (hypertension - high blood pressure)

-Rosuvastatin Calcium Oral Tablet 5 MG (Rosuvastatin Calcium) Give 1 tablet by mouth one time a day for Hyperlipidemia

-Thiamine HCl Oral Tablet 100 MG (Thiamine HCl) Give 1 tablet by mouth one time a day

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 0725 -traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 75 mg by mouth at bedtime for depression

Level of Harm - Minimal harm or -levETIRAcetam Oral Tablet 500 MG (Levetiracetam) Give 1 tablet by mouth two times a day for Seizures potential for actual harm -traMADol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 8 hours for Pain Residents Affected - Some -Acetaminophen Tablet 325 MG Give 2 tablet by mouth four times a day for discomfort

Resident #113

Review of an Admission Record revealed Resident #113 was a female, with pertinent diagnoses which included diabetes, epilepsy (seizure disorder), hypothyroidism, bipolar disorder, depression, and a history of falls.

Review of the October 2024 Medication Administration Record (MAR) for Resident #113 revealed no documentation (missed medications) on 10/12/24 in the evening for the following physician orders:

-Gabapentin Oral Capsule 300 MG (Gabapentin) Give 1 capsule by mouth one time a day related to neuropathy (nerve pain)

-Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 61 unit subcutaneously one time a day for diabetes

-Levothyroxine Sodium Oral Tablet 75 MCG (Levothyroxine Sodium) Give 1 tablet by mouth one time a day related to hypothyroidism

-Colace Oral Capsule 100 MG (Docusate Sodium) Give 1 capsule by mouth two times a day for constipation

-QUEtiapine Fumarate Oral Tablet 50 MG (Quetiapine Fumarate) Give 1 tablet by mouth two times a day related to bipolar disorder

-Refresh Plus Ophthalmic Solution 0.5 % (Carboxymethylcellulose Sodium) Instill 2 drop in both eyes two times a day for Dry eyes

-Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth three times a day for Pain

Resident #120

Review of an Admission Record revealed Resident #120 was a male, with pertinent diagnoses which included dementia, atrial fibrillation (an irregular heart rate that results in poor blood flow), depression, anxiety, schizoaffective disorder (a mental health condition), Wernicke's encephalopathy (neurological disorder), hyperlipidemia, insomnia, diabetes, and hypotension (low blood pressure).

Review of the October 2024 Medication Administration Record (MAR) for Resident #120 revealed no documentation (missed medications) on 10/12/24 in the evening for the following physician orders:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 0725 -Atorvastatin Calcium Oral Tablet 10 MG (Atorvastatin Calcium) Give 1 tablet by mouth one time a day related to hyperlipidemia Level of Harm - Minimal harm or potential for actual harm -Melatonin Oral Tablet 3 MG (Melatonin) Give 1 tablet by mouth one time a day for Sleep

Residents Affected - Some -OLANZapine Oral Tablet 20 MG (Olanzapine) Give 1 tablet by mouth one time a day related to schizoaffective disorder

-traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth one time a day related to depression

-Sotalol HCl Oral Tablet 160 MG (Sotalol HCl) Give 1 tablet by mouth two times a day related to atrial fibrillation

-Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium) Give 4 capsule by mouth three times a day related to dementia

-Lactulose Oral Solution 10 GM/15 ML (Lactulose) Give 30 ml by mouth three times a day related to Wernicke's encephalopathy

-Midodrine HCl Oral Tablet 10 MG (Midodrine HCl) Give 1 tablet by mouth three times a day related to hypotension

-Haloperidol Oral Tablet 5 MG (Haloperidol) Give 1 tablet by mouth four times a day related to schizoaffective disorder

Resident #124

Review of an Admission Record revealed Resident #124 was a male, with pertinent diagnoses which included heart disease, hyperlipidemia (high levels of fat in the blood), seizure disorder, high blood pressure, atrial fibrillation (an irregular heart rate that results in poor blood flow), and BPH (an enlarged prostate that can cause difficulty urinating).

Review of the October 2024 Medication Administration Record (MAR) for Resident #124 revealed no documentation (missed medications) on 10/18/24 in the evening for the following physician orders:

-Atorvastatin Calcium Oral Tablet 40 MG (Atorvastatin Calcium) Give 1 tablet by mouth one time a day for hyperlipidemia

-Tamsulosin HCl Oral Capsule 0.4 MG (Tamsulosin HCl) Give 1 capsule by mouth one time day for BPH

-Eliquis Oral Tablet 5 MG Apixaban) Give 1 tablet by mouth two times a day related to heart disease/atrial fibrillation

-Gabapentin Oral Capsule 100 MG Give 2 capsule by mouth two times a day for Pain

-Lacosamide Oral Tablet 100 MG (Lacosamide) Give 1 tablet by mouth two times a day for seizure

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 0725 -Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours for pain

Level of Harm - Minimal harm or Review of the October 2024 Medication Administration Record (MAR) for Resident #124 revealed no potential for actual harm documentation (missed medications) on 10/26/24 in the morning for the following physician orders:

Residents Affected - Some -Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 1 tablet by mouth one time a day for heart failure/atrial fibrillation

-Senna Oral Tablet 8.6 MG (Sennosides) Give 2 tablet by mouth one time a day for bowels

-Eliquis Oral Tablet 5 MG Apixaban) Give 1 tablet by mouth two times a day related to heart disease/atrial fibrillation

-Gabapentin Oral Capsule 100 MG Give 2 capsule by mouth two times a day for Pain

-Lacosamide Oral Tablet 100 MG (Lacosamide) Give 1 tablet by mouth two times a day for seizure

-Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth every 8 hours for pain

Resident #125

Review of an Admission Record revealed Resident #125 was a male, with pertinent diagnoses which included diabetes.

Review of the October 2024 Medication Administration Record (MAR) for Resident #125 revealed no documentation (missed medications) on 10/18/24 in the evening for the following physician orders:

-Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously one time a day for diabetes

-traZODone HCl Oral Tablet 50 MG (Trazodone HCl) Give 1 tablet by mouth one time a day for Depression

Review of the October 2024 Medication Administration Record (MAR) for Resident #125 revealed no documentation (missed medications) on 10/19/24 in the morning for the following physician orders:

-NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 10 unit subcutaneously three times a day for diabetes

-NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale three times a day for diabetes

Resident #126

Review of an Admission Record revealed Resident #126 was a female, with pertinent diagnoses which included depression, anxiety, and diabetes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 0725 Review of a Minimum Data Set (MDS) assessment for Resident #126, with a reference date of 11/15/24, revealed a Brief Interview for Mental Status (BIMS) score of 14, out of a total possible score of 15, which Level of Harm - Minimal harm or indicated she was cognitively intact. potential for actual harm

In an interview on 1/9/25 at 12:21 PM, Resident #126 recalled several nights in October 2024 where no Residents Affected - Some nurse was assigned to her hall. Resident #126 stated .I guess (the nurse) just didn't show up. I think that is what the excuse was . Resident #126 reported she missed some medications and others were administered late. Resident #126 stated .I was kind of worried because I didn't know. I have sugar (diabetes). I didn't know then if I would have a reaction . Resident #126 reported she was worried about how long she could go without medication. Resident #126 reported issues with anxiety and stated .The anxiety got to be so bad . nobody (was) handing out meds (medications) .there was no one .

41982

In an interview on 1/7/25 at 8:54 AM Certified Nurse Aide (CNA) R reported staffing on The Harbor (the memory care unit) was challenging because of the needs of the residents. CNA R reported there were many residents who were dependent on staff to feed them and generally there were only 3 aides to feed. CNA R reported the nurse on duty would sometimes assist with feeding as well, but it depended on the nurse, and many did not help. CNA R reported sometimes there was only 2 aides and a nurse on the unit which was not enough because they couldn't keep an eye on every resident adequately.

In an interview on 1/7/25 at 2:38 PM, CNA X reported she usually worked on the 400 Hall but sometimes on

the 300 Hall as well. CNA X reported the staffing here is horrible. CNA X gave the example that the facility hadn't had enough staff to feed dependent residents for lunch and dinner the day before. CNA X reported at times, there had not been enough staff to feed residents for breakfast either. CNA X reported when a CNA called off, the facility couldn't always get somebody to come in to fill the open spot, and the CNAs working just do what they can.

In an interview on 1/8/25 at 2:53 PM, Licensed Practical Nurse (LPN) Q reported staffing was frustrating. LPN Q reported staff often showed up late. LPN Q reported call lights didn't always get answered in a timely fashion, it was difficult to keep an eye on some of the residents who have behaviors or who are fall risks, and sometimes meal trays were delivered late or got missed altogether.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 Ensure that residents are free from significant medication errors.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36221

Residents Affected - Few This citation pertains to Intake # MI00147580, MI00149295, & MI00149428.

Based on interview, and record review, the facility failed to ensure residents are free from significant medication errors in 5 of 14 residents (Resident #118, #103, #113, #124, & #125) reviewed for medication administration, resulting in a significant change in condition and hospitalization for Resident #118, and the potential for adverse effects due to missed medications.

Findings include:

The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME]; Hall, [NAME]. Fundamentals of Nursing - E-Book (Kindle Locations 20717-20719). Elsevier Health Sciences. Kindle Edition.

Resident #118

Review of an Admission Record revealed Resident #118 was a male, with pertinent diagnoses which included heart failure, atrial fibrillation (an irregular heart rate that results in poor blood flow), respiratory failure, kidney disease, stroke, and high blood pressure.

Review of a Minimum Data Set (MDS) assessment for Resident #118, with a reference date of 12/17/24, revealed a Brief Interview for Mental Status (BIMS) score of 0, out of a total possible score of 15, which indicated severe cognitive impairment.

Review of a Nursing - Transfer to Hospital Summary for Resident #118, dated 12/30/24 at 6:37 PM, revealed .Resident was in bed alert with prompting .Resident brother at bedside during the morning. Medications reviewed with brother .Brother was concerned resident was not staying awake during visit .VS (Vital Signs) obtained (oxygen via nasal cannula) increased to 5 (Liters) .to maintain (oxygen) above 90%. NP (Nurse Practitioner) called .brother wanted to send patient to ED (Emergency Department) .

In an interview on 1/6/25 at 12:15 PM, Unit Manager LL reported they assessed Resident #118 prior to his hospitalization on [DATE REDACTED]. Unit Manager LL reported they were working on a different unit when Resident #118's nurse came to get them for a second opinion. Unit Manager LL reported Resident #118's family member had been in earlier asking about Resident #118's ordered medications. Unit Manager LL reported Resident #118's oxygen saturation had been low and the assigned nurse had increased his oxygen to keep his saturation above 90%. Unit Manager LL reported Resident #118 appeared calm and did make eye contact and respond to his name. Unit Manager LL reported Resident #118's family member was concerned, and wanted Resident #118 to be sent to the hospital since he seemed more sleepy/tired than usual.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 In an interview on 1/6/25 at 12:23 PM, Agency Licensed Practical Nurse (LPN) DDD reported they were the nurse assigned to Resident #118 at the time of his hospitalization on [DATE REDACTED]. Agency LPN DDD reported Level of Harm - Actual harm Resident #118 was awake but appeared to have labored breathing. Agency LPN DDD reported since they were not sure of Resident #118's baseline, they requested Unit Manager LL to assess Resident #118. Residents Affected - Few Agency LPN DDD reported they checked on him several times and he would respond and make eye contact. Agency LPN DDD stated .the breathing was my concern . and reported both Resident #118's pulse and respiration rate were high. Agency LPN DDD reported Resident #118's family member was concerned that Resident #118 was not his usual self, and wanted him sent to the hospital for further evaluation. Agency LPN DDD reported Resident #118 had a PRN (as needed) medication ordered for anxiety, but no doses were administered on their shift.

Review of an Emergency Department (ED) Physician Note for Resident #118, dated 12/30/24, revealed . presented from nursing facility with acute Encephalopathy, un arousable, only arousing to sternal rub .Drug screen pending .Upper and lower extremities are cold to touch .Concerned if he is in cardiogenic shock .QTC is very prolonged >600s, holding amiodarone .Avoid QT prolonging (medications) .transferred to the intensive care unit (ICU) .

Review of a Hospital Physician Note for Resident #118, dated 12/31/24, revealed .Presented this admission from LTC (Long-Term Care) for change in mentation and abnormal breathing .Amiodarone started last admission .EKG upon admission demonstrated prolonged QTc. Agree with holding at this time .Per ICU notes - may be related to Trazodone use .Monitor QTc and rhythm .

Review of a Hospital Physician Note for Resident #118, dated 1/1/25, revealed .Patient was brought in from his long-term care facility to emergency department with acute encephalopathy leading to worsening acute hypoxic respiratory failure. He was difficult to arouse in the emergency department so he was admitted to intensive care unit for close monitoring .suspected to be medication related: Drug screen was positive for trazodone (not on facility med (medication) list, so unclear how he received this medication), but also had been on Xanax but this did not show on drug screen .

Review of a Hospital Physician Note for Resident #118, dated 1/2/25, revealed .Drug Screen .Trazodone . Facility was contacted, and there was no record of trazodone administration .there is report that the patient did receive Vistaril and Xanax on the days leading up to admission. There was no benzodiazapines identified

on screens .It is felt that the altered mental status may have been related to trazodone (found) on a drug screen, there is no documentation of this ever being given at the facility .

In an interview on 1/7/25 at 9:30 AM, Agency Registered Nurse (RN) BBB reported Resident #118 had a PRN medication for anxiety and recalled administering the medication to Resident #118. Agency RN BBB stated .(Resident #118) had a lot of anxiety. (He) wouldn't keep his oxygen (nasal cannula) on (and) would have episodes of rapid breathing . Agency RN BBB reported Resident #118 took all his medication via a PEG (Percutaneous Endoscopic Gastrostomy) tube (a feeding tube placed through the abdominal wall).

Review of an Order Summary Report for Resident #118 revealed the physician order .Xanax Oral Tablet 0.5 MG (Alprazolam) Give 0.5 mg via G-Tube (feeding tube) every 8 hours as needed for Anxiety . with a start date of 12/19/24. Note this order was discontinued on 12/26/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 Review of an Order Summary Report for Resident #118 revealed the physician order .Xanax Oral Tablet 0.5 MG (Alprazolam) Give 1 tablet via PEG-Tube (feeding tube) every 8 hours as needed for Anxiety . with a Level of Harm - Actual harm start date of 12/29/24.

Residents Affected - Few Review of a Controlled Drug Receipt/Record/Disposition Form for Resident #118 revealed one Alprazolam 0. 5 MG Tablet was pulled from Resident #118's medication supply for administration on 12/19/24 at 7:00 AM, one on 12/19/24 at 7:00 PM, one on 12/28/24 at 9:00 PM, and one on 12/29/24 at 12:22 PM. Note there was no active physician order for Alprazolam 0.5 MG Tablet for Resident #118 on 12/28/24.

Review of the December 2024 Medication Administration Record (MAR) for Resident #118 revealed the medication Alprazolam 0.5 MG Tablet was documented as administered only one time, on 12/29/24 at 12:22 PM. No administration documentation noted in the December 2024 MAR related to the Alprazolam 0.5 MG Tablets pulled from Resident #118's medication supply on 12/19/24 (two doses) and 12/28/24 (one dose).

Review of an Order Summary Report for Resident #118 revealed the physician order .Amiodarone HCl Oral Tablet 200 MG (Amiodarone HCl) Give 1 tablet .one time a day . with a start date of 12/28/24.

Review of an Order Summary Report for Resident #118 revealed no physician order for Trazodone.

In an interview on 1/9/25 at 1:42 PM, Assistant Director of Nursing (ADON) C reported Resident #118 was sent to the hospital on 12/30/24 and a drug screen revealed trazodone (an antidepressant) in his system, which he was not prescribed. ADON C reported the drug screen also indicated no alprazolam in his system, which he did have a prescription for and per the facility medication administration records had been given two doses prior to his hospitalization . ADON C reported Resident #118 was prescribed amiodarone which cannot be taken simultaneously with trazodone, due to the potential for drug interactions.

Resident #103

Review of an Admission Record revealed Resident #103 was a male, with pertinent diagnoses which included stroke and a seizure disorder.

Review of a current Care Plan for Resident #103 revealed the focus .The resident has a seizure disorder r/t (related to) hx (history) intracerebral hemorrhage (stroke) . with interventions which included .Give seizure medication as ordered by doctor. Monitor/document side effects and effectiveness . both initiated 8/14/24.

Review of the October 2024 Medication Administration Record (MAR) for Resident #103 revealed no documentation (missed medication) on 10/18/24 in the evening for the physician order .levETIRAcetam Oral Tablet 500 MG (Levetiracetam) Give 1 tablet by mouth two times a day for Seizures .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 Review of an article titled Missed Medicines as a Seizure Trigger, dated 2024, revealed .Missing doses of seizure medicine is the most common cause of breakthrough seizures. Missed medicines can trigger Level of Harm - Actual harm seizures in people with both well-controlled and poorly controlled epilepsy. Seizures can happen more often than normal, be more intense or develop into long seizures called status epilepticus. Status epilepticus is a Residents Affected - Few medical emergency and can lead to death if the seizures aren't stopped. Missing doses of medicine can also lead to falls, injuries and other problems from seizures and changes in medicine levels . Retrieved from https://www.epilepsy.com/what-is-epilepsy/seizure-triggers/missed-medicines

Resident #113

Review of an Admission Record revealed Resident #113 was a female, with pertinent diagnoses which included diabetes.

Review of a current Care Plan for Resident #113 revealed the focus .Risk (for) adverse outcomes from potential hypoglycemic (low blood sugar) or hyperglycemic (high blood sugar) episodes (diagnosis of diabetes) . initiated 8/14/24.

Review of the October 2024 Medication Administration Record (MAR) for Resident #113 revealed no documentation (missed medication) on 10/12/24 in the evening for the physician order .Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Glargine) Inject 61 unit subcutaneously one time a day for diabetes .

Resident #124

Review of an Admission Record revealed Resident #124 was a male, with pertinent diagnoses which included heart disease, high blood pressure, and atrial fibrillation (an irregular heart rate that results in poor blood flow).

Review of a current Care Plan for Resident #124 revealed the focus .The resident is on anticoagulant therapy r/t (related to) Atrial fibrillation, history of PE (pulmonary embolism) . with interventions which included .Administer medications as ordered by physician. Monitor for side effects . both initiated 8/13/24.

Review of the October 2024 Medication Administration Record (MAR) for Resident #124 revealed no documentation (missed medication) on 10/18/24 in the evening for the physician order .Eliquis (an anticoagulant) Oral Tablet 5 MG Apixaban) Give 1 tablet by mouth two times a day related to heart disease/atrial fibrillation .

Review of the October 2024 Medication Administration Record (MAR) for Resident #124 revealed no documentation (missed medication) on 10/26/24 in the morning for the physician order .Eliquis Oral Tablet 5 MG Apixaban) Give 1 tablet by mouth two times a day related to heart disease/atrial fibrillation .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 Review of a Cleveland Clinic page titled Anticoagulants, last reviewed/updated 1/10/22, revealed . Anticoagulants are a family of medications that stop your blood from clotting too easily. They can break down Level of Harm - Actual harm existing clots or prevent clots from forming in the first place. These medications can help stop life-threatening conditions like strokes, heart attacks and pulmonary embolisms, all of which can happen because of blood Residents Affected - Few clots . Retrieved from https://my.clevelandclinic.org/health/treatments/22288-anticoagulants

Resident #125

Review of an Admission Record revealed Resident #125 was a male, with pertinent diagnoses which included diabetes.

Review of a current Care Plan for Resident #125 revealed the focus .The resident has Diabetes Mellitus . with interventions which included .Administer medication as ordered by the physician . both initiated 8/13/24.

Review of the October 2024 Medication Administration Record (MAR) for Resident #125 revealed no documentation (missed medication) on 10/18/24 in the evening for the physician order .Lantus Subcutaneous Solution 100 UNIT/ML (Insulin Glargine) Inject 10 unit subcutaneously one time a day for diabetes .

Review of the October 2024 Medication Administration Record (MAR) for Resident #125 revealed no documentation (missed medications) on 10/19/24 in the morning for the physician orders .NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject 10 unit subcutaneously three times

a day for diabetes . and .NovoLOG FlexPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale three times a day for diabetes .

Review of a Cleveland Clinic page titled Insulin, last reviewed/updated 1/17/24, revealed .Insulin is an essential hormone. It helps your body turn food into energy and manages your blood sugar levels. If you have diabetes, your body can't make enough insulin or can't use it properly. Your healthcare provider can prescribe manufactured insulin that you take through an injection (shot), injectable pen or pump .Insulin is a naturally occurring hormone your pancreas makes that's essential for allowing your body to use sugar (glucose) for energy. If your pancreas doesn't make enough insulin or your body doesn't use insulin properly,

it leads to high blood sugar levels (hyperglycemia). This results in diabetes .There are also manufactured types of insulin that people with diabetes use to manage the condition .Regular insulin (or short-acting insulin) .They begin working about 30 to 45 minutes after injection and wear off after about five to eight hours. Regular insulin peaks about two to four hours after injection .Long-lasting insulin: It takes about an hour for this type of insulin to reach your bloodstream and start working. It peaks between three and 14 hours after injection. It lasts up to a day. Types include insulin glargine .Follow your provider's instructions carefully . Retrieved from https://my.clevelandclinic.org/health/body/22601-insulin

In an interview on 1/6/25 at 3:48 PM, Licensed Practical Nurse (LPN) QQ reported the evening of 10/18/24

on the 300 Hall, no residents received scheduled medications.

In an interview on 1/8/25 at 9:52 AM, Former Assistant Director of Nursing (ADON) MMM reported they were aware that multiple residents missed medications the evening of 10/18/24 and stated .we did look into that .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 In an interview on 1/8/25 at 10:07 AM, Agency Licensed Practical Nurse (LPN) JJJ reported they worked on

the 100 Hall the evening of 10/18/24. Agency LPN JJJ reported that evening there was no nurse assigned to Level of Harm - Actual harm the 300 Hall from 6:30 PM-11:00 PM.

Residents Affected - Few In an interview on 1/8/25 at 11:49 AM, RN PPP reported they worked at the facility on 10/19/24 and stated .

they were short on nurses that morning . RN PPP recalled going over to the 300 Hall to assist with passing morning medications. RN PPP reported there was no nurse responsible for the 300 Hall at that time. RN PPP stated .It was horrible because a lot of people did not get their medications . on 10/18/24 and 10/19/24.

In an interview on 1/8/25 at 1:22 PM, with Director of Nursing (DON) B and Assistant Director of Nursing (ADON) C, DON B reported the facility recognized an issue related to the 300 Hall and missed medications

on 10/18/24. DON B reported a nurse came in late on 10/19/24 to assist with medication administration on

the 300 Hall and help get everything caught up.

In an interview on 1/8/25 at 3:40 PM, LPN QQ reported at shift change the evening of 10/18/24, no nurse showed up for the 300 Hall. LPN QQ reported they counted the controlled substances with the other day shift nurse and locked the keys in the medication cart before leaving the facility. LPN QQ reported they wrote a shift-to-shift report on a piece of paper and left it at the desk. LPN QQ stated .(With Agency staff) you don't know who will show up . LPN QQ reported RN LLL was on the 400 Hall that night and refused to take responsibility for the 300 hall because .it was too many people . LPN QQ reported the same thing happened

on 10/26/24 on day shift, where no nurse took responsibility for the 300 Hall resulting in residents not receiving their ordered medications. LPN QQ reported residents on the 400 Hall missed medications and had no nurse the evening of 10/12/24. LPN QQ reported that night (10/12/24) the Agency nurse on the schedule arrived and refused the assignment, saying she wasn't going to put her license at risk.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 68 235458 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 235458 B. Wing 01/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Grand Rapids 1950 32nd St S E 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 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 36221 potential for actual harm

This citation pertains to Intake # MI00147580. Residents Affected - Many Based on interview, and record review, the facility failed to ensure it was administered in a manner that maintains the safety and care of residents, so residents may reach their highest practicable physical, mental, and psychosocial well-being, for all 92 residents who reside at the facility, resulting in quality care not being provided to residents, insufficient management of facility staffing, and a lack of follow-up in regard to concerns voiced by staff. For additional information see citations