Optalis Health And Rehabilitation Of Kingsford
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to provide adequate supervision for one Resident #1 (Resident R1) of three residents reviewed for elopement. This deficient practice resulted in Resident R1 leaving the facility unattended and the potential for falls and injury.This citation pertains to intake 2600151Findings include:Resident #1 (Resident R1)Review of Minimum Data Set (MDS) assessment dated [DATE REDACTED], revealed admission to the facility on 7/24/24, with active diagnoses that included anxiety disorder, depression and non-Alzheimer's dementia. Resident R1 scored a 7 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment.Review of document titled Elopement dated 6/30/25, read in part .Resident was visualized by Admissions Director C ambulating towards [Name of business]. Resident entered the business. Admissions Director C notified staff she saw him walking outside. Registered Nurse (RN) D went to the [Name of business] and accompanied resident.Notes.wander guard(C) assessed upon return to the facility .wander guard(C) did not alarm at the entrance of the facility (where resident had exited) .During an
interview on 9/16/25 at 11:23 a.m., Social Worker B reported that Resident R1 prefers to be by himself and doesn't normally get dressed or up during the day.The day Resident R1 eloped, I heard a message on the two-way radio from Admissions Director C that he was outside.I left my office and went outside.Registered Nurse (RN)D saw he was over at the bar and I went and sat with him.his family came and drove him back to the facility as
he was tired.During an interview on 9/16/25 at 11:54 a.m., Admissions Director C reported I was just outside of the facility with another resident.I saw Resident R1 coming out of the facility door with visitors and announced on the two-way radio to alert the staff in the facility and kept watching him. RN D came out of
the facility and went to the [Name of the business].During a phone interview on 9/16/25 at 12:30 p.m., RN D reported I worked down a different wing that day but had heard he was outside of the facility.I walked to the area business (bar) and he was inside having a beer.Review of Resident R1's care plan did not reveal any new interventions were added to the care plan following the elopement.During an interview on 9/16/25 at 12:27 p.m., The Nurse Manager E acknowledged no new interventions were added to the care plan following the elopement.During an interview on 9/16/25 at 2:50 p.m., The Nursing Home Administrator (NHA) and Director of Nursing (DON) acknowledged that the resident eloped from the facility and no interventions had been added to the care plan.Review of policy titled Elopement for Facilities with a Wander alert Bracelet System last revised 5/27/24, read in part Guidelines for when a missing resident has been located.the care plan is updated.resident s care plan and interventions that address the resident's needs.are reviewed and updated.Elopement is a situation in which a resident leaves the facility without the facilities knowledge.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
Optalis Health and Rehabilitation of Kingsford in Kingsford, MI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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 Kingsford, 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 Kingsford or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.