Optalis Health And Rehabilitation Of Three Rivers

F 0600 Level of Harm - Minimal harm or potential for actual harm

the right to be free from abuse.DEFINITIONS: Mental abuse.The use of verbal or nonverbal conduct which may cause the resident to experience.intimidation, fear.agitation or degradation.Verbal Abuse: Use of oral.or gestured communication or sounds to residents within hearing distance regardless of their age, ability to comprehend, or disability. To include but not limited to harassment, mocking, insulting, ridiculing, yelling or hovering with the intent to intimidate, threatening, etc.

Residents Affected - Few Using the reasonable person concept, although Resident #101 was not able to verbally express his feelings related to being physically threatened, referred to in a derogatory manner, or mocked, it is reasonable to assume that Resident #101 experienced anxiety, intimidation and humiliation as the result of Resident #100's actions toward him.

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

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Three Rivers

517 S Erie St Three Rivers, MI 49093

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

included: dementia with behavioral disturbances (the loss of cognitive functioning including the ability to think, remember, or reason), cerebral infarction (stroke- interruption of blood floor to an area of the brain), and joint replacement surgery.Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 7/14/25 revealed a Brief Interview for Mental Status (BIMS) score of 4/15 which indicated Resident #100 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment).In a telephone interview on 10/7/25 at 8:53 AM, Family Member (FM) GG reported Director of Nursing (DON) B told her Resident #101 was being targeted by 2 female residents in the building and they were threatening him and making verbal threats against him. In a telephone interview on 10/7/25 at 1:03 PM, Licensed Practical Nurse (LPN) II reported there was a group of residents who would get irritated with Resident #101 and this group was targeting Resident #101 and they would gang up on him with their complaints.In an interview on 10/7/25 at 2:19 PM, CNA W reported she observed an incident where Resident #101 was the victim/target when Resident #100 was yelling I dare you to hit me and barking at and stating out loud He's not right in the head while both residents were in the dining room. Not near each other, but in the same area of the dining room. CNA W reported that Resident #101 did not engage Resident #100 at any time during the incident or [NAME] she was removing him from the dining room. In an

interview on 10/8/25 at 10:40 AM, Activity Aide (AA) BB reported she observed a situation in the dining room where Resident #100 stated out loud she would Resident #101 if he came near her. AA BB reported

she intervened and removed Resident #101 from the dining room area. AA BB reported she reported the situation to both DON B and NHA A.In an interview on 10/8/25 at 2:22 PM, DON B reported she remembered when CNA W came into a meeting and mentioning that Resident #100 and Resident #101 were separated. DON B reported that nothing that was told to her about the situation indicated that abuse had occurred. DON B reported no contact was made between the two residents, no profanity was used, no one was harmed, none of that indicated abuse or that anything needed to be reported.In an interview on 10/8/25 at 2:54 PM, NHA A reported the incident that was reported by CNA W regarding Resident #100 and Resident #101 was investigated in the moment, but nothing more came of the situation. Review of facility policy Abuse with a date of 5/24/2023 revealed .The facility will develop and implement written policies and procedures that include.identifying abuse.The facility will educate their staff.identify what constitutes abuse.reporting process for suspicions or allegations of abuse.identifying abuse.verbal abuse of

a resident overheard.The facility will ensure that all allegations involving abuse.are reported immediately to

the administrator and reported to the State Survey Agency immediately but not later than two hours after

the allegation is made if the allegation involves abuse.Reported to the State Survey Agency no later than 24 hours if the allegation does not involve abuse.Mental abuse the use of verbal or nonverbal conduct which may cause the resident to experience humiliation, intimidation, fear, shame, agitation.Verbal Abuse use of oral, written or gestured communication and sounds to residents within hearing distance. to include but not limited to harassment, mocking, insulting, ridiculing, yelling or hovering with intent to intimidate, threatening, etc.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Three Rivers

517 S Erie St Three Rivers, MI 49093

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

policy Abuse with a date of 5/24/2023 revealed .The facility will develop and implement written policies and procedures that include.investigating abuse.The facility will educate their staff.identify what constitutes abuse.investigation.to investigate all alleged violations.identify the staff responsible for the investigation. determining the purpose of the investigation. interviewing all involved persons, including the alleged victim, perpetrator, witnesses, others who might have knowledge of the allegations.Mental abuse the use of verbal or nonverbal conduct which may cause the resident to experience humiliation, intimidation, fear, shame, agitation.Verbal Abuse use of oral, written or gestured communication and sounds to residents within hearing distance. to include but not limited to harassment, mocking, insulting, ridiculing, yelling or hovering with intent to intimidate, threatening, etc.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Three Rivers

517 S Erie St Three Rivers, MI 49093

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 0627 Level of Harm - Actual harm Residents Affected - Few

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

reference date of 4/18/25 revealed .GENERAL GUIDELINES: .Once admitted , the resident has the right to remain at the facility unless their transfer or discharge meets one of the following specified exemptions: The discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility.DISCHARGE WHEN NEEDS CANNOT BE MET OR SAFETY OR HEALTH OF INDIVIDUALS IS ENDANGERED: The facility's transfer/discharge notice will be provided to the .resident's representative.The notice will include.:specific reason and basis for discharge .information on how to obtain an appeal.Generally, the notice must be provided at least 30 days prior to a transfer or discharge.For circumstances where the discharge.is necessary for the resident's welfare and the facility cannot meet the resident's needs.the resident's physician must document information about the basis for the discharge and will include: The specific reason resident needs the facility could not meet, the facility efforts to meet those needs and the specific services the receiving facility will provide to meet the needs of the resident which cannot be met at the current facility.Using the reasonable person concept, although Resident #101 could not verbalize the psychosocial harm he endured when the facility failed to add interventions to maintain his safety, and abruptly discharged him to an unfamiliar, locked memory care unit, he clearly experienced increased fear, panic, resistance to care and emotional distress for an ongoing period of time and ultimately required pharmacological intervention for symptom management.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Three Rivers

517 S Erie St Three Rivers, MI 49093

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 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to ensure proper discharge notification was completed for 1 resident (Resident #101) of 2 residents reviewed for the discharge process, resulting in Resident #101's Durable Power of Attorney (DPOA) GG not receiving written notification of the reason for discharge and the right to appeal.Findings include:Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE REDACTED] with pertinent diagnoses which included: dementia (general term used for loss of memory, language, thinking skills that interfere with daily life) with behavioral disturbance.Review of

a Minimum Data Set (MDS) assessment for Resident #101 with a reference date of 9/11/25, revealed a Brief Interview for Mental Status (BIMS) assessment score of 3/15, which indicated the resident was severely cognitively impaired. Section E of the MDS revealed Resident #101 did not display the presence of wandering during the 7-day assessment period.Review of a Care Plan for Resident #101 with a reference date of 7/23/25 revealed the following focus/goal/interventions: Focus: Altered behavior in which resident acts (are) sic characterized by ineffective coping skills.Goal: Decrease episodes of anxiety.Interventions.if (Resident #101) becomes agitated in congested areas assist him into a less congested area. Involve resident in 1:1 recreational activity, keep schedules routine and predictable.In an interview on 10/7/25 at 8:53am, DPOA GG reported she received a telephone call on 9/11/25 from Admissions Coordinator (AC) Z at approximately 1:00pm, who told her Resident #101 had to transfer to another skilled nursing facility on that date. DPOA GG reported she was told she had to come to the facility immediately to transport the resident and was never given the option of appealing the discharge and was not told this discharge was voluntary. DPOA GG reported when she arrived at the facility, Nursing Home Administrator (NHA) A told her Resident #101 was being harassed by another resident and had to leave. DPOA GG reported if given the choice, she wanted Resident #101 to remain at the facility because he had adjusted to living there.In an

interview on 10/7/25 at 3:41pm, NHA A confirmed DPOA GG was not given a written notification of discharge that included the rationale for discharge when Resident #101 was abruptly discharged on 9/11/25. Review of a Transfers and Discharge policy with a reference date of 4/18/25 revealed The facility transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in they can understand. The notice will include the following at the time it is provided: The specific reason and basic for transfer or discharge.an explanation of the right to appeal.information on how to obtain an appeal form, information on obtaining assistance in completing and submitting the appeal hearing request.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Three Rivers

517 S Erie St Three Rivers, MI 49093

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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

disturbances (the loss of cognitive functioning including the ability to think, remember, or reason), cerebral infarction (stroke- interruption of blood floor to an area of the brain), and joint replacement surgery.Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 7/14/25 revealed a Brief Interview for Mental Status (BIMS) score of 4/15 which indicated Resident #100 was severely cognitively impaired. (BIMS score 0-7 indicates severe cognitive impairment).Review of IDT late entry note for Resident #101 dated 9/5/25 at 12:35 PM, revealed .wandering throughout the facility per usual today and is easily redirectableReview of IDT note for Resident #101 dated 9/8/25 at 9:42 AM, revealed .met with resident this morning who is wandering down hallway per baseline. Resident remains confused per baseline and easily redirectable. In a telephone interview on 10/7/25 at 8:53 AM, Durable Power of Attorney (DPOA) GG reported Resident #101 liked to walk the sun in the halls. DPOA GG reported during her visits when Resident #101 would get antsy she would walk next to him, while he was in is wheelchair and they would walk down each hall, touch the door at the end, return to the beginning of the hall, and then walk down the next hall, until they returned to his room; due to the shape of the hallways (4 halls branching from

the circle in the middle) she referred to the activity as walking the sun. DPOA GG reported Resident #101 wandered as a stress relief. DPOA GGreported Resident #101 was confused on where his room was and often entered other's rooms thinking they were his.In an interview on 10/7/25 at 2:02 PM, MDS E reported Resident #101 was often wheeling around the building, wandering.In an interview on 10/7/25 at 1:46 PM, LPN L reported Resident #101 would spend all day going up and down the hallways.In an interview on 10/7/25 at 1:50 PM, CNA Q reported that Resident #101 would wander down the halls and sit at the door and look outside.In an interview on 10/8/25 at 9:47 AM, CNA R and CNA P reported Resident #101 wandered around the facility, in and out of other resident's rooms.In an interview on 10/8/25 at 9:51 AM, Registered Nurse (RN) I reported Resident #101 wandered around the building and didn't know how to get to his room.Review of Care Plan for Resident #101 revealed no indication that Resident #101 wandered the building, was unable to locate his room, or that he would enter other resident's rooms.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Three Rivers

517 S Erie St Three Rivers, MI 49093

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 0745 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

reported she had been assisting the facility with some social work tasks but had not been involved with Resident#101 or Resident #100 care planning or discharge planning.Additional information regarding any interventions the facility put in place to address Resident #101's and Resident #100's behaviors was requested. No additional information was received by the conclusion of the survey. NHA A agreed to provide any additional information if available by the conclusion of the survey. Review of a Staff Social Services Worker job description revealed performance standards.15.Identify resident with current needs for social service interventions.and those residents at risk for psychosocial deterioration.17. Works cooperatively with member of the interdisciplinary team to develop, implements and evaluate plan of care.21. Provides information about community resources.23. Evaluates assigned residents for discharge potential. Provide discharge planning services.25. Provides individual assistance for resident at times of adjustment, crisis, or particular need.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/08/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Three Rivers

517 S Erie St Three Rivers, MI 49093

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)

Federal health inspectors cited Optalis Health and Rehabilitation of Three Rivers in Three Rivers, MI for a deficiency under regulatory tag F-F0842 during a complaint investigation conducted on 2025-10-08.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of Optalis Health and Rehabilitation of Three Rivers.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-31.

Federal health inspectors cited Optalis Health and Rehabilitation of Three Rivers in Three Rivers, MI for a deficiency under regulatory tag F-F0850 during a complaint investigation conducted on 2025-10-08.

Category: Administration Deficiencies

The facility was found deficient in the following area: Hire a qualified full-time social worker in a facility with more than 120 beds.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 9 deficiencies cited during this inspection of Optalis Health and Rehabilitation of Three Rivers.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-31.