Optalis Health And Rehabilitation Of Three Rivers

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

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

resident/responsible party to see if they want to hold the bed per facility policy. BOM S said that follow up should occur no matter what the payor source is per facility policy. During an interview on 10/22/2025 at 10:39 AM, Director of Nursing (DON) B stated that AD C gives the initial bed hold policy upon admission and then the nurses sends the bed hold notice to residents when they are sent out to the hospital and then BOM S follows up the resident/responsible party afterwards to see if they want to hold the bed. For Resident R1, DON B stated that they don't keep a copy of the bed hold notice and that NHA A tried to contact Resident R1's responsible party and had notes in Resident R1's chart. During an interview on 10/22/2025 at 11:36 AM, NHA A stated that she didn't document anything in Resident R1's chart because she knew Resident R1 was coming back to the facility so she didn't see the need to call the responsible party about the bed hold. NHA A said she wasn't sure what the facility policy said but that AD C was in charge of the bed hold follow up. Review of the Bed Hold Procedure with a revision date of 4/18/2023 revealed Policy Overview: Upon a resident's transfer for hospitalization, the facility will provide the resident and the resident representative written notice which specifies the duration of the bed hold policy and address information explaining the return of the resident to

the next available bed. Procedure. Upon discharge for emergency medical treatment the facility's admissions director or designee will attempt to contact the resident and/or the resident's representative within 24 hours and/or the next business day to confirm their decision related to a bed hold and document their attempt(s) and/or the resident's representatives bed hold decision in the resident's record. The admission Director or designee will also send a copy of the Bed Hold Notice to the resident's representative via e-mail or postal mail and document in the resident's record. If a Medicaid resident has used the maximum allowable bed hold days, the resident and/or their representative may choose to pay privately to continue to hold the bed at their discretion.

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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

10/22/2025

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 0689 Level of Harm - Actual harm Residents Affected - Few

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

each time.During an interview on 10/20/2025 at 3:17 PM, Social Services Coordinator (SSC) V stated she wasn't working on 10/11/2025 on the day of the incident but she followed up with both residents when she came back to work. SSC V said they don't have behavior meetings but they discuss residents' medication changes and behaviors in IDT and clinical meetings, and with continued issues they discuss new interventions. SSC V said Resident R1 was confused and wandered the halls and Resident R2 had delusions and wasn't aware of his physical aggression towards others. During an interview on 10/21/2025 at 9:44 AM, CNA O stated that Resident R2 was unpredictable and would yell at staff and gets in their face. CNA O said she doesn't feel safe when she goes into Resident R2's room and will usually take another staff member in with her. CNA O' said management isn't quick to help when it comes to residents with behaviors. During second interview on 10/22/2025 at 9:03 AM, SSC V stated that Resident R1 liked to walk down the halls, and they didn't have a concern with it until the incident on 10/11/2025. SSC V' said staff educated R1about not going into other resident rooms and would redirect her and have her go to activities. When further queried, SSC V said that Resident R1 doesn't attend activities which can keep her busy since she likes alone time and looking out of her window.

When asked if Resident R1 can understand education when she had a dementia diagnosis, SSC V stated that Resident R1 understands education and then forgets so she needs reminders to not go into resident rooms. SSC V stated that she meets with the resident and resident's POA (Power of Attorney) when there are behavior issues, but she wasn't able to get a hold of FM E to discuss Resident R1. During an interview on 10/21/2025 at 8:45 AM, Activities Manager (AM) K stated that Resident R1 doesn't attend any activities, but her staff will provide 1:1 activities with her daily and Resident R2 only attends activities he chooses that involves food. During an interview on 10/22/2025 at 10:35 AM, Minimum Data Set Registered Nurse (MDS) L stated that Resident R1 was currently weight bearing as tolerated and needed assistance now versus before the fracture on 10/11/2025. MDS L said Resident R1 was a 1 assist now with walking and ADLs and as a result a significant change assessment was being completed. During an interview on 10/22/2025 at 10:39 AM, Director of Nursing (DON) B stated that Resident R1 wandering down the halls and into resident rooms wasn't an issue prior to the incident on 10/11/2025 and if that was the case, they would have put interventions into place prior to the incident. DON B said IDT discussed abnormal behaviors and they did not feel a 1:1 with staff supervision was needed for either Resident R1 or Resident R2. DON B stated she wasn't aware that staff were concerned about their safety while being around Resident R2 in

the facility common areas or when going into his room and said other residents would let her know if Resident R2 was bothering them or if they didn't like Resident R1 coming into their room.

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If continuation sheet