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Complaint Investigation

Optalis Health And Rehabilitation Of Three Rivers

October 22, 2025 · Three Rivers, MI · 517 S Erie St
Citations 2
CMS Rating 2/5
Beds 100
Provider ID 235395
Healthcare Facility
Optalis Health And Rehabilitation Of Three Rivers
Three Rivers, MI  ·  View full profile →
Inspection Summary

Optalis Health and Rehabilitation of Three Rivers in Three Rivers, MI — inspection on October 22, 2025.

Found 2 citations. Severity: Standard violations.

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

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Inspection Findings

FF0628
Resident Rights Deficiencies
Potential for More Than Minimal Harm

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 R1, DON B stated that they don't keep a copy of the bed hold notice and that NHA A tried to contact R1's responsible party and had notes in R1's chart.

During an interview on 10/22/2025 at 11:36 AM, NHA A stated that she didn't document anything in R1's chart because she knew 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/22/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Three Rivers

517 S Erie St Three Rivers, MI 49093

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 10/21/2025 at 9:44 AM, CNA O stated that 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 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 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 R1 doesn't attend activities which can keep her busy since she likes alone time and looking out of her window.

When asked if R1 can understand education when she had a dementia diagnosis, SSC V stated that 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 R1.

During an interview on 10/21/2025 at 8:45 AM, Activities Manager (AM) K stated that R1 doesn't attend any activities, but her staff will provide 1:1 activities with her daily and 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 R1 was currently weight bearing as tolerated and needed assistance now versus before the fracture on 10/11/2025. MDS L said 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 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 R1 or R2. DON B stated she wasn't aware that staff were concerned about their safety while being around R2 in the facility common areas or when going into his room and said other residents would let her know if R2 was bothering them or if they didn't like R1 coming into their room.

Facility ID:

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 Three Rivers, 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 Three Rivers or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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