Optalis Health And Rehabilitation Of Troy

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Director of Nursing (DON). The DON was asked if they were aware that Resident R302 was taken to the wrong office

on 7/31/25. They reported they were aware Resident R302 should have been seen but were not certain why they were sent to the wrong office. The DON was asked who arranged for the transportation to office and they noted that Unit Clerk (UC) G generally schedules transportation. The DON was then asked if they were aware that Resident R302 attempted to do their own wound care and as such it was noted that it was delaying the healing process. The DON reported that Resident R302 had a language barrier and believed attempts were made to educate the resident via their daughter. The DON reported that the facility staff are able utilize MARTTI ( My Accessible Real Time Trusted Translator) however, they did not believe staff utilized the system. The DON was asked if they were aware if Resident R302 was supposed to start the antibiotic Vanco on 7/14/25 as written in NP Ms notes. The DON noted that there were no orders for Vanco and the written statement to remain on Vanco was most likely written in error.An attempt to contact NP M was made on 9/4/25 at approximately 1:26 PM. A message was left, and no return call was received.On 9/4/25 at approximately 1:38 PM, an

interview was conducted with UC ‘G. UC G was asked about the error in scheduling for Resident R302. UC G reported that they were instructed to send Resident R302 to see the outside Doctor K and noted the order documented to send them to location A. They arranged the transportation and later found out that Resident R302 should have gone to location B. They then reset the appointment for 8/7/25.On 9/4/25 at approximately 3:38 PM, a phone interview was conducted with Wound Nurse (WN) I. WN I was queried as to the wound care provided to Resident R302 and one week delay in him seeing their outside wound surgeon, Dr. K. WN I reported that

they worked with WN H, and both had been assigned to Resident R302, and they did not believe they were the person who indicated the wrong address to send the resident. When asked about Resident R302's wound to the right 5th digit, they noted that the residents' wound was declining from the time of entry to the facility until their discharge. WN I noted that treatments were implemented but the resident kept treating themselves as well.

When asked if they were aware of what the treatment was, they indicated they were not certain but talked with Resident R302's daughter regarding the self-treatment. WN I was asked if they utilized a translator via MARTTI and they noted they did not. WN I reported that they made a change in the treatment from betadine to Medihoney as noted in the clinical record and reported again that due to the residents decline in healing,

they attempted a new treatment.The facility policy titled, Skin and Wound Guidelines (revised 3/30/34) was reviewed and documented, in part: .Policy Overview: To describe the process steps to.identify prevention techniques and interventions to assist with the management of pressure injuries and skin alterations.Skin Alterations.Weekly evaluation n of skin alterations.The individualized comprehensive care plan addresses

the resident's problem .the goal for prevention and/or treatment and individualized interventions to address

the resident's specific risk factors and plan for reduction of risk.The facility policy titled, Change in Condition Policy (10.2022).Policy: It is the policy of this facility that residents will be routinely monitored and evaluated by all staff members to determine the need for additional health services.Observations or Changes of Condition could indicate the need for additional health services or monitoring.seems different than usual.Change in skin color or condition.

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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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Troy

925 W South Blvd Troy, MI 48085

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 - Minimal harm or potential for actual harm Residents Affected - Few

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

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** This citation pertains to Intake 2597366Based on interview and record review, the facility failed to ensure appropriate supervision was provided to a resident for one (Resident R303) of two residents reviewed for transportation resulting

in Resident R303 being sent multiple times to medical appointments with no staff supervision. Findings include:A complaint was filed with the State Agency (SA) that alleged in part, .On 8/14/2025. (Resident R303) was sent to the appointment and left in the lobby of the doctor's office without any caretaker from the facility.Review of the clinical record revealed Resident R303 was admitted into the facility on 4/11/25 and readmitted [DATE REDACTED] with diagnoses that included: dementia, convulsions and blindness right eye. According to the Minimum Data Set (MDS) assessment dated [DATE REDACTED], Resident R303 had moderately impaired cognition. The clinical record also indicated Resident R303 had a Durable Power of Attorney (DPOA) that was the Responsible Party for financial and medical care.Review of a Physician Statement of Capacity for Medical Treatment and Decisions read in part, lacks the capacity to make reasoned medical decisions and/or provide informed consent for their medical affairs. The specific cause and/or contributing diagnosis to support this decision: impaired insight, impaired reasoning, impaired thinking and memory. It was signed by a Physician/Licensed Psychologist on 3/25/25 and Attending Physician on 3/26/25.Review of Resident R303's physician orders revealed an order with a start date of 8/14/25 that read in part, PATIENT HAS AN APPOINTMENT ON THURSDAY AUGUST 14 @ 2:00 PM.Review of Resident R303's Discharge Care Plan initiated 4/15/25 read in part, DPOA has decided that (Resident R303) is appropriate for long term care placement, discharge plan is to remain long term for 24* care and/or supervision.Review of Resident R303's physician consultation documents revealed a consult dated 7/30/25 that the consulting physician wrote, pt (patient) sent to office twice with no records, no information. She is not able to provide medical history. She does not know why she is here. Someone MUST (underlined) accompany here [sic] to appointments. On 9/4/25 at 12:05 PM, Unit Clerk (UC) F was interviewed and asked who arranged the transportation to appointments at the facility. UC F explained she made the appointments and arranged the transportation. UC F was asked if residents always were sent by themselves or did a staff member accompany them to appointments. UC F explained up until a couple weeks ago, they had been told staff did not accompany residents to appointments, now if the resident is incompetent a staff member goes with them. UC F was asked how it was determined if a resident was incompetent. UC F explained she would go talk to the resident or ask staff if the resident was competent.

UC F was asked if Resident R303 went to appointments alone. UC F explained Resident R303 was sent alone.On 9/4/25 at 12:15 PM, Unit Manager (UM) C was interviewed and asked if residents went alone or were accompanied by staff on appointments. UM C explained it depended, if the resident was competent they could go alone.

When asked about Resident R303, UM C explained she could not say and would need to talk to the Director of Nursing (DON).On 9/4/25 at 12:17 PM, the DON was interviewed and asked about Resident R303 being sent to appointments alone. The DON explained she had thought Resident R303's family was going to meet her at the appointment. The DON was asked if the facility had its own transportation van with a staff member that drove it. The DON explained they did not, they used different companies that provided wheelchair transportation. The DON was asked if Resident R303 could go on a Leave of Absence (LOA) by herself. The DON said no. When asked why was Resident R303 allowed to be put in a transportation van by herself and leave the facility with no staff accompaniment, the DON acknowledged the concern. On 9/4/25 at 1:13 PM, the Administrator was interviewed and asked about Resident R303 having a care plan for 24-hour care and/or supervision but was sent to multiple appointments via a transportation van by herself with no staff accompaniment. The Administrator acknowledged the concern.

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