Optalis Health And Rehabilitation Of Troy

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

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

neglect such as: Aggressive behaviors and/or catastrophic reactions of residents. Wandering or elopement-type behaviors. Resistance to care. Outbursts or yelling out. Difficulty in adjusting to new routines or staff. How to recognize signs of burnout, frustration, and stress that may lead to abuse.

Identification: The facility will educate the staff in identifying abuse (mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services), neglect, exploitation, mistreatment, and misappropriation of resident property. Possible indicators of abuse include, but are not limited to: Resident, representative, or staff reports of abuse. Suspicious or unexplained injuries such as bruises or patterned appearances such as a handprint, belt or ring mark on a resident's body. Resident, representative, or staff reports of theft or missing property. Verbal abuse of a resident overheard. Physical abuse of a resident observed. Psychological abuse of a resident observed. Failure to provide care needs such as feeding, bathing, dressing, turning & positioning. Evidence of photographs or videos of a resident that are demeaning or humiliating in nature of whether the resident provided consent and regardless of the resident's cognitive status. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. Demonstration of catastrophic reactions. Protection: The facility will attempt to coordinate with State and Local law enforcement annually and as needed to determine which crimes are reportable other than those listed in the definition of Crime. Abuse against residents can be perpetrated by various people within the facility. The facility supports and protects patients, family members, and staff from harm during an investigation of alleged abuse including retribution and retaliation. Protective actions depend upon the people involved. Any allegation of abuse must be immediately reported to the supervisor and the Abuse Prevention Coordinator. The Administrator initiates investigating any allegation of abuse against a patient. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm during and after the investigation. Examples include but are not limited to: Immediately removing the resident from contact with the alleged abuser. Evaluation of the physical and psychosocial condition of the resident and providing emotional support to the patient during and after the investigation as needed. Providing a safe and secure environment for all patients If a staff member is the alleged perpetrator, that staff member should be immediately removed from the facility and

the schedule pending the outcome of the investigation. If a non-staff person (visitor, family member, etc.) is

the alleged perpetrator, that non-staff person should be immediately removed from the facility, prevented access to the resident pending the outcome of the investigation, and/or referring the matter to the appropriate authorities as indicated. If a resident is the alleged perpetrator, the facility will ensure other residents are protected as determined by the circumstances, which may include but are not limited to resident room changes, increased supervision, or immediate transfer or discharge, if indicated. Notification to the resident's attending physician and resident representative of the incident or allegation of abuse.Sexual abuse: Non-consensual sexual contact of any type with a resident including but not limited to unwanted touch especially breasts or perineal area, coerced nudity.forced observation of masturbation.

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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

11/21/2025

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

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

11/06/25, after learning about the incident(s). On 11/07/25 at 12:22 p.m,. CNA L was asked during a phone

interview about any resident incidents with Resident R108. CNA L reported on 10/28/25 around 2:00 p.m., they had just finished rounds and heard a coworker yell for them to come to Resident R103 and Resident R104's room. They observed Resident R108 in their room, standing by the curtain area (middle of room), looking confused with their pants down and brief removed. CNA L reported Resident R108 then sat on Resident R104's bed, and Resident R103 approached Resident R108, who became combative, and Resident R10 began shewing him away with their house shoe. CNA L reported LPN E and CNA H were present when the incident occurred. Review of a police report, dated 11/06/25, revealed on 11/06/25 at 5:08 p.m., a suspicious circumstances incident was determined, when the NHA reported an incident on 10/28/25, when Resident R108 walked into Resident R104's room, opened his gown, dropped his underwear, and began fondling himself. Review of the policy, Abuse, updated 5/24/2023, revealed, .Residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property.The facility will develop and implement written policies and procedures that include: Reporting any allegations of abuse, neglect, mistreatment, exploitation.including reporting a reasonable suspicion of a crime to the State Survey Agency and other officials in accordance with state law.Initial reporting: The facility will ensure that all allegations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source.and crimes are reported immediately to the Administrator and: Reported to the State Agency immediately but not later than two hours after the allegation is made if the allegation involves abuse or results in serious bodily injury and to other officials (including adult protective services and/or law enforcement when applicable, OR reported to the State Survey Agency no later than 24 hours if the allegation does not involve abuse and does not result in serious bodily injury to the State Survey Agency and to other officials.Assuring the reporters are free from retaliation or reprisal. Conclusion reporting: The facility will ensure the results of the investigation are reported to the Administrator and a final report will be submitted to the State Survey Agency no later than five working days after the discovery of the incident. Any knowledge it has of any actions by a court of law which indicate an employee is unfit for service is reported to the State nurse aide registry or licensing authorities.

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

11/21/2025

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)

Federal health inspectors cited Optalis Health and Rehabilitation of Troy in Troy, MI for a deficiency under regulatory tag F-F0684 during a complaint investigation conducted on 2025-11-21.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

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 4 deficiencies cited during this inspection of Optalis Health and Rehabilitation of Troy.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-11-30.

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Administrator was asked why they considered Resident R105 to be their own responsible party when they were deemed to lack the capacity for medication treatment and decisions as of 8/3/25. At that time the Administrator acknowledged the concern. The Administrator was then asked how the facility allowed Resident R105 to leave on LOA when they did not have a physician's order as noted in their policy and the Administrator acknowledged the concern. At 1:17 PM, the Administrator returned and stated interventions were put in place (staff accompanying resident for smoke breaks) once the incident with Resident R105 and at the time they believed Resident R105 were their own responsible party as a guardian had not been assigned to Resident R105 at the time of the incident. When asked about the current status of Resident R105's guardianship, the Administrator stated they were informed that Resident R105's sisters were appointed guardianship over Resident R105, however they were waiting for

the documents to be sent to the facility. No further explanation or documentation was provided.

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If continuation sheet