Optalis Health & Rehabilitation Of Whitehall
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
12/26/25.Review of Resident R9's Electronic Medical Record revealed no documentation for the rationale for administering the medication without first obtaining a heart rate or blood pressure.Resident #10 (Resident R10 )
Review of an admission Record revealed Resident R10 was a [AGE] year-old female, admitted to the facility on [DATE REDACTED], with pertinent diagnoses which included: congestive heart failure.Review of Resident R10's Order Summary dated 10/27/25 revealed: Digoxin Oral Tablet 125 MCG (Digoxin) Give 1 tablet by mouth at bedtime for heart failure Hold for HR < 60 (heart rate less than 60). Metoprolol Succinate ER Oral Tablet Extended Release 24 Hour 25 MG (Metoprolol Succinate) Give 0.5 tablet by mouth at bedtime for beta blocker (12.5 mg) Hold for HR < (less than) 60 or SBP < 90.Review of Resident R10's Pulse Summary revealed the only assessments were completed on 12/8/25 and 12/24/25.Review of Resident R10's December Medication Administration Record (MAR) revealed every dose of digoxin was administered from 12/1/25 through 12/22/25 and 12/24/25-12/25/25.Review of Resident R10's Blood Pressure Summary revealed a blood pressure assessment was not completed on 12/2/25, 12/9/25, 12/10/25, 12/14/25, 12/15/25, 12/21/25, 12/23/25, or 12/25/25.Further review of the Blood Pressure Summary revealed:Resident R10's blood pressure of 120/80 was documented in the MAR for 12/8/25, 12/9/25, and 12/10/25. Resident R10's blood pressure of 138/64 was documented in the MAR for 12/13/25 and 12/14/25. Resident R10's blood pressure of 135/67 was documented in the MAR for 12/20 and 12/21. Resident R10's blood pressure of 124/74 was documented in the MAR for 12/22/25 and 12/23/25. Review of Resident R10's Electronic Medical Record revealed no documentation for the rationale for administering the medication without first obtaining a heart rate or blood pressure.Resident #11 (Resident R11)
Review of an admission Record revealed Resident R11 was a [AGE] year-old female, admitted to the facility on [DATE REDACTED], with pertinent diagnoses which included: congestive heart failure.Review of Resident R11's Order Summary dated 11/26/25 revealed, Daily weights, report to provider if > (greater than) 3# (pound) gain in 1 day or 5#
in 1 week every day shift for CHF (congestive heart failure).Review of Resident R11's Weight Summary revealed a weight was not obtained on 12/8/25, 12/15/25, 12/16/25, 12/17/25, 12/20/25, or 12/25/25.From 12/9/25-12/10/25 Resident R11 had a 3 pound 2 ounce weight increase. There was no documentation that the provider was notified.From 12/19/25-12/21/25 Resident R11 had a 9 pound weight increase. There was no documentation that the provider was notified.During an interview on 12/26/2025 at 3:01 PM, the DON confirmed that Resident R8, Resident R9, and Resident R10's ordered parameters were not followed and that Resident R11's weights were not constituently documented or acted upon. The DON reported that the expectation was for licensed nurses to follow the provider orders and act upon them accordingly. The DON reported that all licensed nurses would receive medication administration re-education. Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed, (Nurses) are also responsible for documenting any preassessment data required with certain medications such as a blood pressure measurement for antihypertensive medications or laboratory values, as in the case of warfarin, before giving the medication. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (pp. 643-644). Elsevier Health Sciences. Kindle Edition.Review of Fundamentals of Nursing ([NAME] and [NAME]) 11th edition revealed,
The seven rights of medication administration include the right medication, right dose, right patient, right route, right time, right documentation, and right indication.Responsibilities of medication administration include knowing medication therapeutics, assessing a patient before administration, calculating doses, administering medications using the seven rights, monitoring and evaluating medication effects, and assessing a patient's ability to self-administer medications. [NAME], [NAME] A.; [NAME], [NAME] G.; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 705). Elsevier Health Sciences.
Kindle Edition.
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Optalis Health & Rehabilitation of Whitehall in Whitehall, MI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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 Whitehall, 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 & Rehabilitation of Whitehall or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.