Optalis Health and Rehabilitation of Grand Rapids

In the surveyor’s words

From the most serious findings on record at Optalis Health and Rehabilitation of Grand Rapids, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jan 14, 2025

  This citation pertains to Intake # MI00147580, MI00147822, MI00147838, & MI00149046. This citation has two deficient practice statements, A & B. Deficient Practice Statement A Based on interview, and record review, the facility failed to protect the residents' right to be free from neglect in 7 of 15 residents (Resident #103, #104, #113, #120, #124, #125, #126) reviewed for neglect, resulting in an Immediate Jeopardy when on 10/12/24, 10/18/24, 10/19/24, and 10/26/24 licensed nursing staff did not accept responsibility for the care and supervision of residents on portions of the 300 and 400 Halls, which led to missed medications, significant medication errors (Resident #103 missed seizure medication on 10/18/24, Resident #113 missed insulin on 10/12/24, Resident #124 missed a blood thinner… […]

• Immediate jeopardy, isolatedF678Jun 3, 2026

  This citation pertains to intake 3001998.Based on observation, interview, and record review the facility failed to initiate emergency medical services (EMS) and start cardiopulmonary resuscitation (CPR; an emergency lifesaving procedure performed when a person's heartbeat or breathing has stopped) timely for 1 (Resident #302) of 5 residents reviewed for life sustaining measures, resulting in an Immediate Jeopardy when, on [DATE], Resident #302 who was a full code, was found unresponsive and staff delayed EMS initiation for approximately 34 minutes and provided limited life sustaining measures were attempted by facility staff prior to EMS arrival. Resident #302 was pronounced dead on [DATE] by EMS personnel. […]

• Immediate jeopardy, isolatedF678Dec 29, 2025

  This citation pertains to intakes: 2694470 and 2685061Based on interview and record review the facility failed to perform cardiopulmonary resuscitation (CPR) on [DATE] for 1 (Resident #13) of 1 resident reviewed for code status (medical orders that indicate a resident's preference for treatment in a medical emergency) orders, resulting in an immediate jeopardy when Resident #13 was found unresponsive and subsequently died.Findings include:Interviews and record reviews verified that Agency Registered Nurse (RN) AA did not perform CPR on Resident #13, who was a full code, and was found unresponsive on [DATE] at approximately 5:02 am and subsequently died.The immediate jeopardy began on [DATE] when staff did not perform CPR on a full code resident (Resident #13). […]

• Immediate jeopardy, isolatedF760Nov 24, 2025

  This citation pertains to intake 2648348 and 2640731.Based on interview and record review, the facility failed to ensure residents were free from significant medication errors in 1 of 6 residents (Resident #101) reviewed for medication administration resulting in an Immediate Jeopardy beginning on 10/9/25 at approximately 9:00 AM when Resident #101 received another resident's medications which were administered by an agency nurse and nursing student. Resident #101 was found approximately one hour later and was noted to be lethargic and was hospitalized from [DATE]-[DATE] where she was diagnosed with acute metabolic encephalopathy (significant decline in brain function due to an underlying metabolic disturbance) and iatrogenic polypharmacy (harm caused by the administration of multiple… […]

• Immediate jeopardy, isolatedF678Dec 5, 2023

  This citation pertains to Intake # MI00141034. Based on interview, and record review, the facility failed to perform Cardiopulmonary Resuscitation (CPR) on a resident with a Full Code status, in 1 of 5 residents (Resident #105) reviewed for code status/CPR, resulting in an Immediate Jeopardy when on [DATE] at approximately 9:00 AM Resident #105, who was designated as a Full Code, was found to be non-responsive (no respirations/heart beat). Licensed Nursing staff did not initiate CPR per physician order and facility policy, and Resident #105 passed away. […]