Optalis Health and Rehabilitation of Kingsford

In the surveyor’s words

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

• Immediate jeopardy, patternF686May 29, 2024

  This citation pertains to intake MI00142093 and MI00142802. Based on observation, interview and record review, the facility failed to implement a comprehensive wound care program which resulted in Immediate Jeopardy with identification of the development of multiple facility acquired stage III/IV/Unstageable facility acquired pressure injuries and/or worsening of existing pressure injuries for four Residents (R4, R19, R38, and R48) of five Residents reviewed for pressure injuries. […]

• Actual harm, isolatedF689Jun 26, 2025

  Based on observation, interview, and record review, the facility failed to implement safety measures during transportation to an outside appointment for 1 Resident (#22) of 3 residents reviewed for accidents/hazards. This deficient practice resulted in harm for Resident #22 who sustained 4 fractures (both bones in lower legs broken), and a large laceration requiring sutures on right footAll times are in Eastern Daylight Time (EDT) unless otherwise notedFindings include:Resident #22 (R22)Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 3/15/18 with active diagnoses that included: dementia, depression, and type 2 diabetes mellitus. […]

• Actual harm, isolatedF725Mar 26, 2025

  This citation pertains to intake(s): MI00151324, MI00151372 Based on observation, interview and record review the facility failed to provide sufficient staffing to ensure resident needs were met timely for three Residents (#4, #5, & #3) of five residents reviewed for staffing concerns. This deficient practice resulted in Resident #4 being left wet and soiled for extended periods of time and unmet care needs including oral care, and grooming with the potential to affect all 75 residents. Findings include: Resident #4 (R4) On 3/26/25 at 2:35 PM., Registered Nurse (RN) B was interviewed and reported R4 needs assistance to get in and out of bed, take showers, perform oral care and to be provided overall daily grooming (ADLs). […]

• Actual harm, isolatedF684Nov 12, 2024

  This deficiency pertains to Intake #MI00147846. Based on interview and record review, the facility failed to timely obtain and process physician orders for respiratory assessment, treatment, and radiology diagnostics for one Resident (R1) of three residents reviewed for quality of care. This deficient practice resulted in harm when R1 was hospitalized related to severe respiratory distress and fluid volume overload. Findings include: All times documented are Eastern Standard Time (EST) unless otherwise noted. […]

• Actual harm, isolatedF689Dec 8, 2021

  MI 460 Based on observation, interview, and record review, the facility failed to utilize proper transfer equipment for one Resident (#1) from three residents reviewed for safe transfers which caused harm. This deficient practice resulted in a humerus fracture, increased pain, and risk for deterioration of overall health. Findings include: (Times reflect Eastern Standard Time) Review of Resident #1's Minimum Data Set (MDS) assessment, dated 9/16/21, reflected the following diagnoses: sarcopenia (loss of muscle tissue as a natural part of aging), muscle wasting and atrophy, weakness, [CONDITION(S)], and depression. Resident #1 required two-person assistance with bed mobility, transfers, dressing, and toilet use and was non-ambulatory. […]