Optalis Health & Rehabilitation at Kent-Crossing

In the surveyor’s words

From the most serious findings on record at Optalis Health & Rehabilitation at Kent-Crossing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 1, 2022

  This citation pertains to MI 773, MI 060, MI 189, and MI 463. This citation has 3 Deficient Practice Statements (DPS) A & B & C DPS A Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent an elopement and ensure safety for 1 of 8 residents (Resident #111) reviewed for safety/supervision, resulting in an Immediate Jeopardy when on [DATE] at approximately 2:00 PM, Resident #111 who was identified as an elopement risk, was let out of the facility by facility staff who did not identify her as an elopement risk at 12:31 pm where she walked across a 5 lane 45mph road approximately ,d+[DATE] mile to the gas station and ,d+[DATE] mile back and was seen sitting near the entrance to the facility near a busy highway by a staff member and… […]

• Actual harm, isolatedF760Mar 19, 2026

  This citation pertains to intakes: 2802001, 2802220, 2798542, & 2737401.Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 8 of 9 Residents (#39, #76, #86, #139, #27, #140, #37, #22) reviewed for medication errors when a.) Medication orders were transcribed and administered incorrectly and B.) medications were not administered as ordered resulting in Resident #39 receiving excessive doses of an antipsychotic medication and Resident's #76, #4, #86, #139, #27, #140, #37, #22's medications were omitted resulting in the decompensation (functional deterioration of a physical or mental system) for Resident #76, and the potential for health complications. […]

• Actual harm, isolatedF686Oct 12, 2023

  This citaiton pertains to intake number MI00134147. Based on interview and record review, the facility failed to monitor and treat pressure ulcers per nursing professional standards for 1 resident (R110) of 3 reviewed for pressure ulcers, resulting in the worsening of a pressure ulcer with the potential for infection and overall deterioration of health status. Findings include: According to the Admission Record, R110 admitted to the facility on [DATE] as his own person with diagnoses that included fracture of left femur fracture, protein-calorie malnutrition, megacolon, heart failure, and chronic kidney disease stage 3/4. […]

• Actual harm, isolatedF760Nov 18, 2022

  This citation pertains to intake MI 809. Based on interview and record review, the facility failed to prevent the significant medication errors in 2 of 2 sampled residents (Resident #281 and Resident #113) reviewed for medication errors, resulting in Resident #281 becoming unresponsive, requiring emergency transport and admission to a hospital with intubated and placed on a ventilator and Resident #113 having a [CONDITION(S)] after not recieving his medications for [CONDITION(S)]. Findings include: According to the Minimum Data Set (MDS) dated [DATE], R281 scored 12/15 (moderately cognitively impaired) on her BIMS (Brief Interview Mental Status) with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF888Nov 18, 2022

  Based on interview, and record review, the facility failed to operationalize policies and procedures to ensure all staff were fully vaccinated for COVID-19 or possessed an approved exemption in a timely manner, in 2 of 20 staff members reviewed for COVID-19 vaccination status, resulting in the potential for transmission of COVID-19 to a vulnerable population. Findings include: Review of a COVID-19 Staff Vaccination Matrix, provided by the facility on 11/17/22, revealed Receptionist FF was highlighted in red (indicating exempt per the document key), with no COVID-19 vaccination information or exemption information documented on the form. […]