Optalis Health & Rehabilitation at Leonard

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 9, 2021

  This citation pertains to intake number MI 290. Based on interview and record review, the facility failed to provide adequate supervision to prevent elopement in 1 of 3 sampled residents (Resident #101) reviewed for supervision, resulting in an immediate jeopardy when Resident #101, who was an elopement and fall risk and had a BIMS of 1, eloped from the facility unbeknownst to facility staff and was last seen on 8/13/21 at approximately 6:00 A.M. and found on 8/13/21 at 2:30 P.M. by his son in front of a local church 1.4 miles from the facility and located on a four-lane, 35 mph road in an [NAME] business district. Resident #101 stated he had a fall and had a reddened arm when found. […]

• Actual harm, isolatedF686May 3, 2023

  This citation pertains to MI00133137 and MI00131737. Based on observation, interview, and record review the facility failed to consistently implement pressure ulcer prevention and treatment interventions and ensure complete and accurate skin assessments were performed to monitor, identify and treat skin alterations for 5 residents (Resident #11, #48, #7, #317, and #65) out of 7 residents reviewed for pressure ulcer care, resulting in the formation of new facility acquired pressure ulcers for Resident #11 and Resident #48, a delay in the treatment of a DTI (deep tissue injury) to the right foot and a stage 2 pressure injury to the left foot of Resident #65, and the potential for further clinical compromise for Resident #7 and #317. […]

• Actual harm, isolatedF689May 3, 2023

  Based on observation, interview, and record review the facility failed to provide adequate supervision for 1 of 4 residents (Resident #14) reviewed for accidents/hazards, resulting in the potential for residents to sustain a fall injury which have the potential to negatively affect the residents highest practicable physical, mental, and psychosocial well-being. Findings include: Review of an Admission Record revealed Resident #14 was a female with pertinent diagnoses which included heart failure, diabetes, GI bleed, muscle weakness, cervical disc degeneration (compression on the vertebrae in the neck causing pain), colon cancer, diverticulosis (pockets or small pouches in the intestine which can become inflamed), kidney disease, anxiety, bursitis (inflammation in the cushions of the… […]

• Actual harm, isolatedF725May 3, 2023

  This citation pertains to intake #MI00127894 Based on observation, interview, and record review, the facility failed to ensure adequate nurse staffing to promote the physical, mental, and psychosocial well-being in 5 of 60 sampled residents (Resident #31, #14, #42, #11, & #48) reviewed for staffing, resulting in unmet care needs , reopening of a pressure ulcer for Resident #11, a fall with fracture for Resident #14, and the potential for physical and psychosocial harm for all residents in the facility. […]

• Actual harm, isolatedF689Feb 17, 2021

  This citation pertains to Intake MI 446 and MI 519. Based on interview and record review the facility failed to (1) implement sufficient safety measures and adequate staff and (2) follow care planned interventions to prevent falls for 2 of 5 residents (Resident #104 and Resident #109) reviewed for falls, resulting in a preventable fall (for Resident #109), multiple falls (for Resident #104), and pain/injury and hospitalization . Findings include: Review of the Fall Policy/Procedure dated 10/22/2020, revealed It is the policy of this facility to evaluate extent of injury after a fall, prevent complications and to provide emergency care. Procedure: 1. Resident's will be evaluated after a fall . 6. […]