Optalis Health & Rehabilitation of Muskegon

In the surveyor’s words

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

• Immediate jeopardy, widespreadF726Jul 26, 2022

  Based on interview and record review, the facility failed to ensure staff providing direct patient care had an active unrestricted nursing license and able to practice in the State of Michigan. This deficient practice resulted in an immediate jeopardy beginning on 5/11/22 when Unlicensed Staff B, acting with the authority of a licensed nurse, provided nursing care to residents and subsequently dispensed controlled substances in error for 4 Residents (#21, #30, 49, and #5). Additionally, the facility failed to ensure licensed nursing staff were competent and trained to perform their duties (medication administration) resulting in significant medication errors for 6 Residents (#21, #20, #25, #21, #43, and #36) and the potential for serious harm, injury, and/or death. […]

• Immediate jeopardy, widespreadF760Jul 26, 2022

  Based on observation, interview, and record review, the facility failed to 1). provide controlled substance oversight, 2). ensure facility nursing staff administering the medications were licensed and competent, and 3.) keep residents free from significant medication errors by following the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #20, #43, and #36) reviewed for medication administration. This deficient practice resulted in an immediate jeopardy when, beginning on 5/9/22, facility staff failed to provide proper administration of controlled substances and promptly notify the physician of medication errors. […]

• Immediate jeopardy, isolatedF600Oct 17, 2022

  This citation pertains to intake # MI 663 & MI 2013 Based on interview and record review, the facility failed to protect one residents' right to be free from neglect (Resident #800) resulting in an Immediate Jeopardy when beginning on [DATE], the facility failed to prevent neglect for Resident #800. This deficient practice led to Resident #800 being found unresponsive after choking on vomit, requiring emergency medical intervention, and subsequent death and the potential for further residents to experience serious harm, injury and/or death if not corrected. Findings Include: Resident #800 (R800) Review of an Admission Record revealed R800 was a [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, isolatedF835Oct 17, 2022

  This citation pertains to intake # MI 663 Based on interview and record review, the facility Administrator failed to follow established risk management and abuse/neglect prevention policies and procedures, resulting in an Immediate Jeopardy when beginning on [DATE], the Administrator did not (a) report and investigate the sudden and unexpected death of Resident #800 and (b) report and investigate an allegation of neglect that resulted in the death of Resident #800. This deficient practice resulted in the potential for the Administrator to continue to arbitrarily not report allegations of abuse and neglect and not follow established risk management guidelines for sudden and unexpected deaths and policies and procedures for reporting and investigating allegations of Abuse/Neglect and… […]

• Immediate jeopardy, isolatedF692Dec 21, 2021

  This citation refers to MI 429: Based on observation, interview and record review the facility failed to provide adequate nutrition monitoring and interventions for 3 residents (R6, R10, R11) of 7 residents reviewed for nutrition/hydration resulting in an Immediate Jeopardy (IJ) that began on 12/13/2021 when R6 experienced a significant weight loss and the facility failed to implement identified interventions to prevent weight loss and R6 continued to lose weight. This deficient practice has the high likelihood to affect all residents in this facility potentially resulting in harm, serious injury or death. […]