Optalis Health & Rehabilitation of Whitehall

In the surveyor’s words

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

• Actual harm, patternF744Jun 30, 2021

  Based on observation, interview and record review, the facility failed to develop and implement person centered interventions and approaches to address behaviors exhibited by residents with dementia for 3 (Resident #1, Resident #3, and Resident #4), resulting in continued unsupervised wandering, repeated unwitnessed falls and injuries and the potential for all 13 residents who wander at risk for further unwitnessed incidents and accidents, harm, and abuse. Findings include: Resident #1 Review of a Face Sheet revealed Resident #1 was an [AGE] year old male admitted to the facility on [DATE] with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF600Mar 5, 2026

  Based on observations, interviews, and record review, the facility failed to protect the resident's (R6, R7, R9, R15, R26, R34, R35, R58 and F60) right to be free from mental abuse and verbal abuse by R52 resulting in fear and physical anguish in the resident's home. Findings include:Resident #58 (R58)Review of an Face Sheet revealed R58 admitted to the facility 3/4/2025 with pertinent diagnoses which included heart failure, acute respiratory failure, anxiety disorder, and major depressive disorder. […]

• Actual harm, isolatedF684Mar 5, 2026

  Based on observation, interview and record review, the facility failed to monitor weights in a CHF resident and drug allergies in one (R89) and failed to implement and monitor ace wrap orders for one (R40) of two residents reviewed for change in condition, contributing to R89's death in the facility. Findings include:R89Review of a Face Sheet revealed R89 had pertinent diagnoses of congestive heart failure (CHF), diabetes and vascular dementia. Allergies: . Morphine (Opioid). WeightsReview of R89's weights revealed between January 2025 and July 2025 his weights averaged between 331 pounds (lbs) to 336 pounds. On August 17, 2025, R89's weight was 347 lbs. […]

• Actual harm, isolatedF686Mar 5, 2026

  Based on observation, interview, and record review, the facility failed to prevent further pressure ulcer development for 1 resident (R7) out of 2 residents reviewed for pressure ulcers resulting in 3 facility acquired pressure ulcers for R7. Findings include:Review of an Face Sheet revealed R7 originally admitted to the facility on [DATE] with pertinent diagnoses which included neuropathy, chronic obstructive pulmonary disease, and stage IV sacral pressure ulcer. Review of a Minimum Data Set (MDS) (a tool used for assessing a resident's care needs) assessment for R29, with a reference date of 12/18/2025 revealed a Brief Interview for Mental Status (BIMS) (a scale used to determine a resident's cognitive status) score of 15, out of a total possible score of 15, which indicated R7 was… […]

• Actual harm, isolatedF686Feb 3, 2023

  Based on observation, interview, and record review the facility failed to accurately document weekly skin assessments, monitor wounds, and promote the healing of pressure ulcers for one resident, Resident #537 (R537) reviewed for skin integrity and pressure ulcers. This deficient practice resulted in R537's skin impairments, two Stage II, one unstageable and one Stage III pressure ulcer to go unassessed, measured, and monitored and potential for nonhealing and infection to occur. Findings include: The facility provided a copy of the policy for Skin Monitoring and Management - Pressure Ulcer dated 7/11/2018 for review. […]