Deficiency Records for Optalis Health and Rehabilitation of Three Rivers
Updated as of March 01, 2024
A list of the most recent deficiencies for Optalis Health and Rehabilitation of Three Rivers. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-04 | 2024-02-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-04 | 2024-02-09 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-04 | 2024-02-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-08-02 | 2023-08-30 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-08-02 | 2023-08-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-08-02 | 2023-08-30 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-08-02 | 2023-08-30 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-08-02 | 2023-08-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-02 | 2023-08-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-02 | 2023-08-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-08-02 | 2023-08-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-02 | 2023-08-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-02 | 2023-08-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-08-02 | 2023-08-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-08-02 | 2023-08-30 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-08-02 | 2023-08-30 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-08-01 | 2023-08-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-08-01 | 2023-08-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-01 | 2023-08-30 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-08-01 | 2023-08-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-01 | 2023-08-30 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-01 | 2023-08-30 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2023-08-01 | 2023-08-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-08-01 | 2023-08-30 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-01 | 2023-08-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-31 | 2023-06-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-31 | 2023-06-13 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-07-01 | 2022-07-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-01 | 2022-07-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-01 | 2022-07-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-01 | 2022-07-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-01 | 2022-07-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-07-01 | 2022-07-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-01 | 2022-07-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-07-01 | 2022-07-28 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-07-01 | 2022-07-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-01 | 2022-07-28 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-07-01 | 2022-07-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-01 | 2022-07-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-01 | 2022-07-28 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-01 | 2022-07-28 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-30 | 2022-07-28 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-06-30 | 2022-07-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-30 | 2022-07-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-30 | 2022-07-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-06 | 2022-06-14 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-06 | 2022-05-03 | Y |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-03-10 | 2021-07-01 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-03-10 | 2021-04-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-10 | 2021-04-16 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-03-10 | 2021-04-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-10 | 2021-04-16 | N |
| Dispose of garbage and refuse properly. | Health | 2021-03-10 | 2021-04-16 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-03-10 | 2021-04-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-03-10 | 2021-04-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-10 | 2021-04-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-03-10 | 2021-04-16 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-03-10 | 2021-04-16 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-03-10 | 2021-04-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-03-10 | 2021-04-16 | N |
