Deficiency Records for Optalis Health and Rehabilitation of Ann Arbor
Updated as of March 01, 2024
A list of the most recent deficiencies for Optalis Health and Rehabilitation of Ann Arbor. 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? |
|---|---|---|---|---|
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-05 | 2023-12-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-05 | 2023-12-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-30 | 2023-07-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-17 | 2023-06-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-17 | 2023-06-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-17 | 2023-06-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-17 | 2023-06-29 | 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 | 2023-04-17 | 2023-06-29 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-04-17 | 2023-06-29 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-04-17 | 2023-06-29 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-04-17 | 2023-06-29 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-03-30 | 2023-05-19 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-04-17 | 2023-05-19 | 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 | 2023-04-17 | 2023-05-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-04-17 | 2023-05-19 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-04-17 | 2023-05-19 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-04-17 | 2023-05-19 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-04-17 | 2023-05-19 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-04-17 | 2023-05-19 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-04-17 | 2023-05-19 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-04-17 | 2023-05-19 | 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 | 2023-04-17 | 2023-05-19 | N |
| Provide or obtain dental services for each resident. | Health | 2023-04-17 | 2023-05-19 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-04-17 | 2023-05-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-17 | 2023-05-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-17 | 2023-05-19 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-17 | 2023-05-19 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-04-17 | 2023-05-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-04-05 | 2023-05-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-05 | 2023-05-16 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-04-05 | 2023-05-16 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-04-05 | 2023-05-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-05 | 2023-05-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-30 | 2023-04-18 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-03-30 | 2023-04-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-29 | 2022-05-05 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-03-29 | 2022-05-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-29 | 2022-05-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-03-29 | 2022-05-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-03-29 | 2022-05-05 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-03-29 | 2022-05-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-29 | 2022-05-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-29 | 2022-05-05 | 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 | 2022-03-29 | 2022-05-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-29 | 2022-05-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-03-29 | 2022-05-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-29 | 2022-05-05 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-03-29 | 2022-05-05 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-03-29 | 2022-05-05 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-03-29 | 2022-05-05 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-03-29 | 2022-05-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-29 | 2022-05-05 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-29 | 2022-05-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-29 | 2022-05-05 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2022-03-29 | 2022-05-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-29 | 2022-05-05 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-03-29 | 2022-05-05 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-03-29 | 2022-05-05 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-03-29 | 2022-05-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-29 | 2022-05-05 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-03-29 | 2022-05-05 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-29 | 2022-05-05 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-24 | 2022-05-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-24 | 2022-05-05 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-24 | 2022-05-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-24 | 2022-05-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-24 | 2022-05-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-24 | 2022-05-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-24 | 2022-05-05 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-09-02 | 2021-10-12 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-09-02 | 2021-10-12 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-21 | 2021-07-20 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-21 | 2021-07-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-21 | 2021-07-20 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-06-21 | 2021-07-20 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-21 | 2021-07-20 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-21 | 2021-07-20 | 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 | 2019-11-06 | 2020-02-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-11-06 | 2020-02-12 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-11-06 | 2019-12-12 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-11-06 | 2019-12-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-06 | 2019-12-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-06 | 2019-12-12 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-06 | 2019-12-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-11-06 | 2019-12-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-06 | 2019-12-12 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-11-06 | 2019-12-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-11-06 | 2019-12-12 | 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 | 2019-11-06 | 2019-12-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-06 | 2019-12-12 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-11-06 | 2019-12-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-11-05 | 2019-12-12 | N |
