Deficiencies (last 3 years)
Deficiencies (over 3 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
169% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 18, 2025
Visit Reason
The inspection was conducted due to a complaint intake #MI00151905 regarding inadequate supervision of a high fall risk resident (Resident #101) who eloped from the facility unattended on 3/27/25.
Complaint Details
The complaint investigation substantiated that Resident #101 eloped from the facility unattended on 3/27/25 despite known exit-seeking behavior and high fall risk. Staff failed to increase supervision as required. The resident had multiple unwitnessed falls prior to the incident. The facility was short staffed on the day of the elopement. Past noncompliance was cited but corrective actions were implemented and monitored.
Findings
The facility failed to provide adequate supervision to Resident #101, who exited the building unattended and descended 16 concrete steps to a parking lot, posing a risk of serious injury. Staff did not implement increased supervision despite the resident's known exit-seeking behavior and high fall risk. Multiple staff interviews confirmed the resident's agitation, wandering, and exit seeking prior to the elopement. The facility had a history of noncompliance but demonstrated corrective actions including staff education and monitoring.
Deficiencies (1)
Failed to provide adequate supervision to prevent elopement of a high fall risk resident.
Report Facts
Date of elopement: Mar 27, 2025
Number of stairs descended: 16
Number of unwitnessed falls: 6
Time of elopement: 510
Number of residents reviewed for elopement: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant F | CNA | Reported hearing door alarm and observed Resident #101 in parking lot during elopement |
| Registered Nurse C | RN | Reported Resident #101 was high fall risk, agitated, and exit seeking; shared hall coverage during elopement |
| Registered Nurse K | RN | Reported Resident #101 exit seeking on 3/26/25 and door alarms going off |
| Certified Nursing Assistant M | CNA | Reported Resident #101 wandering and exit seeking on 3/27/25 and door alarms |
| Certified Nursing Assistant L | CNA | Reported Resident #101 roaming halls with walker and hearing door alarm on morning of elopement |
| Director of Nursing B | DON | Reported Resident #101 history of exit seeking and high fall risk; expected increased supervision |
| Director of Therapy P | DOT | Reported Resident #101 was unsafe to ambulate unsupervised and had therapy recommendations for supervised walking |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 26, 2025
Visit Reason
The inspection was conducted due to a complaint intake (MI00146840) regarding the facility's failure to implement consistent venous ulcer interventions, monitoring, and treatments for Resident #34.
Complaint Details
This citation pertains to Intake # MI00146840. The complaint investigation found that Resident #34 had missed wound care treatments, including one on 2/25/25 documented as missed due to the resident sleeping. Nursing staff interviews revealed issues with treatment completion and communication failures. The Director of Nursing confirmed the missed treatment and stated it was unacceptable to document treatments as missed due to resident sleeping.
Findings
The facility failed to consistently implement wound care treatments as ordered for Resident #34, resulting in missed treatments and potential worsening of wounds. Interviews and record reviews confirmed missed wound care treatments, inadequate communication among nursing staff, and concerns about nursing compliance with wound care protocols.
Deficiencies (1)
Failure to implement consistent venous ulcer interventions, monitoring, and treatments consistent with physician orders for Resident #34.
Report Facts
Wound size: 1.7
Wound size: 3.2
Missed treatments: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Former Unit Manager | Reported responsibility for overseeing wound care program and voiced concerns about nurses not completing wound treatments |
| N N | Registered Nurse | Documented missed wound care treatment due to resident sleeping |
| BB | Unit Manager | Monitored wounds, confirmed missed treatment on 2/25/25, and reviewed treatment records |
| O | Registered Nurse | Reported expectations for treatment completion and noted RN N frequently skipped treatments |
| AA | Unit Manager | Reported nurses should reapproach residents and communicate missed treatments; unaware of missed treatment on 2/25/25 |
| B | Director of Nursing | Confirmed nurses are expected to complete all treatments and communicate missed treatments; unaware of missed treatment on 2/25/25 |
Inspection Report
Routine
Deficiencies: 9
Date: Feb 26, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, wound care, infection control, and food safety at Optalis Health & Rehabilitation at Leonard.
Findings
The facility was found deficient in multiple areas including failure to update and revise care plans timely for residents using orthotic devices, inadequate assistance with activities of daily living such as shaving and changing clothes, inconsistent wound care treatments, failure to prevent worsening of contractures, inadequate respiratory care for a resident with a tracheostomy, improper use of adaptive feeding equipment, food safety violations in the kitchen, and failure to implement enhanced barrier precautions and infection control measures.
Deficiencies (9)
Failed to update and revise person centered care plans timely for residents using orthotic devices (Residents #3 and #25).
Failed to provide assistance with activities of daily living, specifically personal hygiene (shaving) and changing clothes daily for residents (Residents #13 and #54).
Failed to implement consistent venous ulcer interventions and treatments consistent with physician orders for Resident #34.
Failed to implement care plan interventions to prevent worsening of contractures for Resident #13.
Failed to provide adequate respiratory care for Resident #35 with tracheostomy, including failure to replace empty oxygen tank and suction as needed.
Failed to provide or use adaptive feeding equipment correctly for Resident #25, resulting in potential aspiration risk.
Failed to prepare food in accordance with professional food safety standards, including lack of soap at hand sink, open food packaging, dirty equipment, and improper food storage.
Failed to implement posted Enhanced Barrier Precautions and don required PPE prior to providing direct resident care for residents requiring such precautions (Residents #9, #35, #24, and #10).
Failed to maintain equipment and surfaces to reduce risk of bacterial harborage, including leaking vacuum breaker, leaking toilet, non-cleanable shelving, and chipping wall surfaces.
Report Facts
Residents reviewed for care plan deficiencies: 2
Residents reviewed for ADL care deficiencies: 2
Residents reviewed for wound care deficiencies: 1
Residents reviewed for contracture care deficiencies: 1
Residents reviewed for respiratory care deficiencies: 1
Residents reviewed for adaptive feeding equipment deficiencies: 1
Residents reviewed for infection control deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN J | Licensed Practical Nurse | Named in respiratory care deficiency for Resident #35 for failure to replace oxygen tank and suction as needed. |
| Director of Nursing B | Director of Nursing | Reported on multiple deficiencies including care plan issues, wound care, respiratory care, and infection control. |
| Certified Nursing Assistant V | CNA | Reported on care plan deficiencies for Residents #3 and #25. |
| Director of Physical Therapy HH | Director of Physical Therapy | Reported on therapy communication and care plan update issues. |
| Unit Manager BB | Unit Manager | Reported on therapy communication, wound care monitoring, and respiratory care. |
| Certified Nursing Assistant T | CNA | Reported on adaptive feeding equipment use and infection control practices. |
| Speech Language Pathologist JJ | Speech Language Pathologist | Reported on adaptive feeding equipment recommendations for Resident #25. |
| Food Services Director F | Food Services Director | Reported on food safety deficiencies in the kitchen. |
| Certified Nursing Assistant Q | CNA | Reported on infection control PPE use misunderstandings. |
| Certified Nursing Assistant U | CNA | Reported on infection control PPE use misunderstandings. |
| Infection Preventionist OO | Infection Preventionist | Reported on enhanced barrier precautions education and monitoring. |
| Occupational Therapist II | Occupational Therapist | Reported on splint condition and use for Resident #13. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: May 30, 2024
Visit Reason
The inspection was conducted due to a complaint intake MI00144400 regarding a fall and serious injury of Resident #101 during a transfer using a sit to stand mechanical lift.
Complaint Details
The complaint investigation was substantiated. Resident #101 fell during transfer due to staff failure to follow mechanical lift policies and care plan. CNA F was suspended and terminated for the incident.
Findings
The facility failed to safely transfer Resident #101, resulting in a fall causing a distal left femoral fracture requiring surgery. Staff did not follow the care plan or facility policy for mechanical lifts, including inadequate assistance and improper use of straps during transfer.
Deficiencies (4)
Failure to ensure safe transfer of Resident #101 using sit to stand mechanical lift, resulting in a fall and serious injury.
Staff member did not follow care plan requiring 2 person assist with sit to stand lift.
Resident was transferred without chest and leg straps buckled, causing sling to slip and resident to fall.
CNA F failed to adhere to policies and procedures related to mechanical lift transfers, resulting in suspension and termination.
Report Facts
Date of fall: Apr 25, 2024
Date of surgery: Apr 26, 2024
Date of discharge: Apr 30, 2024
Number of staff required for transfer: 2
Number of audits per week: 5
Audit duration: 4
Audit duration: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA F | Certified Nursing Assistant | Failed to follow mechanical lift policy, suspended and terminated after resident fall |
| RN D | Registered Nurse | Reported incident and described resident condition after fall |
| RN H | Registered Nurse | Responded to fall report and noted resident was not wearing appropriate footwear |
| RD J | Rehab Director | Reported resident's therapy status and capability to use sit to stand lift safely with proper assistance |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 14, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the misappropriation of a resident's narcotic medications at the facility.
Complaint Details
The complaint investigation was substantiated. The facility identified that narcotic medications for Resident #163 were missing. The nurse (LPN KK) was suspended and terminated after investigation revealed suspicious activities including altering medication sign-off sheets and taking narcotic count sheets home. The local police department and State of Michigan were notified. No harm came to the resident as a result of the missing medications.
Findings
The facility failed to prevent misappropriation of narcotic medications for Resident #163, resulting in missing pain medication. An internal investigation identified a nurse (LPN KK) as responsible, leading to suspension and termination. The facility implemented corrective actions including staff education, audits, and collaboration with the pharmacy, and demonstrated ongoing compliance.
Deficiencies (1)
Failed to prevent misappropriation of a resident's narcotic medications resulting in missing pain medication and potential for uncontrolled pain and discomfort.
Report Facts
Missing medication count: 2
Date of incident: Sep 7, 2023
Date of report: Mar 14, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN KK | Licensed Practical Nurse | Nurse suspended and terminated for suspected misappropriation of narcotic medications. |
| DON B | Director of Nursing | Reported and led investigation into missing narcotics. |
| RN Y | Registered Nurse | Reported missing narcotics and participated in investigation. |
| LPN EE | Licensed Practical Nurse | Participated in investigation, education, and audits following the incident. |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 14, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of narcotic medications and concerns about resident care including activities of daily living, staffing sufficiency, infection control, and medical record accuracy.
Complaint Details
The complaint investigation was triggered by allegations of narcotic medication misappropriation for Resident #163, and concerns about inadequate care, staffing shortages, infection control, and medical record maintenance.
Findings
The facility failed to prevent misappropriation of narcotic medications for one resident, failed to provide adequate activities of daily living care including bathing and grooming for multiple residents due to staffing shortages, failed to maintain sufficient nursing staff to meet resident needs resulting in missed care and long call light wait times, failed to employ a full-time qualified dietitian or certified dietary manager, failed to maintain complete and accurate medical records for residents' code status, and failed to ensure infection control practices for cleaning shared resident equipment.
Deficiencies (6)
Failed to prevent misappropriation of a resident's narcotic medications resulting in missing pain medication and potential for uncontrolled pain.
Failed to provide activities of daily living care including bathing and grooming for 3 residents resulting in frustration, anxiety, and self-consciousness.
Failed to provide enough nursing staff to meet resident needs resulting in long call light wait times, incontinence with embarrassment, missed showers, and potential unmet needs.
Failed to employ a full-time Registered Dietitian or Certified Dietary Manager to oversee kitchen and clinical nutritional services.
Failed to maintain complete and accurate medical records for 2 residents, including missing documentation of residents' code status in electronic medical records, physician orders, and medication administration records.
Failed to ensure infection control practices were followed for cleaning shared resident equipment (transfer lifts), resulting in visibly soiled equipment and potential for bacterial harborage and cross contamination.
Report Facts
Missing oxycodone medication count: 2
Residents reviewed for abuse/misappropriation: 4
Residents sampled for ADL care: 15
Scheduled showers missed: 7
Scheduled showers missed: 6
Days not fully staffed with CENAs: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN KK | Licensed Practical Nurse | Named in narcotic medication misappropriation investigation and termination. |
| DON B | Director of Nursing | Reported and led investigation into narcotic medication misappropriation. |
| RN Y | Registered Nurse | Reported narcotic count discrepancy and participated in investigation. |
| LPN EE | Licensed Practical Nurse - Unit Manager | Participated in narcotic investigation and nursing education. |
| RN F | Registered Nurse | Reported on shower sheets and staffing issues. |
| CENA K | Competency Evaluated Nursing Assistant | Reported missed showers and infection control practices. |
| CENA L | Competency Evaluated Nursing Assistant | Reported missed showers and call light delays due to staffing. |
| CENA DD | Competency Evaluated Nursing Assistant | Reported staffing shortages leading to missed care tasks. |
| Scheduler W | Scheduler | Reported frequent staff call ins and unfilled shifts. |
| FSD C | Food Service Director | Not a Certified Dietary Manager; part-time dietitian coverage. |
| Administrator A | Administrator | Reported plans to enroll FSD C in CDM course. |
| RN-ICP Y | Registered Nurse/Infection Control Preventionist | Reported infection control policies and practices. |
| UM EE | Unit Manager | Reported missing resident code status documentation. |
| RN F | Registered Nurse | Reported missing resident code status documentation. |
| LPN I | Licensed Practical Nurse | Reported missing resident code status documentation. |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 6
Date: May 3, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding resident care, staffing shortages, medication misappropriation, pressure ulcer care, and failure to provide adequate assistance with activities of daily living.
Complaint Details
The visit was complaint-related, triggered by multiple resident and family complaints about inadequate care, staffing shortages, medication misappropriation, and pressure ulcer management. Substantiation status is not explicitly stated.
Findings
The facility was found to have multiple deficiencies including failure to provide adequate assistance with toileting and dignity, misappropriation of narcotic medication, failure to provide routine showers, inadequate pre-surgical preparation, inconsistent pressure ulcer care, and insufficient staffing leading to unmet resident needs and adverse outcomes such as falls and pressure ulcer worsening.
Deficiencies (6)
Failure to provide an environment that promoted and enhanced resident dignity, resulting in feelings of humiliation and loss of self-worth for 2 residents.
Failure to prevent misappropriation of narcotic pain medication in 1 resident, resulting in potential delayed pain treatment.
Failure to document and provide routine showers to dependent residents, resulting in poor hygiene and potential decline in well-being for 3 residents.
Failure to follow pre-surgical preparation procedures for 1 resident, resulting in cancellation of scheduled surgery.
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents, resulting in actual harm.
Failure to provide enough nursing staff every day to meet the needs of every resident, resulting in unmet care needs, pressure ulcer reopening, falls with fracture, and potential physical and psychosocial harm.
Report Facts
Residents reviewed for dignity: 16
Residents reviewed for misappropriation: 3
Residents reviewed for ADL care: 4
Residents reviewed for pressure ulcer care: 7
Facility census: 60
Nurse aide staffing on 100 hall: 1
Nursing assistants working on 4/29/2023: 3
Resident #11 wound size: 0.2
Resident #11 wound size: 1.1
Resident #11 wound size: 0.2
Resident #48 heel wound size: 3.5
Resident #48 heel wound size: 6.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agency Nurse MM | Agency RN | Named in medication misappropriation investigation and statements |
| LPN P | Licensed Practical Nurse | Named in medication misappropriation investigation and statements |
| Director of Nursing B | Director of Nursing | Provided statements on call light policy, medication storage, staffing, and investigation |
| Nursing Home Administrator A | Nursing Home Administrator | Provided statements on investigation and staffing |
| LPN AA | Licensed Practical Nurse | Provided statements on medication counts and staffing |
| PA/WCD DD | Physician Assistant/Wound Care Provider | Observed wound care and provided clinical recommendations |
| RN I | Registered Nurse | Reported on fall event and care |
| Scheduler CC | Scheduler | Provided information on staffing and scheduling |
| CNA NN | Certified Nursing Assistant | Reported staffing shortage and resident care difficulties |
| CNA Y | Certified Nursing Assistant | Reported staffing shortage and care challenges |
| CNA U | Certified Nursing Assistant | Reported staffing shortage and care challenges |
| RN X | Registered Nurse | Reported awareness of resident pain and care |
| CNA S | Certified Nursing Assistant | Reported staffing shortage and care challenges |
| CNA O | Certified Nursing Assistant | Reported on repositioning practices |
Inspection Report
Routine
Census: 60
Deficiencies: 14
Date: May 3, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, safety, staffing, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to provide adequate resident dignity and assistance, medication misappropriation, incomplete care plans, inadequate pressure ulcer care, insufficient staffing, improper food safety practices, incomplete medical records, and failure to ensure COVID-19 vaccination for residents and staff.
Deficiencies (14)
Failure to provide an environment that promoted and enhanced resident dignity for 2 residents, resulting in feelings of humiliation and loss of self-worth.
Failure to prevent misappropriation of narcotic pain medication in 1 resident, resulting in potential delayed pain treatment.
Failure to provide a bed hold for 1 resident during hospitalization, risking the resident not returning to the same room.
Failure to accurately complete Minimum Data Set (MDS) assessments for 1 resident, resulting in inaccurate resident status documentation.
Failure to create and implement a baseline care plan within 48 hours of admission for 1 resident, risking ineffective care.
Failure to document and provide routine showers to dependent residents for 3 residents, resulting in poor hygiene and risk to well-being.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for multiple residents, resulting in new and worsening pressure injuries.
Failure to provide adequate supervision to prevent accidents for 1 resident, resulting in a fall with fracture.
Failure to ensure adequate nurse staffing to meet resident needs, resulting in unmet care needs, pressure ulcer reopening, and fall with fracture.
Failure to limit PRN psychotropic medication orders to 14 days or document rationale, resulting in prolonged unnecessary medication use for 1 resident.
Failure to ensure proper cold holding temperature of walk-in cooler and proper working order of hot water sanitizing dish machine, increasing risk of foodborne illness.
Failure to maintain complete and accurate medical records for 1 resident, risking miscommunication and negative outcomes.
Failure to have an active plan for reducing risk of legionella and other waterborne pathogens, and failure to perform incontinence care using adequate infection control practices for 1 resident.
Failure to ensure COVID-19 immunizations were offered to 4 residents and failure to ensure staff received all required COVID-19 vaccine doses with accurate records.
Report Facts
Residents requiring assistance: 60
Census: 60
Dish machine temperature failures: 19
Dish machine rinse temperature failures: 13
Nurse aide staffing: 3
Nurse aide staffing: 3
Nurse aide staffing: 1
Scheduled showers missed: 3
PRN psychotropic medication duration: 90
Residents tested positive for COVID-19: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Agency Nurse MM | Agency RN | Named in medication misappropriation investigation and statements |
| LPN P | Licensed Practical Nurse | Named in medication misappropriation investigation and statements |
| Director of Nursing B | Director of Nursing | Provided multiple interviews regarding staffing, infection control, and findings |
| Nursing Home Administrator A | Nursing Home Administrator | Provided interviews regarding staffing, infection control, and findings |
| Pharmacist EE | Pharmacist | Provided interview regarding psychotropic medication order |
| MD GG | Physician | Provided interview regarding psychotropic medication order |
| CNA Y | Certified Nursing Assistant | Named in infection control and staffing interviews |
| CNA U | Certified Nursing Assistant | Named in staffing interviews |
| CNA S | Certified Nursing Assistant | Named in staffing interviews |
| Agency CNA NN | Agency Certified Nursing Assistant | Named in fall incident and resident transfer |
| LPN AA | Licensed Practical Nurse | Named in staffing and fall incident interviews |
| Wound Care Provider DD | Physician Assistant/Wound Care Provider | Named in pressure ulcer care observations |
| Family Member KK | Family Member | Provided interviews regarding resident care and staffing |
| Family Member FM II | Family Member | Provided interview regarding resident care and surgery cancellation |
| Family Member FM LL | Family Member | Provided interview regarding resident care and wounds |
| IP D | Infection Preventionist | Provided interview regarding infection control program |
| Food Service Director J | Food Service Director | Provided interview regarding kitchen equipment and food safety |
| Scheduler CC | Scheduler | Provided interview regarding staffing and scheduling |
| Resident #14 | Named in fall incident and dignity deficiency |
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