Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation Of Ann Arbor during CMS and state inspections, most recent first.
Missing Controlled Medications and Inaccurate Controlled Substance Records A resident’s oxycodone blister pack went missing from the med cart, and the controlled substance count sheets had unclear and incomplete entries at shift change. Surveyors also found multiple controlled meds for several residents were short on two carts, with staff saying the doses were given and documented on the MAR but not on the controlled substance forms. The DON stated controlled meds should be signed out right away when removed from the cart.
A resident who required a two-person assist for bed mobility was left in the care of a CNA who, unable to find assistance, provided care alone against the care plan. The resident was later found on the floor with multiple injuries, including bilateral femur fractures, and was not transferred to the hospital for several hours. The resident died from blunt force trauma related to the fall.
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 134 residents. Observations included soiled ventilation grills, dirty light covers, and a lack of date marking on milk. Additional issues were found in food service pantries, such as damaged equipment and mineralized ice machine spouts. These deficiencies indicate non-compliance with the 2022 FDA Model Food Code and inadequate implementation of the facility's sanitation and maintenance policies.
The facility failed to maintain cleanliness and repair issues, affecting 138 residents. Observations revealed worn floor mats, damaged flooring, stained carpets, and soiled air conditioning filters. Common areas had damaged furniture, missing fixtures, and soiled surfaces. Resident rooms had non-functional lights, damaged surfaces, and soiled bedding. The facility's work order system lacked entries for these issues, indicating ineffective maintenance tracking.
A resident with multiple sclerosis and cognitive intactness expressed frustration over the facility's failure to honor his choices regarding his morning routine and outdoor access. Despite a physician's order allowing him to leave the facility, he was consistently denied the opportunity to go outside independently in his motorized wheelchair. The facility's care instructions prohibited him from exiting, contributing to his feelings of depression and frustration.
A resident with cognitive and physical impairments did not receive necessary oral care assistance at an LTC facility. Despite an order for oral care supplies to be prepared, the resident reported not having their teeth brushed since admission and lacked the supplies to do so independently. Observations confirmed the absence of toothpaste and an unused toothbrush. The issue was only addressed after state agency involvement.
A resident in an LTC facility experienced loss of personal clothing, affecting their psychological wellbeing. Despite being cognitively intact and labeling clothes to prevent loss, the resident was observed in a hospital gown due to missing items. The resident reported the issue to the DON, but no formal grievance was filed, as the resident was unaware of the process. The facility's grievance logs lacked documentation of the resident's complaints, indicating a communication gap.
A resident with cognitive impairment and behavioral disturbances was documented by an LPN as verbally abusing and threatening another resident. The LPN did not report the incident, and the Nursing Home Administrator was unaware of it, resulting in a failure to follow required abuse reporting procedures.
A resident with cognitive impairment and behavioral disturbances was documented by an LPN as verbally abusing and threatening another resident. The LPN did not report the incident, and the NHA was unaware of the allegation, resulting in no investigation being conducted.
Two residents with cognitive and behavioral impairments did not have comprehensive care plans addressing repeated incidents of wandering and entering other residents' rooms. Despite documented behaviors and staff observations, care plans lacked interventions to minimize these actions, and the DON confirmed the absence of appropriate planning.
Two residents with physical limitations and intact cognition did not receive scheduled showers as outlined in their care plans. Instead, staff offered bed baths due to inadequate staffing, and when the residents declined the bed bath, it was documented as a refusal of a shower. Staff interviews confirmed that insufficient staffing and high resident acuity prevented completion of required care tasks, including showers, and nursing leadership stated that residents should receive showers if requested.
Several residents requiring assistance with mobility and personal care experienced long delays in call light responses and were not provided scheduled showers, as staff frequently reported being too busy and offered bed baths instead. Direct care staff and a staffing coordinator confirmed that staffing assignments were based on census rather than resident acuity, leading to incomplete care tasks and extended wait times for residents. Staff also faced challenges covering multiple units, further delaying care and leaving essential needs unmet.
A facility failed to include necessary communication and coordination with an endocrinologist in a resident's care plan, despite the resident having Type II Diabetes and specific instructions in the EMR for managing blood glucose levels. The care plan omission was acknowledged by the DON as an area for improvement.
A facility failed to follow a physician's order to coordinate diabetes care with an endocrinology clinic for a resident with multiple malignancies, resulting in unmanaged high blood glucose levels. Despite an order to contact endocrinology for frequent high glucose levels, there was no documentation of such communication over several days. Interviews revealed a lack of clarity and coordination in communication with endocrinology, which was acknowledged by the DON as a concern.
A resident with a history of infection and prosthetic heart valve was prescribed Vancomycin for C-Diff, to be taken every six hours. The resident missed three doses due to a perceived lack of stock, leading to dissatisfaction and leaving the facility for medical care. Interviews revealed a misunderstanding about the availability of backup medication in the PYXIS system, which was later found to have the necessary medication in stock.
Missing Controlled Medications and Inaccurate Controlled Substance Records
Penalty
Summary
The facility failed to prevent a missing controlled substance medication for one resident and failed to maintain accurate controlled substance records for five other residents. One resident had diagnoses including low back pain, chronic pain, and systemic lupus erythematosus, and the January 2026 MAR showed an order for oxycodone 10 mg every six hours as needed for pain. A blister pack of that resident’s oxycodone was reported missing between the 7:00 AM and 7:00 PM nursing shift on 1/30/26, after the medication had been delivered to the facility on 1/28/26 and doses had been documented as administered through 1/30/26. The facility’s investigation and controlled substance shift inventory documentation showed unclear counts at shift change and incomplete entries for the controlled medication log. The outgoing and oncoming nurses signed for the total number of controlled medications at 7:00 AM, but the starting and ending counts were unclear. A later entry at 7:00 PM also had an incomplete date, unclear starting count, one medication documented as received from the pharmacy, and an ending count of 9 without the oncoming nurse’s signature. During the investigation, the DON reported that the oxycodone delivered for the resident was missing and that the count sheet for the medication could not be found. During a controlled substance count on two medication carts, surveyors found discrepancies between the documented stock and the actual medications present. For one cart, oxycodone, pregabalin, morphine sulfate, methadone, and oxycodone for five residents were each short by one or two units compared with the Controlled Drug Receipt/Record/Disposition Form, and staff stated the medications had been administered and signed out on the MAR but not on the controlled substance form. On the second cart, pregabalin for another resident was also short by one capsule, and the nurse reported it had been administered but not signed out on the controlled substance form. The DON stated nurses should sign controlled medications on the Controlled Drug Receipt/Record Disposition Form right away when the medication is removed from the medication cart.
Failure to Follow Care Plan Results in Resident Fall and Fatal Injuries
Penalty
Summary
A resident with significant physical disabilities, morbid obesity, and moderate cognitive impairment was care planned to require a two-person assist for bed mobility and activities of daily living. The resident was totally dependent on staff for movement and unable to reposition or turn independently. On the night of the incident, a Certified Nurse Aide (CNA) was unable to locate another staff member to assist with the resident's care, despite waiting and searching for approximately 45 minutes. The CNA proceeded to provide bed mobility care alone, contrary to the resident's care plan, and subsequently found the resident on the floor after leaving and returning to the room. Upon assessment by a nurse, the resident was found with a skin tear to the left elbow, hematomas to the left knee and left side of the forehead, and complaints of pain. Neuro checks were initiated, and the physician was notified. X-rays were ordered and later revealed fractures of both femurs. The resident was not transferred to the hospital until several hours after the fall, despite ongoing pain and abnormal X-ray findings. There was a lack of documentation regarding the resident's pain and status updates between the time of the fall and the transfer to the hospital. Interviews with staff confirmed that the CNA was aware of the two-person assist requirement but proceeded alone due to lack of available help. Other staff members stated that the resident was unable to move himself in bed or reach for objects independently. The death certificate indicated that the resident died from blunt force trauma to the right thigh, with the manner of death listed as an accident resulting from a fall at the facility.
Deficiencies in Food Service Equipment Maintenance and Sanitation
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 134 residents. During an initial tour of the food service area, several deficiencies were observed, including a soiled ceiling-mounted return-air-exhaust ventilation grill and dirty overhead light assembly plastic lens covers. Additionally, a half-gallon of lactose-free milk was found in a cooler without an effective open or discard date, contrary to the facility's date marking procedure. The can opener assembly was also noted to be soiled with encrusted food residue. Further observations revealed a broken atmospheric vacuum breaker on the dish machine room hand sink faucet assembly and a mechanical dish machine psi gauge reading outside the acceptable range during the final rinse cycle. In the facility's food service pantries, various issues were identified, such as a damaged microwave oven face plate, mineralized ice machine dispensing spouts, and soiled ventilation grills. These findings indicate a lack of adherence to the 2022 FDA Model Food Code, which requires regular cleaning and maintenance of food-contact surfaces and equipment. Record reviews of the facility's policies and procedures highlighted a General Kitchen Sanitation Policy and a Preventative Maintenance Program, both of which were not effectively implemented. The policies outlined the need for a written cleaning schedule, daily sanitation rounds, and monthly audits, as well as a maintenance schedule to ensure a safe and sanitary environment. However, the observed deficiencies suggest that these protocols were not adequately followed, leading to potential risks of cross-contamination and inadequate sanitization.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to effectively clean and maintain the physical plant, affecting 138 residents. During an environmental tour of the facility's laundry service, it was observed that two padded floor mats were worn and attached to the flooring with duct tape, and the flooring surface adjacent to the washers was damaged. Additionally, the corridor carpeted surface was stained and soiled near resident rooms. These conditions increase the likelihood of cross-contamination and bacterial harborage. Further observations during a common area environmental tour revealed several deficiencies. In the 200 Hall, a clean linen cart cover was threadbare, and in the 300-400 Hall, chairs at the nursing station and activity room were damaged, exposing inner padding. The main dining room was missing a chair railing, and the physical therapy hand sink faucet was loose. In the 500 Hall, light lens covers were soiled, and a shower wand assembly was missing a vacuum breaker. The 600 Hall had a soiled fan and cabinetry with food residue, and the dining room kitchenette had broken cabinet drawers. An environmental tour of sampled resident rooms revealed multiple issues, including non-functional light assemblies, soiled air conditioning unit filters, damaged drywall and laminate surfaces, and soiled bedding. The facility's manual work order system did not have specific entries related to these maintenance concerns, indicating a lack of effective tracking and resolution of maintenance issues. The facility's policies on cycle cleaning, maintenance inspection, and routine cleaning and disinfection were not effectively implemented, contributing to the deficiencies observed.
Failure to Honor Resident's Choices in Daily Routine and Outdoor Access
Penalty
Summary
The facility failed to honor a resident's choices regarding his daily routine and outdoor access, leading to a deficiency. The resident, who is cognitively intact and has a history of multiple sclerosis, depression, bipolar disorder, and anxiety, expressed a strong desire to be assisted out of bed early in the morning, as he had been accustomed to being active early in his life. Despite his requests and a promise from the facility to adjust his morning routine, the resident continued to experience delays in receiving assistance, often being left in bed until after lunch. This situation contributed to his feelings of depression and frustration. Additionally, the resident, who has a physician's order allowing him to leave the facility, was consistently denied the opportunity to go outside independently in his motorized wheelchair. The facility's care instructions prohibited him from exiting the facility in his wheelchair, despite his expressed need for sunshine and fresh air, which he associated with his lifelong passion for the outdoors. The Director of Nursing acknowledged that residents should be allowed to get up at their requested time and be offered assistance to go outside, indicating a failure in the facility's practices to support resident self-determination and choice.
Failure to Provide Oral Care Assistance
Penalty
Summary
The facility failed to ensure proper oral care for a resident, identified as R81, who was admitted with diagnoses including atherosclerotic heart disease and essential tremor. R81 was cognitively intact, as indicated by a score of 14 out of 15 on the Brief Interview for Mental Status, and required setup or clean-up assistance for oral hygiene due to impairments in one upper and one lower extremity. Despite these needs, R81 reported that their teeth had not been brushed since admission, and they had not been provided with the necessary supplies to perform oral hygiene independently. Observations confirmed that R81's toothbrush was still in a sealed package, and no toothpaste was available in their room. Further investigation revealed that the facility's staff, including CNA N, did not offer the necessary setup assistance for oral care, as R81 was not feeling well on the morning of the observation. Documentation in R81's medical record indicated an order for the nurse to prepare a toothbrush for oral care after medication pass in the morning and at bedtime, which was marked as completed in the Medication Administration Record. However, R81 only received assistance to brush their teeth after the State Agency's involvement, highlighting a lapse in the facility's adherence to the prescribed oral care routine. The Director of Nursing confirmed that residents should receive oral care at least once a day, but R81's experience demonstrated a failure to meet this standard until external intervention occurred.
Failure to Protect Resident's Personal Property
Penalty
Summary
The facility failed to protect a resident's personal property, specifically clothing, from loss, which potentially affected the resident's psychological wellbeing. The resident, who was cognitively intact and required moderate assistance with activities of daily living, reported missing clothing items. Despite the resident's efforts to label his clothing to prevent loss, he was observed wearing a hospital gown due to a lack of personal clothing. The resident expressed frustration and embarrassment over the situation, indicating that he had to purchase new clothes with limited financial resources. The Director of Nursing (DON) was informed by the resident about a missing pair of grey pants but was not made aware of the extent of the missing clothing items. The resident claimed to have informed the DON multiple times about the missing clothes, but no formal grievance or concern form was filed, as the resident was unaware of the need to do so. The facility's grievance logs did not contain any documentation of the resident's complaints, highlighting a communication gap between the resident and the facility staff regarding the loss of personal property.
Failure to Report Suspected Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime as required by section 1150B of the Act. A resident with cognitive impairment and a history of anxiety disorder and dementia was documented in a nursing progress note as having verbally abused another resident and threatened physical harm. The note was authored by an LPN who later stated she did not recall the details of the incident and did not report the allegation. The Nursing Home Administrator confirmed she was unaware of the incident and stated that the expectation was to report any abuse allegations immediately. This sequence of events demonstrates that the facility did not ensure timely reporting of suspected abuse as required.
Failure to Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving one resident who was admitted with diagnoses including anxiety disorder, vascular dementia, and dementia with behavioral disturbances. The resident, who was cognitively impaired as indicated by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, was documented in a nursing progress note as having verbally abused another resident and threatened physical harm. The note was authored by an LPN, who later stated she did not recall the details of the incident and did not report the allegation. The Nursing Home Administrator confirmed she was unaware of the incident and stated that the expectation is to report any abuse allegations immediately. No investigation into the alleged abuse was initiated by the facility.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Behavioral Issues
Penalty
Summary
The facility failed to develop and implement comprehensive care plans to address the needs of two residents with cognitive impairments and behavioral issues. One resident, admitted with anxiety disorder, vascular dementia, and dementia with behavioral disturbances, was documented as cognitively impaired and known to ambulate independently with a walker. Multiple behavior and nursing notes over several months recorded this resident wandering into other residents' rooms, particularly during evening and nighttime hours, and requiring redirection by staff. Staff interviews confirmed that this resident frequently entered other residents' rooms, causing distress among peers, and that staff struggled to manage these behaviors, especially during times of limited staffing. Despite repeated observations and documentation of wandering and room entry behaviors, the resident's care plan did not include interventions to address or minimize these actions. Additionally, another resident with aphasia, who was rarely understood, had no care plan interventions to prevent the first resident from re-entering her room after a documented incident. The Director of Nursing confirmed the absence of care plan measures for these behaviors, indicating a lack of comprehensive planning to meet the residents' needs and ensure their safety and well-being.
Failure to Provide Scheduled Showers per Care Plan Due to Staffing Issues
Penalty
Summary
Two residents with cognitive intactness and significant physical limitations did not receive showers as scheduled per their care plans. Both residents were observed to be ungroomed and expressed dissatisfaction with the care provided, specifically noting that showers were not given on their scheduled days. Instead, staff offered bed baths, which the residents did not want, and when they declined the bed bath, it was documented as a refusal of a shower. The residents reported that this was a recurring issue and that their requests for showers were not accommodated, even on designated make-up days. Multiple direct care staff and CNAs confirmed that staffing levels were inadequate, particularly on the units where these residents resided, which had higher acuity and behavioral needs. Staff reported that due to insufficient staffing, they were unable to complete all required care tasks, including providing showers, oral care, and timely responses to call lights. Staff also described logistical challenges, such as having to cover adjacent units and being unable to monitor call lights in both areas, further impacting their ability to provide care as outlined in residents' care plans. Nursing leadership, including an RN and the DON, acknowledged that the expectation is to provide a shower to any resident who requests one and that offering a bed bath instead is not acceptable if the resident wants a shower. Documentation reviewed for both residents showed multiple instances where showers were not provided as scheduled, with some entries marked as "not applicable," "refused," or "bed bath" instead of a shower. The deficiency was substantiated through observation, resident and staff interviews, and record review.
Failure to Provide Sufficient Staffing and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in delayed responses to call lights and failure to provide scheduled showers for multiple residents. Several residents, all cognitively intact and requiring varying levels of assistance for mobility and personal care, reported long wait times for assistance, sometimes up to an hour. Residents described situations where staff would turn off call lights without providing the requested help and would not return, leading to residents remaining in soiled conditions for extended periods. Residents also reported that staff frequently complained about being short-staffed and told them they would have to wait for care. Multiple residents expressed dissatisfaction with the lack of consistent showers, stating that on scheduled shower days, staff would inform them that they were too busy and offer bed baths instead. Residents who declined bed baths in favor of showers were documented as having refused showers, despite their insistence that they wanted a shower and not a bed bath. This issue was reported as recurring, with residents stating that they were not offered showers on makeup days and that their personal hygiene needs were not being met as planned. Interviews with direct care staff and a staffing coordinator confirmed that staffing levels were determined by facility census rather than resident acuity. Staff reported being unable to complete all required care tasks, including showers, oral care, and timely response to call lights, due to insufficient staffing. Staff also described logistical challenges, such as having to cover multiple units separated by double doors, which prevented them from being notified of call lights in other areas. Staff consistently reported that the units in question housed residents with higher acuity and behavioral needs, further compounding the difficulty in providing adequate care with the available staffing.
Failure to Include Endocrinologist Coordination in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with multiple serious health conditions, including Type II Diabetes and several malignant neoplasms. The resident was under the care of an endocrinologist for diabetes management, with specific instructions in the Electronic Medical Record (EMR) to contact the endocrinology clinic if the resident experienced frequent high or low blood sugar levels. However, the care plan dated January 20, 2024, did not include any intervention for communication and coordination with the endocrinologist, which was a critical component of the resident's diabetes management. During an interview with the Director of Nursing (DON), it was acknowledged that the care plan lacked an entry regarding communication and coordination with the endocrinologist. The DON noted that this was not typically included in care plans but recognized it as an area for improvement. The deficiency was identified through a review of the EMR and care plan, highlighting the potential for a lack of needed care due to the omission of this critical intervention.
Failure to Coordinate Diabetes Care with Endocrinology
Penalty
Summary
The facility failed to adhere to a physician's order for communication and coordination with an endocrinology clinic for the management of a resident's diabetes care. The resident, who had multiple malignant neoplasms and was receiving cancer treatment, had an order dated 3/22/24 to contact the endocrinology clinic if blood glucose levels were frequently high or low, with a target range of 100-200 mg/dl. Despite this order, the resident experienced consistently high blood glucose levels from 7/4/24 to 7/9/24, with no documentation indicating that the endocrinology clinic was notified during this period. Interviews with facility staff revealed a lack of clarity and coordination regarding the communication with endocrinology. A Nurse Practitioner mentioned that endocrinology was monitoring the resident closely due to their cancer treatment and steroid use, but was unsure of the frequency of contact with endocrinology. The Director of Nursing acknowledged the lack of documentation and expressed concern over the communication and coordination of care services with endocrinology. The deficiency was identified as a failure to follow the physician's order, resulting in unmanaged high glucose levels for the resident.
Medication Administration Failure Leads to Resident Dissatisfaction
Penalty
Summary
The facility failed to administer medications as ordered for a resident, resulting in the resident's dissatisfaction with care and eventual departure from the facility to seek medical treatment elsewhere. The resident, who had been admitted with diagnoses including an infection following a procedure and the presence of a prosthetic heart valve, was prescribed Vancomycin to be taken every six hours for Clostridioides Difficile. However, the Medication Administration Record indicated that the resident missed three doses of Vancomycin due to it being out of stock, as noted by the Licensed Practical Nurse (LPN) on duty. The resident expressed anger and dissatisfaction with the missed doses and ultimately decided to leave the facility against medical advice. Interviews with the nursing staff and the Director of Nursing (DON) revealed that there was a misunderstanding regarding the availability of backup medication in the facility's automated medication dispensing system, PYXIS. Although the DON initially believed there was no backup medication available, a subsequent review of pharmacy records showed that there were indeed eight capsules of Vancomycin in stock at the time the doses were missed. This lack of awareness and communication among the staff led to the resident missing critical doses of medication, contributing to their decision to leave the facility.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Ann Arbor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glacier Hills | 1.6 mi | ★★★★★ | 0 | 0 |
| The Gilbert Residence | 3.4 mi | ★★★★★ | 10 | 0 |
| Villa At Willow Place | 3.7 mi | ★★★★★ | 19 | 0 |
| The Villa At Parkridge | 3.9 mi | ★★★★★ | 16 | 0 |
| Regency At Bluffs Park | 4.6 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.