Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Grosse Pointe during CMS and state inspections, most recent first.
A resident was hospitalized with a concussion after allegedly being assaulted by an unidentified agency staff member. The DON and NHA conducted an internal investigation and, finding the abuse unsubstantiated, did not report the allegation to the State Agency as required by facility policy.
The facility did not offer or provide COVID-19 immunization or education to 11 staff members, and lacked documentation showing that unvaccinated staff received vaccine education or were offered the vaccine, contrary to facility policy.
The facility did not adequately protect six female residents during a sexual abuse investigation involving a male resident with intact cognition and multiple diagnoses. After the incident, the male resident was moved to a different room but remained on the same floor as the alleged victim and other female residents, without additional protective measures or increased supervision, despite facility policy requiring such actions.
A resident with diabetes and hyperglycemia did not receive insulin as ordered on multiple occasions, including a missed dose for a high blood sugar reading and lack of documentation for another elevated reading. The nurse failed to notify the physician as required, and the DON confirmed these omissions, which were not in accordance with facility policy.
The facility did not post daily nurse staffing information as required, with the only visible staffing sheet being outdated by 12 days. Staff interviews confirmed that sheets were printed weekly but not posted daily, contrary to facility policy.
The facility's kitchen was found to have multiple sanitation deficiencies, including the presence of gnats and flies, improper glove use by staff, and ineffective cleaning practices. Observations revealed food debris, standing water, and inadequate hand hygiene during food preparation, contrary to the facility's sanitation policy.
A resident with multiple diagnoses, including Anemia and Acute Kidney Failure, experienced a significant change in condition that was not timely reported to the physician or family. After returning from the hospital for hypoglycemia, the resident's low blood pressure was not communicated, leading to the resident being found unresponsive later. The DON acknowledged the oversight, which violated the facility's notification policy.
The facility failed to reposition and provide range of motion exercises for three residents, leading to potential risks for skin integrity and mobility issues. One resident was observed in a supine position with minimal repositioning despite having a care plan for assistance due to dementia and muscle weakness. Another resident, dependent on staff for care, did not receive regular range of motion exercises, and a third resident was not repositioned despite impaired mobility and therapy refusals.
The facility failed to maintain proper hand hygiene during medication administration and resident care. Staff members, including LPNs and a wound care consultant, did not adhere to hand hygiene protocols, such as washing hands for the recommended duration and sanitizing equipment. The infection control nurse confirmed the necessity of hand hygiene between glove changes and after resident contact, as outlined in the facility's policy.
A resident's tube feeding equipment was observed to be significantly soiled over several days, despite the facility's policy requiring routine cleaning and disinfection. The DON acknowledged the equipment should be cleaned when soiled, but it remained uncleaned, indicating a failure to adhere to the facility's sanitation policy.
The facility failed to ensure pressure ulcer treatments were consistently provided as ordered for a resident with a history of Type II Diabetes and Protein calorie malnutrition. The Treatment Administration Record showed blank documentation for the treatment of the resident's ulcers for several months, and the care plan lacked interventions for treatment refusal or repositioning. The DON acknowledged the inconsistency in documentation and treatment administration.
Failure to Report Alleged Abuse Resulting in Resident Injury
Penalty
Summary
The facility failed to report an allegation of employee-to-resident abuse involving one resident who was hospitalized with a concussion after allegedly being physically assaulted in the forehead with an unknown object by an unidentified agency staff member. The resident reported the incident to local police and was transferred to the hospital following the event. The facility's Director of Nursing (DON) and Nursing Home Administrator (NHA) conducted an internal investigation within an hour of being informed of the allegations but determined that the abuse was unsubstantiated and therefore did not report the incident to the State Agency. A review of the facility's abuse policy indicated that all allegations of abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, and crimes are to be reported immediately to the Administrator and to the State Survey Agency within two hours if the allegation involves abuse or results in serious bodily injury. Despite this policy, the facility did not report the allegation to the State Agency, as required, after concluding their internal investigation.
Failure to Offer and Document COVID-19 Vaccination and Education for Staff
Penalty
Summary
The facility failed to offer and provide COVID-19 immunization and education to 11 out of 99 staff members. During interviews, the Infection Control Preventionist (ICP) stated that while the vaccine continued to be offered to residents, it was no longer offered to staff as of the beginning of the year. Instead, staff members seeking vaccination were referred to local pharmacies. Record review confirmed that there was no documentation showing that unvaccinated staff were provided education about the COVID-19 vaccine, nor that they were offered the vaccine or information on how to obtain it. Additionally, the facility's own COVID-19 policy requires that staff be offered the vaccine unless medically contraindicated or already immunized, and that staff receive education regarding the risks, benefits, and potential side effects of the vaccine. The policy also mandates documentation of staff education and offers of vaccination. However, the ICP confirmed that there was no documentation to show that staff were being offered or declining the vaccine or vaccine education, indicating noncompliance with the facility's stated procedures.
Failure to Protect Female Residents During Sexual Abuse Investigation
Penalty
Summary
The facility failed to ensure the safety and protection of six confidential female residents during the investigation of a sexual abuse incident. An unknown male resident, with diagnoses including Diabetes Mellitus, Bipolar Disorder, and Vascular Dementia and an intact BIMS score, was observed engaging in sexual activity with a female resident in a hallway. After staff intervened, the male resident was initially returned to his room and later moved to another room on the same floor, but still in proximity to the alleged victim and other female residents. The facility did not implement additional protective measures beyond relocating the resident, despite the potential for further contact with vulnerable residents. Observations revealed that the hallway where the male resident was moved was directly accessible to several other rooms occupied by female residents, and there were periods when no staff were present on the floor or at the nurse's station. Interviews with facility leadership confirmed that no further precautions were taken to protect the other residents during the period between the incident and the male resident's discharge. The facility's abuse policy required protection of residents during investigations, including increased supervision or immediate transfer if indicated, but these measures were not fully implemented.
Failure to Document and Administer Insulin per Physician Orders
Penalty
Summary
A deficiency was identified in the administration and documentation of insulin for a resident admitted with diagnoses including Critical Illness Myopathy and Type II Diabetes Mellitus with Hyperglycemia. The resident was cognitively intact and required supervision to limited assistance for activities of daily living. Physician orders specified a sliding scale for Insulin Lispro administration based on blood sugar (BS) readings, with instructions to notify the physician if BS was less than 70 or greater than 400. On one occasion, the resident had a BS reading of 570, but the amount of insulin administered was not documented, nor was there documentation that the physician was notified as required by the order. Additionally, there was a medication error where the resident did not receive insulin for a BS of 395, and the nurse involved stated she forgot to administer the medication and did not obtain the required blood sugar reading at lunch. Further review of the medical record and incident reports revealed that the nurse failed to follow the facility's Medication-Insulin Administration policy, which requires verification and documentation of insulin administration. The DON confirmed that the nurse did not provide the medication and failed to contact the physician as ordered. These actions and omissions resulted in a failure to provide appropriate treatment and care according to physician orders and facility policy.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information as required, affecting all 78 residents. On observation, the nurse staffing sheet displayed in the lobby was dated 12 days prior to the survey, and staff confirmed that this was the only location where the information was posted. Interviews with the receptionist and staffing coordinator revealed that nurse staffing sheets were printed weekly and kept in the office, but were not posted daily as required. The facility's own policy states that nursing direct care staffing data must be posted daily in a location accessible to residents and visitors in a clear and readable format. This deficiency was identified through observation, staff interviews, and review of facility policy.
Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, affecting 74 residents. Observations revealed multiple hygiene issues, including gnats and a fly in the kitchen, a puddle of water between the coffee dispenser and refrigerator, and food particles under the garbage disposal. A tan-colored sludge was noted extending from the dishwasher, which also had a buildup of food and sticky soil underneath. Standing water was observed under the drying side of the dishwasher, and a sanitizer bucket was found to be ineffective. Additionally, food debris was left on various kitchen utensils, and a box of meat was not properly closed to prevent contamination. Further observations during breakfast service showed improper glove use by staff, including failure to perform hand hygiene between glove changes. A staff member was seen handling trash and then returning to food preparation without washing hands. A fly was observed landing on a light fixture, which was missing a cover and appeared rusty. The facility's policy on kitchen sanitation emphasized the importance of hand hygiene and proper glove use, but these practices were not followed, contributing to the unsanitary conditions.
Failure to Notify Change in Resident's Condition
Penalty
Summary
The facility failed to provide timely notification of a change in condition for a resident, identified as R65, who was admitted with diagnoses including Anemia, Gastrointestinal Hemorrhage, and Acute Kidney Failure. On 05/25/24, R65 was found primarily unresponsive with a blood pressure of 90/58, prompting notification to the physician, management, and family, and the resident was sent to the hospital. R65 returned from the hospital the same day after treatment for hypoglycemia. However, on 05/26/24, a blood pressure reading of 84/58 was recorded at 10:14 AM, but there was no documentation indicating that this was reported to the physician or that any follow-up action was taken. Later on 05/26/24, R65 was found unresponsive at 5:10 PM. An interview with R65's family member revealed they were not notified of any change in condition until after the resident was found unresponsive. The Director of Nursing confirmed that the blood pressure reading should have been reported to the physician, as per the facility's policy on Change in Condition Notification, which requires notifying the resident, physician, and designated representative of significant changes in the resident's status.
Failure to Reposition and Provide Range of Motion Exercises
Penalty
Summary
The facility failed to ensure that dependent residents were repositioned or provided with range of motion exercises, as evidenced by the observations of three residents, R35, R44, and R116. R35 was observed multiple times over several days to be in a supine position in bed without significant repositioning. Despite having a care plan that required assistance with repositioning due to dementia, muscle weakness, and reduced mobility, R35 was not observed to be out of bed or repositioned during the survey. The resident had a wound on the heel and a discolored area on the coccyx, indicating a risk for skin integrity issues. R44 was similarly observed to be in a supine position in bed with minimal repositioning. The resident was dependent on staff for care, including turning and repositioning, and had a care plan that included passive range of motion exercises. However, the resident was not observed to receive these exercises regularly, and there were no devices in place to assist with repositioning. The resident's friend reported that R44 was not getting the range of motion exercises regularly, and the resident was not observed to be out of bed during the survey. R116 was observed to be off-center in bed, leaning towards the right side, and was not repositioned during the survey. The resident had a care plan that included repositioning and range of motion exercises, but these were not consistently provided. The Therapy Manager reported that R116 had refused physical therapy and exhibited rigidity and impaired mobility. Despite these challenges, the resident was not observed to be out of bed, and there was a lack of consistent repositioning or range of motion exercises provided by the staff.
Inadequate Hand Hygiene Practices
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during medication administration and resident care, as observed in several instances involving multiple staff members. On one occasion, an LPN washed their hands for only five seconds after completing medication administration. Another LPN did not perform hand hygiene after removing gloves post-medication pass. A nurse failed to perform hand hygiene before and after medication preparation, and did not sanitize the blood pressure apparatus after use on a resident. Additionally, a nurse did not perform hand hygiene after handling medication and retrieving a dropped capsule from the floor. During a wound care observation, the wound care consultant washed their hands for less than the recommended 20 seconds and used a gloved hand to access supplies from the treatment cart. The consultant also failed to sanitize their phone after using it during the procedure. The infection control nurse confirmed that hand washing should be done between glove changes and should last at least 20 seconds when using soap. The facility's hand hygiene policy, revised in April 2023, outlines the need for hand hygiene before handling medications, before resident care, and after contact with contaminated objects or equipment.
Failure to Maintain Clean Tube Feeding Equipment
Penalty
Summary
The facility failed to maintain clean and sanitary tube feeding equipment for a resident with a diagnosis of Cerebral Infarction and Gastrostomy Status. Over the course of three days, the resident's tube feeding pole and base were observed to be significantly soiled with tube feeding fluid. Despite multiple observations, the equipment remained in the same soiled condition, indicating a lack of proper cleaning and maintenance. The Director of Nursing (DON) acknowledged the issue upon observation with the surveyor, stating that the equipment should not be in such a soiled condition and should be cleaned whenever it becomes soiled. The facility's policy on Routine Cleaning and Disinfection emphasizes the importance of maintaining a safe and sanitary environment to prevent infections, yet the policy was not adhered to in this instance, as evidenced by the continued soiling of the tube feeding equipment.
Failure to Consistently Provide Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure pressure ulcer treatments were consistently provided as ordered for one resident out of three reviewed for pressure ulcers. The resident, who had a history of Type II Diabetes and Protein calorie malnutrition, was noted to have an unstageable pressure ulcer on the left ischial tuberosity. Despite the resident's care plan indicating the need for specific treatments and interventions, the Treatment Administration Record (TAR) showed blank documentation for the treatment of the resident's ulcers for the months of January, February, and March. This included missing documentation for orders to apply Triad Hydrophilic Wound Dress External Paste to the bilateral buttocks every shift and as needed for wound care. The care plan also lacked interventions to address the resident's refusal of treatments or repositioning. The Director of Nursing (DON) acknowledged that the treatments were not documented consistently and that the facility had identified issues with how wounds were being followed. The DON explained that the resident had been in and out of the hospital and had started to decline, exhibiting signs of dehydration and refusing food. The facility's policy on skin and wound care required treatments to be ordered by a medical practitioner and documented appropriately, but this was not adhered to in the case of the resident. The facility's failure to document and administer the prescribed treatments for the resident's pressure ulcers as ordered by the physician led to the deficiency. The lack of consistent documentation and appropriate interventions in the care plan contributed to the inadequate care provided to the resident, who was at high risk for skin integrity issues due to their medical history and condition at the time of the deficiency.
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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.
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Nursing homes near Grosse Pointe Woods
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regency At St. Clair Shores | 0.8 mi | ★★★★★ | 0 | 0 |
| The Orchards At Harper Woods | 1.4 mi | ★★★★★ | 11 | 0 |
| The Rivers Health & Rehabilitation Center Of Gross | 2 mi | ★★★★★ | 9 | 0 |
| Shorepointe Nursing Center | 2.4 mi | ★★★★★ | 1 | 0 |
| The Orchards At Roseville | 2.5 mi | ★★★★★ | 3 | 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.