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 & Rehabilitation Of Ionia during CMS and state inspections, most recent first.
Surveyors found that a spa room in the Memory Care Unit was cooler than the adjacent hallway, with measured temperatures of 69°F in the room and 70°F in the hallway, while wall-mounted heating fixtures in the spa room were not turned on despite being available for additional heat. In multiple rooms (31–42), floors had debris and caked-on dirt outlining and scattered across the tiles that could not be removed by wiping, and housekeeping staff reported the buffer had not been used for months and that the floors had been sealed and waxed without prior stripping. Additional observations included bugs trapped in a bathroom light fixture and cracked, peeling sealant around a toilet base, all contributing to a failure to maintain a clean, comfortable, homelike environment.
A resident with major depressive disorder, diabetes, and heart failure, who had documented behaviors of possible delusions and confabulation, gave cash to an activities aide who was supposed to purchase a phone for the resident. According to a concern reported by the resident’s daughter, the aide instead used the money for her own daughter’s birthday, leaving the resident and daughter very upset. The aide’s written statement acknowledged receiving the money, claimed there was an agreement to help with her daughter’s party, denied stealing, and indicated she would quit after returning the funds. The resident later recalled the aide taking her money but did not recall getting it back, while interviews with the daughter and the NHA confirmed the aide had taken and then returned the money before quitting, constituting misappropriation of resident property.
A resident’s family member reported to staff that an activities aide took over one hundred dollars from the resident, allegedly to buy a phone but instead using it for a personal purpose, leaving the resident and family very upset. Although facility policy required immediate reporting of any abuse or misappropriation to leadership and the State Survey Agency, the allegation was not reported to the state within the required timeframe, as the NHA did not notify the agency until several days after staff first received the report. This delay in reporting the alleged misappropriation resulted in a deficiency for failure to follow abuse and misappropriation reporting procedures.
Two residents who required staff assistance with toileting and ADLs did not receive timely or respectful care. One resident was left in soiled clothing after a CENA failed to return as promised, while another waited extended periods for call light responses, resulting in incontinence and feelings of dehumanization. These actions did not honor the residents' rights to dignity and respect.
Two dependent residents who required staff assistance for showering did not consistently receive their scheduled showers, instead receiving bed baths or, in one case, no hygiene care on scheduled days. Both residents, who were cognitively intact, expressed dissatisfaction and feelings of uncleanliness. Staff interviews indicated that showers were sometimes missed or replaced with bed baths due to staffing shortages or time constraints, despite facility policy supporting resident preferences.
The facility failed to accurately conduct infection surveillance, investigate a COVID-19 outbreak, and properly store oxygen supplies. Two residents were incorrectly included in the infection rate, and no outbreak investigation was conducted for a COVID-19 outbreak. A resident with COPD and pneumonia had improperly stored oxygen equipment, contrary to infection control expectations. Facility policies lacked clear instructions on oxygen equipment storage, leading to deficiencies in infection control measures.
The facility failed to prevent repeated falls for two residents, one with severe cognitive impairment and another with dementia. Despite multiple incidents, the facility did not implement adequate supervision or preventive measures. Incident reports lacked detailed investigation and analysis, and care plans did not include necessary interventions. The facility's policy focused on post-fall injury assessment without addressing fall prevention, leading to repeated falls without effective interventions.
The facility failed to follow its Antibiotic Stewardship policy for two residents. One resident was prescribed antibiotics despite a urine culture showing no bacterial growth and a chest x-ray indicating clear lungs. Another resident was given antibiotics for a UTI despite a negative urinalysis and no treatable infection indicated. The facility continued antibiotic treatments without documented rationale from the provider.
The facility failed to administer the COVID-19 vaccine to two residents after receiving consent. One resident, who was their own responsible party, signed a consent form for the Spikevax Moderna COVID-19 vaccine, while another resident's Durable Power of Attorney provided consent for the updated COVID-19 vaccine. The Infection Control LPN confirmed that the vaccine was not administered, and there was no documentation explaining the oversight, which was against the facility's policy.
Inadequate Temperature Control and Poor Floor Cleanliness in Memory Care Unit
Penalty
Summary
Surveyors identified a failure to maintain comfortable temperatures in the Memory Care Unit spa room and to provide a homelike, clean environment in multiple resident rooms. On 03/23/2026 at 2:43 PM, the spa room on the Memory Care Unit was observed to feel cooler than the adjacent hallway. A rapid-read digital thermometer showed an air temperature of 69°F in the spa room, and an infrared thermometer reading off the tile wall showed 64°F. The Maintenance Director stated that 69°F seemed cool for a shower room and acknowledged that there were wall-mounted heating fixtures available in the spa room that could be turned on for additional heat, but these fixtures were not in use at the time of observation. The hallway temperature near the spa room entrance was measured at 70°F, and the thermostat controlling the Memory Care Unit was set at 71°F. During the initial tour on 03/23/2026 at 9:33 AM, rooms 31–42 were observed to have dirty floors with debris and a heap of caked-on dirt outlining the floor tiles and scattered caked-on dirt that was not easily removable. On 03/24/2026 at 12:48 PM, a housekeeper reported that the floors were hard to clean but stated they do sweep and mop; the housekeeper also reported that the floor buffer machine had not been used for at least six months and verified that the caked-on dirt outlining the tiles in one room did not come off. At 12:56 PM, another housekeeper reported that rooms 31–42 looked dirty because they had been sealed and waxed without stripping the floors first, resulting in dirt that would not come up. Attempts to wipe away the heaped-up dirt in the tile cracks and on top of the tile with a paper towel were unsuccessful. In addition, a bathroom light fixture contained three bugs trapped inside, and the toilet base sealant was observed to be cracked and peeling.
Failure to Prevent Misappropriation of Resident Funds by Staff
Penalty
Summary
The deficiency involves the facility’s failure to prevent misappropriation of a resident’s money by a staff member. A resident with major depressive disorder, diabetes, and heart failure had a care plan noting behaviors of making false accusations, possible delusions, and confabulation when she does not recall events or where she places items. A concern form documented that the resident’s daughter reported an activities aide took cash from the resident, stating that the aide was supposed to use the money to purchase a phone for the resident but instead used it for her own daughter’s birthday. The resident and her daughter were described as very upset about the incident. A written statement from the activities aide indicated that the resident had given her $135.00, that she had $140.00 in her possession, and that she believed she and the resident were in agreement about using the money to help with her daughter’s party, denying that she was stealing. The aide stated she would quit after returning the money. In a later interview, the resident recalled the aide taking her money but did not recall receiving it back. The facility’s investigation, including interviews with the resident’s daughter and the nursing home administrator, confirmed that the aide had taken the resident’s money and later returned it, and that the aide then quit her job. This sequence of events constituted misappropriation of resident property in violation of the facility’s abuse policy, which prohibits exploitation and misappropriation of resident property.
Failure to Timely Report Alleged Misappropriation of Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse and misappropriation reporting policies when an allegation of misappropriation of a resident’s money was made. A concern form documented that a resident’s daughter reported to staff that an activities aide had taken money from the resident, stating that the aide was supposed to use the funds to purchase a phone for the resident but instead used the money for her own daughter’s birthday. The amount reported taken was between $135 and $143. The resident and her daughter were described as very upset by the incident. The facility’s abuse policy required that any allegation of abuse, including misappropriation of resident property, be immediately reported to a supervisor, the Abuse Prevention Coordinator, the Administrator, and to the State Survey Agency within specified time frames. The Nursing Home Administrator stated in an interview that any abuse, including misappropriation, should have been reported immediately and acknowledged that the allegation was reported to staff on one date but not reported to the State Agency until several days later, when she was notified. This delay in reporting the allegation of misappropriation to the proper authorities constituted the failure to follow facility policy and procedures and led to the cited deficiency.
Failure to Provide Dignified Care and Timely Assistance with Toileting
Penalty
Summary
The facility failed to provide dignified care to two residents who required staff assistance with toileting and activities of daily living. One resident, who was cognitively intact and occasionally incontinent of urine, reported that after requesting help to be changed upon waking, a CENA responded with a dismissive comment and left the room, stating she would return after passing meal trays. The CENA did not return, and the resident, despite being instructed not to do so without assistance, changed herself an hour later. This incident left the resident feeling frustrated, helpless, and depressed. The CENA later acknowledged forgetting to return and admitted to similar behavior with another resident, after which a supervisor instructed her to prioritize resident care over passing meal trays. Another cognitively intact resident, also requiring staff assistance with toileting, reported waiting up to 30 minutes for help after activating the call light, and on one occasion waited over 20 minutes, resulting in incontinence. This experience made the resident feel dehumanized. The facility's policy on resident rights states that residents are to be treated with dignity and respect and have reasonable accommodation of their needs and preferences. The events described demonstrate a failure to honor these rights for the residents involved.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers for two dependent residents who required staff assistance for activities of daily living, specifically showering. One resident, with diagnoses including depression and apraxia and who was cognitively intact, was scheduled to receive showers twice weekly but went without a shower for two weeks, receiving only bed baths during this period. Documentation and a concern form confirmed the lack of showers, and the resident reported feeling dirty as a result. Another resident, also cognitively intact and requiring staff assistance for showering, was scheduled for showers twice weekly but reported receiving bed baths instead of showers about three times a month, and on one occasion did not receive either a shower or a bed bath. This resident also expressed feeling unclean due to the substitution of bed baths for showers. Staff interviews revealed that showers were sometimes replaced with bed baths due to staffing shortages or time constraints, with staff acknowledging that resident preferences for showers were not always met. The Director of Nursing confirmed that resident preferences should be accommodated. Facility policy indicated that residents have the right to reasonable accommodation of their needs and preferences, including being treated with dignity and respect.
Infection Control Deficiencies and Improper Oxygen Equipment Storage
Penalty
Summary
The facility failed to implement an accurate monthly infection surveillance system, conduct an outbreak investigation, and properly store oxygen supplies according to its Infection Control plan. During an interview, the Infection Control (IC) Licensed Practical Nurse (LPN) reported that infections were mapped and included in a line listing, but two residents were incorrectly included in the infection rate for January 2025 despite not having infections. The facility also experienced a COVID-19 outbreak in December 2024, but no outbreak investigation was conducted, and employee illnesses were not considered in the spread of the virus. The facility's mapping tool did not distinguish COVID-19 from other respiratory illnesses, which hindered the identification of trends and outbreaks. Resident #25, who has heart failure, chronic obstructive pulmonary disease (COPD), and pneumonia, was observed with improperly stored oxygen equipment. The resident's nasal cannula tubing and nebulizer mask were left un-stored and exposed to air, contrary to the facility's infection control expectations. The Director of Nursing and the Infection Control Preventionist both stated that oxygen equipment should be stored in clear plastic bags when not in use, but this practice was not followed for Resident #25. The facility's policies on oxygen therapy and infection prevention did not provide clear instructions on the safe storage of oxygen equipment when not in use. Despite the lack of policy guidance, staff members indicated that they were aware of the proper storage practices through their experience. However, the failure to adhere to these practices was evident in the observations made during the survey, highlighting a deficiency in the facility's infection control measures.
Failure to Prevent Repeated Falls in Residents
Penalty
Summary
The facility failed to adequately investigate, analyze, and implement meaningful interventions to prevent repeated falls for two residents, R32 and R117. R32, a female resident with severe cognitive impairment and a history of falls, was observed with bruises on her face and forehead, indicating recent falls. Despite multiple incidents, the facility's documentation lacked comprehensive investigation, analysis, or implementation of preventive measures. The care plan for R32 did not include interventions for supervision or supervised activities, and the facility's policy focused only on post-fall injury assessment without addressing fall prevention. R32 experienced several falls between December 2024 and March 2025, with incident reports lacking detailed information on the resident's condition prior to the falls or any new interventions to prevent future incidents. The Director of Nursing (DON) acknowledged the inconsistency in completing post-fall tools and the absence of information to guide the Interdisciplinary Team (IDT) in implementing effective interventions. Despite the resident's severe cognitive impairment and lack of safety awareness, no supervision was provided when R32 was in her wheelchair, and no supervised activities were offered. Similarly, R117, a resident with a history of stroke and dementia, experienced multiple falls without adequate preventive measures being implemented. The incident reports and IDT notes for R117's falls lacked new interventions for increased assistance or supervision. Although the resident's mental status fluctuated, and she had impaired memory, the facility did not provide additional support or supervision to prevent further falls. The facility's failure to address these deficiencies highlights a lack of comprehensive fall prevention strategies for residents at risk.
Failure to Follow Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship policy for two residents, R1 and R64, as identified during a survey. R1 was readmitted to the facility after hospitalization with suspected urinary tract infection symptoms, including confusion and dysuria. Despite a urine culture showing no bacterial growth, R1 was prescribed Keflex. Later, R1 was sent to the emergency department, diagnosed with pneumonia and a urinary tract infection, and prescribed antibiotics for eight days. However, the hospital's urine culture showed mixed flora with no significant pathogens, and a chest x-ray indicated interstitial and hazy opacities, but R1's lungs were clear upon physical examination. The facility continued the antibiotic treatment without documented rationale from the provider. Similarly, R64 was readmitted with a diagnosis of infection and inflammatory reaction and was prescribed Amoxicillin for a urinary tract infection. However, the urinalysis was negative, and the hospital documentation did not indicate a treatable infection, with few bacteria identified and no culture attempted. Blood cultures showed no organism isolated. The facility continued the antibiotic treatment without evidence of a documented rationale. The facility's Antibiotic Stewardship policy requires that lab results and the current clinical situation be communicated to the prescriber to determine the necessity of antibiotic therapy, which was not followed in these cases.
Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to administer the COVID-19 vaccine to two residents, R12 and R29, despite having received consent for vaccination. R12, who was their own responsible party, signed a consent form for the Spikevax Moderna COVID-19 vaccine on January 17, 2025. R29, whose Durable Power of Attorney (DPOA) provided consent, signed a pharmacy immunization consent form for the updated COVID-19 vaccine on May 24, 2024. However, neither resident received the vaccine, and there was no documentation explaining the oversight. During an interview, the Infection Control Licensed Practical Nurse (IC/LPN C) confirmed that once consent is obtained, the vaccine order should be entered into the Electronic Medical Record (EMR) and administered shortly thereafter. Upon reviewing the clinical records, IC/LPN C found that the COVID-19 vaccine had not been administered to either resident, and there was no supporting documentation to explain the failure. This oversight was contrary to the facility's policy, which mandates an immunization program against COVID-19 in collaboration with the medical director, in accordance with national standards of practice.
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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 Ionia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Point Nursing & Physical Rehabilitation Ce | 11.4 mi | ★★★★★ | 9 | 0 |
| The Laurels Of Kent | 15.8 mi | ★★★★★ | 12 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 16.4 mi | ★★★★★ | 3 | 0 |
| The Laurels Of Carson City | 16.9 mi | ★★★★★ | 1 | 0 |
| Corewell Health Greenville Hospital Rehabilitation | 17.2 mi | ★★★★★ | 0 | 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.