Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation Of Dearborn Heig during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple medical conditions, including vascular dementia and thoracic spine fractures, had a care plan and Kardex requiring two-person assist for bed mobility and toileting at bed level. A CNA, who acknowledged knowing the resident was a two-person assist but did not seek help because staff were busy and was unfamiliar with the facility’s fall-prevention protocol, provided incontinence care and changed bed linens alone. During this one-person care, the resident rolled out of bed, sustained a head laceration, was found on the floor in a pool of blood, and required hospital evaluation and suturing before returning to the facility, where the resident was later observed crying and pointing to the sutured forehead.
A resident with severe cognitive impairment, mobility limitations, and a history of falls was observed in bed with the call light wrapped around the television and out of reach, despite a care plan requiring the call light to be kept within reach. Another cognitively intact resident with neuromuscular impairment, care planned for weighted utensils and a plate guard, received a meal tray containing only a weighted fork and no weighted knife or spoon, causing visible difficulty and frustration while attempting to cut and eat a chicken breast. Resident Council minutes from two consecutive months documented repeated complaints from residents that call lights were not accessible and were not answered in a timely manner.
A resident with dysphagia and muscle wasting, requiring assistance with mobility, did not receive scheduled OT and PT sessions as ordered. Documentation and staff interview confirmed that several therapy sessions were missed before the resident was transferred to the hospital and did not return.
A CNA was observed using unsanitary methods to fill water cups with ice, including using bare hands and picking up cups from the floor. The NHA confirmed the procedure should involve a scoop, but no written policy existed for using bagged ice.
A resident with heart failure did not receive prescribed elastic bandage leg wraps, despite their delivery and documentation indicating they were applied. The ADON confirmed the discrepancy between documentation and actual care, highlighting a failure to follow physician orders.
A resident sustained a second-degree burn after spilling hot water from an unstable foam cup during a meal. The facility failed to serve hot beverages in stable, handled, thermal cups and did not adhere to safe temperature guidelines, with water temperatures reaching 164 degrees Fahrenheit. The resident, who had muscle weakness and coordination issues, was not adequately assessed or monitored for handling hot liquids, leading to the injury.
The facility's water management plan was found deficient as it lacked comprehensive documentation and necessary components to effectively reduce the risk of legionella and other pathogens. The Maintenance Director confirmed that only yearly legionella testing was conducted, with no results or prior documentation available. The Nursing Home Administrator acknowledged the plan's shortcomings, which increased the risk of waterborne pathogens affecting the 86 residents.
A resident sustained a second-degree burn from hot water, and the facility failed to update the care plan to prevent further incidents. Despite the burn, the resident continued to receive hot water in unstable foam cups at scalding temperatures. The care plan lacked interventions for meal tray setup, monitoring, or adaptive equipment, contrary to facility policy requiring updates after significant condition changes.
A resident expressed frustration and uncleanliness due to receiving only one shower since admission, despite not refusing any. The resident, who required maximal assistance and was cognitively intact, had been on infection precautions but did not receive a shower after coming off isolation. The facility's logs showed one shower and four bed baths in 30 days, contrary to the resident's preference and the facility's policy on maintaining hygiene.
A resident with impaired cognition and malnutrition did not receive a meal tray as ordered by the physician. The resident was observed without a lunch tray on several occasions, and staff confirmed the oversight. The Registered Dietitian noted the resident should receive a tray for pleasure and assistance with meals, but the diet was not updated in the system, stopping meal ticket printing.
A resident undergoing dialysis three times a week did not receive a lunch or snack from the facility, despite their care plan indicating the need for meals on dialysis days. The resident, who had severe malnutrition and significant weight loss, reported missing meals and being hungry until dinner. Facility staff confirmed the oversight, and the Nursing Home Administrator and Assistant Dietary Manager were unaware of the issue, despite having prepacked lunches available.
Failure to Provide Required Two-Person Assist During Bed Mobility Resulting in Fall
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring two-person assistance for bed mobility and toileting at bed level, resulting in a fall from bed. The resident had multiple diagnoses, including cerebral infarction, vascular dementia, thoracic spine wedge compression fractures (T11–T12), major depression, anxiety, and adjustment disorder, and had a BIMS score of 2/15 indicating severely impaired cognition. The resident’s care plan, in place prior to the incident, specified that two staff members were required to assist with bed mobility and toileting at bed level. On the day of the incident, a CNA provided incontinence care and changed bed linens for the resident without obtaining the required second staff member, despite acknowledging awareness that the resident was a two-person assist and having reviewed the Kardex that specified two-person assistance for bed mobility. The CNA reported not seeking assistance because other staff were busy and also stated unfamiliarity with the facility’s “Happy Feet” fall prevention protocol. During this one-person care, the resident rolled out of bed and fell to the floor. Following the fall, a nurse responded to the room and found the resident on the floor with a pool of blood and an abrasion on the right side of the forehead, later documented as a facial laceration requiring five sutures at the hospital. The resident was transported to the hospital for evaluation, including imaging and other diagnostic tests, and returned the same day with instructions for suture care and pain relief. Later observation documented the resident lying in bed, nonverbal, crying, and pointing to the forehead where the stitches were present. Interviews with the Administrator and DON confirmed that the fall was attributed to the CNA not following the care plan and not waiting for another staff member to assist with ADL care and bed mobility.
Failure to Ensure Accessible Call Lights and Consistent Provision of Adaptive Eating Devices
Penalty
Summary
The deficiency involves failure to honor residents' rights to dignity, self-determination, communication, and exercise of rights by not ensuring call lights were accessible and answered timely, and by not providing ordered adaptive eating equipment. One resident with a displaced intertrochanteric fracture of the right femur, Type 2 diabetes mellitus, deafness, nonverbal status, difficulty walking, and severely impaired cognition (BIMS score of 0) was observed lying in bed with the bed in the lowest position and the call light wrapped around the television, tucked away and far from the resident’s reach. The resident’s MDS documented dependence in toileting, showers, and ADLs, and the care plan identified risk for falls with interventions including keeping the call light within reach and orienting the resident to surroundings and use of the call light. During the observation, the RN confirmed the call light was not within the resident’s reach. Another resident with diagnoses including rhabdomyolysis, major depressive disorder, anxiety disorder, and chronic inflammatory demyelinating polyneuritis, and a BIMS score of 15 indicating intact cognition, was care planned to receive adaptive equipment for eating, including weighted utensils and a plate guard. The resident reported that meal portions were sometimes too small and that they had been receiving double portions recently. While eating independently, the resident struggled to cut a chicken breast using only a weighted fork, became frustrated, and resorted to picking up the chicken breast with the fork and nibbling it, leaving crumbs and honey glaze on their face. The resident stated that a weighted knife and spoon were supposed to be provided but were not sent with the meal this time, and that sometimes they were provided and sometimes not. The lunch meal ticket documented that a weighted fork, weighted knife, and weighted spoon were ordered, but only a weighted fork was present on the tray. Resident Council minutes from two consecutive months documented repeated complaints that call lights were not answered timely, were not accessible, and were not within reach.
Failure to Provide Ordered Therapy Services
Penalty
Summary
The facility failed to provide Occupational Therapy (OT) and Physical Therapy (PT) services as ordered for one resident. The resident was admitted with diagnoses of dysphagia and muscle wasting, and required staff assistance with bed mobility and transfers. According to the medical record, the resident was scheduled to receive PT and OT five days a week during a specified certification period. However, documentation showed that the resident missed OT sessions on two days and PT sessions on three separate days within that period. The Director of Rehabilitation confirmed that the resident missed several therapy sessions before being transferred to the hospital and did not return to the facility. The therapy services agreement required therapy to be provided according to the attending physician's written orders and plan of care, but these services were not consistently delivered as scheduled for the resident.
Unsanitary Ice Handling Practices
Penalty
Summary
The facility failed to maintain sanitary practices while filling water cups with ice, which had the potential to affect all 104 residents who drink water in the facility. During an observation, a Certified Nursing Assistant (CNA) was seen using an empty cup to scoop ice from a bag and then using their bare hand to scoop ice into empty cups. Additionally, some cups fell to the floor, and the CNA picked them up, filled them with ice and water, and did not respond when asked if these cups would be used for residents. The Nursing Home Administrator (NHA) confirmed that the procedure should involve using a scoop from a cooler, but there was no written policy for using bagged ice.
Failure to Follow Physician Orders for Elastic Bandage Application
Penalty
Summary
The facility failed to adhere to physician orders for a resident requiring elastic bandage leg wraps. The resident, who was admitted with a diagnosis of Acute on Chronic Diastolic (Congestive) Heart Failure, expressed concerns during a care conference about not receiving timely care, including the application of elastic bandage wraps. Despite the delivery of the wraps on a Sunday, they remained unused and unopened by the following Tuesday, as observed during a visit. The resident's Treatment Administration Record indicated that the wraps were to be applied daily at 9:00 AM and removed at bedtime, but this was not done. The Assistant Director of Nursing confirmed that the order was documented as completed but was not actually provided to the resident. The facility's policy on medication administration emphasizes the importance of following physician orders and documenting medication administration accurately. However, in this case, the documentation did not reflect the actual care provided, leading to a deficiency in the resident's treatment plan.
Resident Burned Due to Unsafe Hot Beverage Service
Penalty
Summary
The facility failed to ensure that a resident, identified as R132, was served hot beverages in a stable, handled, thermal cup, and provided with proper meal setup. This deficiency resulted in an Immediate Jeopardy situation when R132 sustained a second-degree burn after spilling hot scalding water for tea on themselves. The incident occurred during a lunch meal when R132 attempted to place a tea bag into a foam cup without a lid, causing the hot water to spill onto their blanket, shirt, and skin, leading to a burn on their abdomen. Observations and interviews revealed that the hot water served to R132 was at a dangerously high temperature, with measurements taken at 164 degrees Fahrenheit on their lunch tray and 184.6 degrees from the kitchen hot water dispenser. Despite the facility's policy stating that hot liquids should be served at temperatures between 130 to 160 degrees, the actual temperatures exceeded these limits, posing a risk of burns. Additionally, the facility's investigation indicated a lack of consistent use of stable thermal mugs with handles, as R132 reported that hot beverages were often served in unstable foam cups. R132's medical history included conditions such as coronary artery disease, kidney disease, muscle wasting, and repeated falls, requiring assistance with eating and transfers. Despite being assessed as cognitively intact, R132 had muscle weakness and coordination issues, which may have contributed to the incident. The facility's failure to adhere to safe practices for serving hot beverages, combined with inadequate assessment and monitoring of R132's ability to handle hot liquids, led to the burn injury and the Immediate Jeopardy finding.
Removal Plan
- Resident #132 remains a resident of the facility and is being served their hot liquids in a stable thermal cup with a handle and is being offered assistance with hot liquids.
- Like residents have been audited to ensure their liquids are being served in a stable, handled, thermal cup and staff are offering and/or providing assistance with set-up as needed.
- Dietary staff have been re-educated to ensure hot liquids are being served in a stable, handled, thermal cup. Dietary staff has also been re-educated on ensuring hot liquids are being serviced at a temperature less than 160 degrees Fahrenheit. Any staff member who is currently not working will be reeducated prior to the start of their next shift of duty.
- LPN/RN/CENA has been re-educated to ensure when meals are served resident with hot liquids are in a stable, handled, thermal cup and they are offering and/or providing assistance when serving hot liquids as needed. Any staff member who is currently not working will be reeducated prior to the start of their next shift of duty.
- An Ad Hoc QA Committee meeting was held with the Medical Director and IDT to discuss the deficient practice and plan to ensure compliance. The NHA/Designee will conduct audits to ensure that hot liquids are served in a stable, handled, thermal cup. The NHA/Designee will audit to hot liquid temperature logs to ensure temperatures are less than 160 degrees Fahrenheit prior to leaving the kitchen. Audits will be completed weekly and monthly. Results of the audits will be taken to the QA committee for review and recommendation. Any areas of non-compliance will be addressed immediately. The Administrator is responsible for maintaining compliance.
- The Administrator is responsible for sustained compliance.
Deficient Water Management Plan for Legionella Prevention
Penalty
Summary
The facility failed to implement an effective water management plan to reduce the risk of legionella and other opportunistic pathogens in its plumbing system. During a survey, it was found that the water management plan provided by the Maintenance Director (MD C) only included a policy on safe water temperature and weekly temperature logs for specific areas, such as toilets in resident rooms, dish machines, laundry, and kitchen hand sinks. Additionally, the plan contained a monthly log of eyewash station flushes, which was unsigned. The Maintenance Director confirmed that the facility's water is tested yearly for legionella by an outside company, but they did not have the results for the current year's test or documentation of prior tests. Furthermore, the only prevention measures in place between these yearly tests were checks of water temperatures, and there was no flow mapping of the facility's plumbing included in the plan. The Nursing Home Administrator (NHA) acknowledged that the water management plan did not include all necessary components as outlined in the facility's instructions. The NHA stated that the Maintenance Director was responsible for conducting daily audits of water temperatures, checking for legionella twice a month, and inspecting fixtures for smells or abnormalities. However, the NHA confirmed that the water management plan lacked comprehensive documentation and did not meet the required standards. This deficiency increased the potential risk of waterborne pathogens spreading within the facility, posing a threat to the respiratory health of the 86 residents.
Failure to Update Care Plan After Resident Burn Injury
Penalty
Summary
The facility failed to update a resident's care plan after the resident sustained a second-degree burn on their abdomen from spilling hot water during a meal. Despite the incident, the care plan did not include new interventions to prevent further burns, such as meal tray setup, increased monitoring, or the provision of adaptive equipment. Observations revealed that the resident continued to receive hot water in foam cups, which were unstable and often served at temperatures above the scalding point, placing the resident at risk for additional burns. The resident expressed concern about the stability of the foam cups and the temperature of the hot water, indicating fear of another incident. The facility's policy requires care plans to be revised when there is a significant change in a resident's condition, but this was not done in this case. The interdisciplinary team did not implement necessary changes to the care plan to address the resident's burn injury and prevent future occurrences, as evidenced by the continued use of foam cups and the lack of temperature checks before serving hot beverages.
Failure to Provide Showers Per Resident Preference
Penalty
Summary
The facility failed to provide and document showers according to the preferences of a resident, identified as R132, who was unable to perform activities of daily living independently. R132 expressed feelings of frustration and uncleanliness due to receiving only one shower since their admission to the facility, despite not refusing any showers. The resident, who was cognitively intact with a Brief Interview for Mental Status score of 13/15, required maximal assistance with bed mobility, transfers, and showers. The resident had been on infection precautions earlier in their stay but had not received a shower even after coming off isolation precautions. The facility's shower logs indicated that R132 received one shower and four bed baths in the last 30 days, with one recorded refusal. The resident and their family member both reported dissatisfaction with the care provided, as bed baths were not considered an adequate substitute for showers, especially given the resident's history of accidents during infections. The facility's policy on Activities of Daily Living, revised in December 2023, stated that residents unable to carry out activities of daily living independently should receive necessary services to maintain good hygiene, including appropriate support and assistance with bathing.
Failure to Provide Meal Tray Per Physician's Order
Penalty
Summary
The facility failed to provide a meal tray per physician's order for a resident diagnosed with Unspecified Protein-Calorie Malnutrition and Cerebral Infarction. The resident, who had impaired cognition and was dependent on staff for bed mobility and transfers, was observed without a lunch tray on multiple occasions. A Certified Nursing Assistant noted that the resident used to receive a pleasure tray but had not received one for the past few days. The Registered Dietitian confirmed that the resident should receive a tray for pleasure and 1:1 assistance with meals, with documentation of intake, but acknowledged the resident was not receiving the tray as required. The issue was identified during a Quality Assurance meeting, where it was revealed that the diet was not updated in the computer system, resulting in the cessation of printing meal tickets for the pleasure tray. The facility's policy on Nutritional Management did not address the delivery of pleasure trays, contributing to the oversight. The deficiency highlights a lapse in ensuring the resident's nutritional needs were met as per the physician's orders.
Failure to Provide Meals for Dialysis Resident
Penalty
Summary
The facility failed to provide a lunch and/or snack for a resident (R6) who required dialysis care. R6, who was observed to be thin and gaunt, reported that they did not receive a lunch or snack on their dialysis days, which occurred three times a week. R6 attended dialysis from 10:30 a.m. to 1:00 p.m., missing the facility's lunch service, and stated they were hungry until dinner time. Despite R6's requests for food, they did not receive any, and their care plan indicated that a meal or snack should be sent with them to dialysis. R6's medical history included kidney failure, heart failure, and severe protein-calorie malnutrition, with a significant weight loss noted. The facility's staff, including a CNA and an LPN, confirmed that they did not provide R6 with a lunch or snack before leaving for dialysis. The Nursing Home Administrator and the Assistant Dietary Manager were unaware of the issue, despite having prepacked lunches available for dialysis residents. The facility's policy on hemodialysis care required the provision of meals or snacks on dialysis days, but this was not adhered to, leading to the deficiency. The lack of communication and follow-through by the staff resulted in R6 missing meals on dialysis days, contrary to their care plan and dietary needs.
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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 Dearborn Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Four Chaplains Nursing Care Center | 2.4 mi | — | 8 | 0 |
| Fountain Bleu Health And Rehabilitation Center | 3.4 mi | — | 11 | 0 |
| Imperial, A Villa Center | 3.8 mi | — | 3 | 1 |
| Maple Manor Rehab Center | 4.8 mi | — | 0 | 0 |
| The Orchards At Wayne | 5 mi | — | 10 | 0 |
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