Optalis Health: Locked Dementia Unit Without Consent - MI
Optalis Health and Rehabilitation of Grand Rapids confined Resident #109 to the memory care unit during daytime hours despite her guardian's repeated refusal to authorize the placement. The facility had no documentation showing the guardian ever agreed to the arrangement.
The guardian, identified as Family Member EE, told inspectors the facility had been trying to convince him for months to move his mother to the locked unit. He refused because he felt the facility hadn't provided evidence she was trying to leave the building, and he believed the move would create unnecessary stress before her planned transfer to another facility.
"He felt like the facility was pushing him to allow Resident #109 into the locked unit because she was exit seeking but he felt the facility had not provided evidence of Resident #109 exit seeking," inspectors wrote.
Staff described the unauthorized confinement in interviews with federal inspectors. CNA JJ said facility management instructed staff to have Resident #109 "do day care on the memory unit until her guardian consented to having her moved." The aide noted it didn't make sense because the resident enjoyed wandering and couldn't wander as much on the locked unit.
CNA Q told inspectors the facility had been placing the resident in the locked unit until bedtime "for awhile" because they felt she needed more supervision due to her wandering and behaviors. The resident returned to the main unit at night because her guardian opposed the locked placement.
Neither aide reported observing the resident attempting to leave the building.
Director of Social Services HH claimed the facility was "trialing" the resident on the locked unit for additional supervision. She said the facility physician had assessed the resident and recommended the unit placement, and that they had a doctor's order to move her but were waiting for guardian consent.
The social services director thought the guardian had consented to daytime placement but couldn't confirm because she wasn't part of that conversation.
Director of Nursing B told inspectors she had tried discussing the locked unit move with the guardian over the phone, but he refused to discuss it. She acknowledged the resident "was not really on the unit because her room was not over there" but said they kept her there during the day "for her own safety."
The nursing director couldn't say how long the facility had been sending the resident to the locked unit during the day and didn't know if the guardian had given consent for the daytime placement.
A February care conference note provided the only documentation of the guardian's position. The note from the facility's former administrator recorded a phone conference with the guardian, ombudsman and facility staff about transferring the resident to the dementia unit.
"After a half hour of speaking with guardian he still decided that he did not want his mother moved to the Dementia unit," the note stated. "He told all parties that he was going to move her to another facility as soon as he is able to."
When inspectors requested all verification that the facility had obtained consent from the guardian for any placement on the locked unit, Nursing Home Administrator A could provide no additional documentation.
The administrator confirmed "the facility was not able to provide any further documentation or verification that the facility had obtained consent from Resident #109's guardian to have her in the locked dementia unit during the day."
The guardian told inspectors he felt moving his mother to the locked unit before transferring her to a new facility would create more stress and confusion. He said the facility had mentioned trialing the locked unit during their last care conference, but he had not given explicit consent for daytime placement either.
Federal inspectors cited the facility for failing to ensure residents' rights to make choices about aspects of their care. The violation carried a designation of minimal harm or potential for actual harm affecting few residents.
The case illustrates how nursing homes can circumvent family wishes through creative interpretations of care arrangements. By calling the unauthorized confinement "day care" and claiming it was temporary, the facility continued the placement for months without proper consent while pressuring the guardian to approve a permanent move he had repeatedly rejected.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Optalis Health and Rehabilitation of Grand Rapids from 2025-08-18 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Optalis Health and Rehabilitation of Grand Rapids in Grand Rapids, MI was cited for violations during a health inspection on August 18, 2025.
The facility had no documentation showing the guardian ever agreed to the arrangement.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.