Optalis Health & Rehabilitation: Resident Falls From Bed - MI
She had been on her side, facing the doorway, while a certified nursing assistant cleaned her up after a bowel movement. The CNA noticed a bruise on the back of the resident's leg and asked about it. The resident turned to look. And then she rolled off the bed.
According to a federal inspection report completed in late May 2026 at Optalis Health & Rehabilitation of Muskegon, the CNA who provided that care already knew, in the moment she was doing it, that she was breaking a basic rule of resident safety. She said so herself.
The resident, identified in inspection records only as R2, told an inspector on May 26 that the CNA had her positioned facing the doorway when she went over the edge. She said she hit her head on the nightstand on the way down. She was taken to the hospital by ambulance. She said the CNA didn't seem rushed or careless in her manner — "It was just an accident" — but the inspection record makes clear the conditions that produced that accident were not accidental.
CNA D, as the worker is identified in the report, gave her own account during an interview the same afternoon. She said she had gone into the room alone to provide incontinence care after the resident had what she described as an extra-large bowel movement. She rolled the resident away from her rather than toward her. She noticed the bruise on the resident's leg. She asked about it. The resident tried to look. The resident's balance shifted, and she went off the edge of the bed. The bed, CNA D noted, was raised to a high position — she had raised it herself before beginning care.
Then CNA D said the quiet part plainly.
She told the inspector she was "technically not supposed to roll residents away from themselves when they are alone." She said she knew she was not supposed to roll the resident away from her at the time. She said she did it anyway because she was trying to clean the resident up. She said she should have called for help but didn't think anything would happen. She called it "a lack of judgement."
The facility's own repositioning policy, revised in April 2025 and reviewed again in February 2026, is specific on this point: when repositioning a resident in bed, staff are to place the resident in the middle of the bed first, then reach across and place one hand behind the shoulder and the other behind the hip, rolling the resident toward the caregiver. Not away. Toward.
CNA D did the opposite. Alone. With the bed raised. With a resident who was supposed to receive two-person care.
That last detail surfaces in both accounts. R2 told the inspector that at the time of the incident, the facility was using only one CNA for her incontinence care. She said that after the fall, the facility changed the practice and now sends two. CNA D confirmed that R2 was designated as a one-person-assist at the time — meaning, in theory, a single aide could handle her care — but also acknowledged the rolling technique she used was not something a solo caregiver was supposed to do.
The fall happened on April 29, 2026. CNA D's employee counseling record, dated May 1, shows the facility issued her a Final Written Warning two days later. The warning cited carelessness or negligence and neglect of duty, specifically connected to the incident with R2. She received written education on repositioning procedure.
A Final Written Warning is typically the last formal step before termination in a progressive discipline system. Whether CNA D remained employed at the facility at the time of the inspection is not stated in the report.
What the report does capture is the sequence on the night of the fall. After R2 went to the floor, CNA D opened the room door and told the nurse in the hallway what had happened. The nurse was already just outside the door with the medication cart. She came in immediately, saw that R2 was bleeding, and called 911. CNA D stayed with the resident and tried to clean her up before EMS arrived. She and another aide moved the bed slightly because R2 was leaning against it and uncomfortable — they did not move R2 herself. EMS arrived and transported her to the hospital.
The inspection classified the violation as causing actual harm to a few residents — the lowest end of the harm scale that still involves a real injury to a real person, as opposed to potential risk.
R2, in her interview, did not assign blame in the way the inspection record does. She described the CNA's demeanor as unhurried. She called it an accident. She spoke without apparent anger about a woman who was trying to clean her up and made a choice that sent her to the hospital with a bleeding head wound.
That gap — between how the resident described the moment and what the CNA admitted to the inspector — is where the story actually lives. CNA D wasn't rushing. She wasn't cutting corners to get to the next room faster. By her own account, she was trying to do the job in front of her, alone, with a resident who'd had a significant bowel movement, and she made a calculation: I know the rule, I'll skip it this once, nothing will happen.
Something happened.
R2 told the inspector she hit her head on the nightstand when she fell. She said her head broke the fall. She denied any other injuries. She was sent to the hospital.
The facility's repositioning policy had been reviewed just three months before the fall. CNA D had been trained on proper technique. None of that stopped what happened on April 29 in that room, with the bed raised high and one aide working alone and a resident turning her head to look at a bruise she didn't know she had.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Optalis Health & Rehabilitation of Muskegon from 2026-05-28 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
Optalis Health & Rehabilitation of Muskegon in Muskegon, MI was cited for violations during a health inspection on May 28, 2026.
She had been on her side, facing the doorway, while a certified nursing assistant cleaned her up after a bowel movement.
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.