Optalis Health & Rehabilitation Of Muskegon
Optalis Health & Rehabilitation of Muskegon in Muskegon, MI — inspection on May 28, 2026.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 5/26/26 at 9:00 AM, R2 stated a CNA
movement and asked her where the bruise came from. R2 stated she went to look at what the CNA
when she rolled out of bed. R2 stated she hit her head on her nightstand when she fell.
She denied any other injuries. My head broke the fall.
She stated the facility sent her to the hospital. R2 stated at the time they were only using one CNA to provide incontinent care to her.
She stated the facility now uses two CNA's. R2 stated the CNA at the time of the fall did not seem like she was in a hurry or rushing through the care.
She stated, It was just an accident.
During an interview on 5/26/26 at 4:50 PM, Certified Nursing Assistant (CNA) D stated she went into R2's room to provide care.
She stated she rolled R2 away from her and R2 was too close to the edge. CNA D stated during care she noticed a bruise to the back of R2's leg and asked R2 about it.
She stated R2 tried to look at it and it threw off her balance and she rolled off the bed. CNA D stated R2's bedside drawer was open and R2 hit it on the way to the floor. CNA D stated after R2 fell to the floor she opened up the door and told the nurse that R2 had fallen out of bed.
She stated the nurse was right outside R2's door with the medication cart and immediately came into the room.
She stated when the nurse came in the room she saw that R2 was bleeding and the bed was at a high height (CNA D had raised the bed prior to starting care).
CNA D stated the nurse called 911 while she stayed with R2 and tried to clean her up to the best of my ability prior to EMS arriving. CNA D stated she and another aide moved R2's bed because R2 was leaning up against it and R2 was uncomfortable.
She stated they did not move R2.
She stated EMS arrived and took her to the hospital.
During the interview on 5/26/26 at 4:50 PM, CNA D stated R2 was a one-person with care at the time of the incident.
She stated they are technically not supposed to roll residents away from themselves when they are alone.
She stated she knew she was not supposed to roll R2 away from her at the time. CNA D stated she did it anyway because she was just trying to clean R2 up after she had an extra-large bowel movement in her brief.
She stated she should have called for help instead of doing the care herself, but she did not think anything would happen.
CNA D stated trying to do the care herself and rolling R2 away from her and not towards her was a lack of judgement.
She stated she received individual written education for the incident. A review of CNA Ds Employee Counseling & Corrective Action Record, dated 5/1/26, revealed she received her Final Written Warning on 5/1/26 for Carelessness or Negligence, Neglect of Duty related to a resident (R2) being rolled away from her, rolling out of bed, and sustaining an injury on 4/29/26.
She was educated on the proper policy and procedure for repositioning. A review of the facility's Repositioning Policy and Procedure, revised on 4/24/25 and reviewed on 2/2/26, revealed when repositioning a resident in the bed, staff are to position resident so that when they are turned they are in the middle of the bed and they are to reach across the resident and place one hand behind their shoulder and the other behind the hip and gently roll the resident towards you.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.