Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 & Rehabilitation Of Muskegon during CMS and state inspections, most recent first.
A resident with significant physical and cognitive impairments was sent alone to an outside medical appointment via contracted transportation, despite rarely getting out of bed and being dependent for mobility. Upon arrival, the resident was found sliding out of the wheelchair, unable to reposition, and in pain, requiring EMS transport back. Facility staff did not assess the need for accompaniment or notify the resident's representative, contrary to facility policy.
A resident with cryptococcus meningoencephalitis missed 19 doses of itraconazole due to the facility's failure to request the medication timely. The facility also did not perform necessary lab tests and an EKG as ordered by the Infectious Disease clinic. Despite procedures to address unavailable medications, the DON was unaware of the issue, and the facility canceled a follow-up appointment without proper documentation.
The facility failed to meet food safety standards, with issues such as inadequate handwashing water temperature, improper food date marking, and unsanitary kitchen conditions. Observations included mislabeled nutritional shakes, improperly thawed ground beef, and debris on equipment. Ice machines had crusted debris and leaks, and refrigeration units were improperly set, leading to discarded milk. Wet pans were not air-dried, violating FDA guidelines.
The facility failed to maintain cleanliness and repair, leading to potential contamination risks. Missing light shields were observed in various areas, including the kitchen and linen rooms. A janitor's closet setup caused undue back pressure on a vacuum breaker, and a non-operational sink in a restroom lacked signage. Items were found on the floor in a storage room, and raw wood shelves in a linen closet were not easily cleanable.
Two residents experienced delays in receiving care, impacting their dignity and self-determination. A resident with a history of stroke reported feeling forgotten due to staff delays in responding to his call light, particularly in the mornings. Another resident, who is cognitively intact, experienced prolonged waits for assistance with changing his brief, especially during the day shift.
A resident with hemiplegia and hemiparesis was not provided with appropriate care planning and follow-up after falls. The facility failed to update the care plan after a reported fall, did not complete required assessments, and inaccurately documented MDS assessments. The resident expressed concerns about his functional capabilities and lack of assistance with ambulation, contrary to his care plan. The facility's fall policy was not adhered to, resulting in fragmented care.
A facility failed to monitor a resident's Stage 4 pressure ulcer for six weeks due to a change in dialysis schedule and staff responsibilities. The resident, with multiple health issues, was admitted with the ulcer, and the care plan required weekly assessments. The oversight occurred as the wound care company visited on a day conflicting with the resident's new schedule, and a new staff member was assigned to wound rounds.
A resident with a history of stroke-related conditions and moderate cognitive impairment was not provided with proper care for enteral feeding and PEG tube site management. A registered nurse disconnected the resident from the feeding infusion without flushing the tube, violating facility policy. Additionally, the dressing at the infusion site was not consistently changed as per physician orders, with no documentation of refusals or communication with the interdisciplinary team.
The facility failed to maintain complete and timely medical records for two residents, leading to potential issues in care continuity. Both residents required updated PASARR Level II Evaluations, but the documentation was delayed, being added to their EMRs months after the evaluations were conducted and only after surveyor requests.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a wound and PEG tube, as staff did not wear gowns during high-contact activities. The resident's Treatment Administration Record lacked EBP orders for two months, and the Care Plan did not reflect the need for EBP, despite the facility's policy requiring PPE use to prevent MDRO transfer.
The facility failed to ensure effective hot water sanitization of dishware, as the dishwashing machine did not reach the required 160°F surface temperature. Despite the incoming water temperature being 194°F, tests showed dishware temperatures below the required level. Logs from May to July consistently recorded temperatures below 160°F, and no corrective action was documented.
A resident with Parkinson's Disease, Arthritis, and Anxiety, dependent on staff for toilet use, was injured during a mechanical lift transfer. A CNA conducted the transfer alone, contrary to facility policy requiring two staff members. The resident reported the CNA moved too fast and grabbed her hand, resulting in a bruise. An X-ray showed soft tissue swelling. The CNA admitted to performing the transfer alone due to staff unavailability.
Failure to Assess Resident's Appropriateness for Unaccompanied Transfer to Medical Appointment
Penalty
Summary
The facility failed to properly assess whether a resident was appropriate for lone transfer to an outside medical appointment, as required by professional standards of care. The resident in question had a history of functional quadriplegia, chronic pain syndrome, morbid obesity, mobility deficits, and moderate cognitive impairment, as evidenced by a BIMS score of 10 out of 15. Therapy notes indicated the resident was dependent for mobility and self-care, rarely got out of bed, and frequently refused therapy. Despite these factors, the resident was sent alone via a contracted medical transportation company to a dermatology appointment, seated in a standard large facility wheelchair. Upon arrival at the appointment, the resident was found sliding out of the wheelchair, with wet feet and only socks on, and was unable to reposition themselves. It required four people to assist the resident back into the wheelchair, but the resident continued to slide out and cried out in pain. The dermatologist's office refused to see the resident, and EMS was contacted to transport the resident back to the facility. There was no progress note in the medical record documenting the resident's status or the fact that they left the facility for the appointment on the day of the incident. Interviews with facility staff and the resident's representative revealed that the resident rarely, if ever, got out of bed or used a wheelchair for any length of time, and staff expressed uncertainty about the resident's ability to safely use a wheelchair or understand how to reposition themselves. The facility's own policy required assessment of the need for accompaniment to outside appointments based on cognitive and physical status, but this was not followed. The resident's representative was not notified of the appointment or transportation arrangements, and only learned of the incident after being contacted by the emergency department.
Failure to Administer Medication and Conduct Required Monitoring
Penalty
Summary
The facility failed to adhere to professional standards by not administering a physician-ordered medication, itraconazole, to a resident diagnosed with cryptococcus meningoencephalitis. The resident missed 19 doses of the medication from the date of admission to the facility until 10 days later. The pharmacy did not receive a request for the medication until the 10th day, and the Director of Nursing (DON) was unaware of the medication's unavailability despite procedures in place to address such issues. Additionally, the facility did not obtain necessary labs and tests to monitor the medication's efficacy and safety, as ordered by the Infectious Disease clinic. The facility also failed to maintain communication with the Infectious Disease clinic, which had faxed orders for lab tests and an EKG, and had scheduled a follow-up appointment for the resident. The facility canceled the appointment citing transportation issues but did not document the reason for the cancellation in the resident's electronic health record. The Infectious Disease clinic made multiple attempts to contact the facility regarding the missed doses and the need for lab tests, but the facility did not respond adequately.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. The hand wash sink near the dish machine did not have hot water, with the temperature only reaching 66°F, contrary to the FDA Food Code requirement of at least 100°F. Additionally, the facility did not properly date mark ready-to-eat foods, with items such as sliced turkey, tomato soup, and hot dogs either lacking discard dates or exceeding the safe consumption period. Nutritional shakes were mislabeled and stored improperly, and raw ground beef was thawed incorrectly in a pot of water without running water, violating FDA guidelines. The kitchen inspection also revealed unsanitary conditions and improper equipment maintenance. The meat slicer had dried debris on the blade, and the bottom of a cold hold unit was covered in spilled juice. Clean utensils were stored in a drawer with crumb debris, and ice scoops were stored in a manner that allowed stagnant water accumulation. Ice machines in nourishment rooms had crusted and slimy debris, with one machine leaking water onto the counter and floor, and disposable straws were stored in a contaminated area. Further deficiencies included improper storage and handling of food and equipment. The internal thermometer of a refrigeration unit read 50°F, leading to the disposal of milk cartons, and the unit was set to the lowest setting. Wet pans were stacked without proper air drying, contrary to FDA requirements. These observations indicate a failure to maintain food safety and sanitation standards, potentially leading to foodborne illnesses among residents.
Facility Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises, which increased the potential for contamination and possibly decreased resident satisfaction. During a kitchen tour, it was observed that some non-LED lights were missing their light shields over the preparation and serving area. In the 300 hall, a janitor's closet had a Y valve connected to the sink spout with both valves closed and the sink left on, creating undue back pressure on the faucet's internal vacuum breaker. Additionally, the clean linen room and soiled utility room in the 300 hall had missing light shields, exposing clean linens to potential contamination. An outside hose bib connection near trash containers was left on with a spray handle connected, also causing undue back pressure on the vacuum breaker. Further observations included numerous items on the floor in the 500 hall nursing storage room, such as foley insertion trays, pill bottles, and dust debris. A mop sink faucet and valve were found sticking out of the wall, and upon testing, it was discovered they were still connected to the potable water supply. In the 400 hall linen closet, two shelves were made of raw wood boards, which were not smooth or easily cleanable. The laundry room had a missing light shield over the washing machines. Lastly, a restroom in the 300 hall had a non-operational sink with no signage indicating it was out of order, preventing proper handwashing.
Failure to Provide Dignified Care and Timely Assistance
Penalty
Summary
The facility failed to provide care in a dignified manner for two residents, as observed in the report. Resident #73, who has a history of stroke, hemiplegia, and dysphagia, reported frequent delays in staff response to his call light, particularly in the mornings. He expressed feelings of being forgotten when staff would turn off his call light and not return promptly. During an observation, an LPN informed him that his shower would be delayed until after lunch due to staff scheduling issues, which caused distress to the resident. Resident #57, who is cognitively intact but has a history of repeated falls and coordination issues, also reported delays in staff response to his call light. He described situations where he would wait for extended periods, sometimes up to two hours, for assistance with changing his brief. The resident noted that the day shift was particularly slow in responding to his needs, often turning off the call light and not returning for significant periods, especially when he required a brief change.
Deficiencies in Care Planning and Fall Management
Penalty
Summary
The facility failed to develop, implement, and evaluate the effectiveness of care planned interventions for a resident who was admitted following a stroke, resulting in hemiplegia and hemiparesis. The resident expressed concerns about understanding his functional capabilities and reported that staff were not assisting him with ambulation as part of a restorative program, despite his care plan indicating the need for assistance with ambulation using a quad cane and one-person assist. The care plan was not updated after the resident reported a fall on 8/31/24, and there was no documentation of staff assisting the resident with ambulation in the electronic medical record. The facility also failed to complete required assessments and follow-up after the resident experienced falls. The resident reported two falls, one on 8/9/24 and another on 8/31/24, but the Director of Nursing was only aware of the first fall. The second fall was not documented in an incident report, and there were no post-fall assessments or updated care plan interventions addressing this fall. Additionally, the x-ray ordered on 9/1/24 did not have a documented indication, and the results led to new orders for antibiotics without clear respiratory assessment findings. Furthermore, the facility did not accurately complete Minimum Data Set (MDS) assessments, as the quarterly MDS assessment did not reflect the resident's two falls, including one with injury. This omission meant that pertinent data was not available for care planning decisions and quality measures. The facility's fall policy, which requires evaluation of injury, documentation, and updating care plans after falls, was not followed, leading to fragmented care and potential delays or omissions in care.
Failure to Monitor Pressure Ulcer
Penalty
Summary
The facility failed to assess and monitor a pressure ulcer for a resident over a period of six weeks, which could have led to the worsening of the condition. The resident, a female with multiple diagnoses including osteomyelitis, end-stage renal disease, and cognitive impairment, was admitted with a Stage 4 pressure ulcer. The care plan required weekly assessments of the wound, but there was a significant gap in documentation from September 11 to October 30, during which no evaluations were recorded. The deficiency occurred due to a change in the resident's dialysis schedule and a transition in staff responsibilities for wound care assessments. The Director of Nursing (DON) acknowledged that the resident's wound assessments were missed because the wound care company visited on a day that conflicted with the resident's new dialysis schedule. Additionally, a new staff member was assigned to conduct wound rounds, which contributed to the oversight. The DON confirmed that the resident was the only one affected by this lapse in wound evaluation.
Deficiency in Enteral Feeding and PEG Tube Care
Penalty
Summary
The facility failed to ensure that licensed staff adhered to physician orders and professional standards for the care of a resident receiving enteral feeding. The resident, who was moderately cognitively impaired and had a history of stroke-related conditions, was observed being disconnected from his tube feeding infusion by a registered nurse without the required flushing of the tube with water. This action was contrary to the facility's policy, which mandates tube irrigation before and after interruptions in feeding to maintain patency and hydration. Additionally, the facility did not consistently follow physician orders for the care of the resident's PEG tube site. The dressing at the infusion site was not dated or initialed, and records indicated that the dressing was not changed on several occasions. The treatment administration record showed that the dressing was not changed on nine out of twenty-nine days, with no documentation of the resident's refusals or any attempts to re-approach or educate the resident about the importance of the dressing change. There was also no evidence of communication with the interdisciplinary team or physician regarding these refusals.
Incomplete and Delayed Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, R8 and R12, which could potentially prevent providers from having a comprehensive understanding of the residents' conditions and care needs. For R8, the facility's records showed that a PASARR Level I Screening indicated the need for a Level II Evaluation, but the most recent Level II Evaluation in the electronic medical record (EMR) was outdated. The necessary documentation for the updated Level II Evaluation was only added to R8's EMR three months after it was conducted and after the surveyor requested it during the annual survey. Similarly, for R12, the facility's records indicated that a PASARR Level I Screening required a Level II Evaluation, but the last recorded Level II Evaluation was expired. The updated Level II Evaluation documentation was added to R12's EMR nine months after it was conducted and after the surveyor's request. This delay in documentation could interfere with the ability of healthcare professionals not directly involved in the residents' care to make informed decisions, as timely, accurate, and complete documentation is crucial for continuity of care.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) according to its policy for a resident with specific medical needs. The resident, who was moderately cognitively impaired and had a history of stroke, hemiplegia, and dysphagia, was admitted with a wound on the right ankle and a PEG tube for enteral feeding. Despite these conditions, the Treatment Administration Record (TAR) for August and September did not reflect an order for EBP, and the order was only entered on October 30, 2024. Additionally, the comprehensive Care Plan did not include the requirement for EBP, even though it addressed the resident's need for enteral feeding and wound care. Observations revealed that staff did not adhere to the EBP policy. A sign indicating EBP was present on the resident's door, but staff members were observed not wearing gowns during high-contact activities. Specifically, a registered nurse was seen disconnecting the resident from tube feeding without donning a gown, and both an LPN and RN assisted the resident in bed without using any PPE. The facility's policy, revised in March 2024, mandates the use of gowns and gloves during high-contact activities to prevent the transfer of multi-drug resistant organisms, yet this was not followed, as confirmed by the Director of Nursing's communication.
Failure in Dishware Sanitization Due to Faulty Equipment
Penalty
Summary
The facility failed to ensure effective hot water sanitization of resident dishes, utensils, and facility cookware, as required by the 2017 Food Code. During an observation, interview, and record review, it was found that the dishwashing machine did not achieve the necessary surface temperature of 160 degrees Fahrenheit for effective sanitization. The temperature gauge of the incoming hot water showed 194 degrees Fahrenheit, but the surface temperature of the dishware was recorded at 149.5 degrees Fahrenheit and 155.6 degrees Fahrenheit in repeated tests. The facility's High Temperature Dish Machine Logs from May to July 2024 consistently recorded temperatures below the required 160 degrees Fahrenheit, with some readings in the low 140-degree Fahrenheit range. The Dietary Manager (DM) attempted to address the issue by obtaining a different puck and temperature strips from a sister facility to re-test the dishwashing cycle. The re-test confirmed that the original facility puck was faulty. However, there was no documentation provided to show that corrective action had been taken when the logs consistently recorded temperatures below the required minimum. The facility's logs included a printed directive indicating that staff should have been aware of the requirement for a puck temperature of 160 degrees Fahrenheit or higher.
Failure to Follow Mechanical Lift Policy Results in Resident Injury
Penalty
Summary
The facility failed to implement the mechanical lift transfer policy for a resident, resulting in an accident hazard. The resident, who was admitted with diagnoses including Parkinson's Disease, Arthritis, and Anxiety, was dependent on staff assistance for toilet use. On a specific date, the resident complained of a bruise on her left hand after being transferred by a mechanical lift by a CNA. The CNA admitted to using the lift alone, despite knowing that the facility policy required two staff members for such transfers. The resident reported that the CNA was moving too fast and grabbed her hand, causing the bruise. The facility's investigation revealed that the CNA conducted the transfer alone because the other CNA was on a break and the nurse was unavailable. The CNA claimed that the resident insisted on being taken to the bathroom immediately and denied touching the resident's hand. An X-ray confirmed soft tissue swelling but no fracture. The facility's policy clearly stated that two staff members should assist with mechanical lift transfers, with one controlling the lift and the other supporting the resident. This policy was not followed, leading to the incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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Nursing homes near Muskegon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Roosevelt Park Nursing And Rehabilitation Communit | 0.8 mi | — | 3 | 0 |
| Harbor Terrace Senior Living | 1.7 mi | — | 10 | 0 |
| Lake Woods Nursing & Rehabilitation Center | 2.8 mi | — | 2 | 0 |
| Hillcrest Nursing And Rehabilitation Community | 4.1 mi | — | 12 | 0 |
| Christian Care Nursing Center | 4.3 mi | — | 4 | 0 |
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