Optalis Health and Rehabilitation of Canton

Inspectors wroteThis citation pertains to intakes #2786224 and 2965279. Based on interview and record review, the facility failed to utilize a two-person assist and appropriate bed mobility techniques during a brief change of one resident (R511) of three residents reviewed for falls, resulting in the resident sustaining a closed head injury, abdominal hematoma, and a closed fracture of the femur requiring hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to (1) ensure the use of personal protective equipment when providing care for residents on Enhanced Barrier Precautions and (2) failed to continuously maintain, implement and operationalize a comprehensive infection control program, encompassing outcome and process surveillance, accurate data collection/documentation/analysis, resulting in missed opportunities to prevent the spread of infection.

Inspectors wroteBased on interview and record review the facility failed to maintain a continuous Antibiotic Stewardship Program that includes monitoring antibiotic usage, tracking resistance, prevent emergence of resistance, and following protocols for antibiotic use, which has the potential to affects all residents residing in the facility.

Inspectors wroteThis citation is related to intake #2962412. Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect for one resident (R504) of three residents reviewed for neglect, resulting in the resident calling three times to the local police/ fire departments for allegations of neglect of care by the nursing staff.

Inspectors wroteThis citation is related to intake #2962412. Based on observation, interview, and record review the facility failed to adequately address and resolve grievances in a timely manner for one (R504) of four residents reviewed for grievances, resulting in neglect related to care by nursing staff.

Inspectors wroteThis citation is related to intake #2962412. Based on interview and record review the facility failed to develop and revise a comprehensive Care plan for one resident (R504) of 14 residents reviewed for care plans, resulting in the potential for unmet care and services.

Inspectors wroteThis citation pertains to 2980193, 2981179, 2966122, 2962412, 2962938, 2795382, 2794223, 2797203 and 2791414Based on observation, interview and record review, the facility failed to ensure appropriate urinary incontinence care for two residents (R519 and R520) of 14 residents reviewed, resulting in the potential to cause skin breakdown, discomfort and poor moisture management. Findings Include:On 4/15/2026 at 5:18 AM, a strong smell of urine was noted to come from the room of R519 and R520. At that time, Licensed Practical Nurse (LPN) C was interviewed regarding the smell of urine. LPN C said they did notice a smell and the room floor was sticky. At 5:43 AM Certified Nurse Aid (CNA) B took a white incontinence brief and towels in the room of R519 and R520. CNA B left the items and exited the room. At 5:58 AM (CNA) B returned to the room and asked R519 about performing incontinence care. [...]

Inspectors wroteThis citation pertains to intakes 2980193 and 2962412Based on observation, interview and record review the facility failed to ensure that one resident (R519) with a stage III pressure injury received necessary treatment and services to promote healing of six reviewed for wound care.

Inspectors wroteThis citation pertains to intake #2786224 Based on observation, interview and record review, the facility failed to ensure training, evidence of skills performed, and confirmed Certified Nurse Assistants (CNAs) were capable of delivering safe care to vulnerable residents, resulting in one resident (R511) of three residents reviewed for falls, resulting in R511 sustaining a closed head injury, abdominal hematoma, and a closed fracture of the femur, requiring hospitalization. This has the potential to affect all residents

Inspectors wroteBased on observation, interview and record review the facility failed to ensure operational, systemic systems were maintained to ensure the highest, practicable, physical, mental and psychosocial well-being of each resident, resulting in multiple complaints related to Quality of Care and Quality of Life in the facility. This deficient practice has the potential to affect all residents residing in the facility.

Inspectors wroteThis citation pertains to intake: 2785066. Based on interview and record review the facility failed to thoroughly investigate an allegation of an injury of unknown origin for one (R603) of three residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake: 2785066. Based on interview and record review the facility failed to follow physician orders for one (R603) of three residents reviewed for standards of practices resulting in R603 not having a urinalysis collected in a timely manner.

Inspectors wroteThis citation pertains to intake 2723333. Based on observation, interview and record review, the facility failed to protect one resident (R905) from the right to be free from verbal abuse and neglect by Certified Nurse Assistant (CNA) A, out of five residents reviewed for abuse. This failure resulted in R905 experiencing degradation, humiliation, and episodes of tearfulness when retelling the incident.

Inspectors wroteThis citation pertains to intakes 2724140 and 2718825. Based on interview and record review the facility failed to adequately document, monitor and access one resident (R901) out of three residents reviewed for wound care, resulting in the potential for delayed treatment and worsening of R901's frost-bitten feet.

Inspectors wroteThis citation pertains to 2663449 and 2668212. Based on interview and record review, the facility failed to ensure resident-to-resident verbal and physical abuse did not occur for two residents (R104 and R105), resulting in verbal and physical abuse.

Inspectors wroteThis citation pertains to intakes 2650924, 2663449, and 2668212. Based on interview and record review, the facility failed to implement policies and procedures for ensuring proper reporting of abuse to the State Agency for four residents (R102, R103, R104, R105) out of eight resident reviewed for abuse, resulting in the likelihood of further abuse and subsequent physical or psychological distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure showers for (R104) and grooming (R111) were provided per resident's preference resulting in unmet care needs and resident dissatisfaction.

Inspectors wroteThis citation pertains to 2598018. Based on observations interview, and record review, the facility failed to implement intervention to prevent falls in a timely manner for one resident (R101).

Inspectors wroteThis citation pertains to 2598018. Based on observation, interview, and record review, the facility failed to ensure nutritional supplement administration and hospital transfer documentation were accurately documented for two residents (R101and R104) and failed to ensure a complete medical record that documented a resident-to-resident altercation for one resident (R104), resulting in the potential for staff and providers lacking accurate information to care for residents.

Inspectors wroteBased on interview and record review, the facility failed to initiate Cardiopulmonary Resuscitation (CPR) for one resident (R108-with full code status by default on [DATE]) of one resident reviewed for CPR. R108 was found unresponsive with absent vital signs and CPR was not initiated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food contact and non-food contact surfaces were adequately cleaned and sanitized. This deficient practice had the potential to affect all residents who consumed food from the kitchen, resulting in the increased potential for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly dispose of rubbish and maintain cleanliness of the outside garbage area, resulting in a visually unappealing property and the potential for harborage of pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure consistent proper working order of the handwashing sink faucet, commercial ice dispenser, and walk-in freezer which had the potential to affect all residents that eat from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to obtain consent for psychotropic medications (drugs that affect behavior, mood, thoughts, or perception) use for two residents (R2, R4) out of five residents sampled for unnecessary medications.

Inspectors wroteThis citation pertains to intake # 1221139 Based on interview and record review the facility failed to ensure security and accountability for 30 oxycodone-acetaminophen 10-325 mg (milligram) tablets for one resident (R1) of three reviewed for drug diversion of controlled substances, resulting in 30 missing oxycodone-acetaminophen without resolution and a delay in pain relief. A review of the facility's incident report was received by the State Agency via online submission on: 6/23/25 revealed the following: Incident Summary On 6/22/25, the facility's routine narcotic count revealed a discrepancy involving (drug name, Oxycodone 10-325mg prescribed to resident R1. A total of 30 tablets were unaccounted for during the beginning of the day shift count. Upon further review of the narcotic sign-out sheet along with the blister pack of medication noted missing. [...]

Inspectors wroteThis citation pertains to intake # 1221139 Based on interview and record review the facility failed to report to law enforcement drug diversion of 30 Oxycodone tablets (controlled substances) for one resident (R1) of three residents reviewed for missing medications.

Inspectors wroteThis citation pertains to intake # 1221139 Based on interview and record review the facility failed to ensure the misappropriation of 30 oxycodone-acetaminophen 10-325 mg (milligram) tablets was thoroughly investigated for one resident (R1) of three reviewed for drug diversion of controlled substances, resulting in 30 missing oxycodone-acetaminophen without resolution and a delay in pain relief. The review of the incident report revealed the following: Incident Summary On 6/22/25, the facility's routine narcotic count revealed a discrepancy involving (drug name, Oxycodone 10-325mg prescribed) to resident (R1). A total of 30 tablets were unaccounted for during the beginning of the day shift count. Upon further review of the narcotic sign-out sheet along with the blister pack of medication noted missing. Investigation initiated immediately by the Director of Nursing. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate transfer documentation was in place for one resident (R6) out of one resident reviewed for hospital transfer, resulting in the lack of information regarding resident's health status, safety, and transfer arrangements upon transfer from the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Pre-admission Screening and Annual Resident Review (PASARR - determines whether or not an individual who has a diagnosis of Mental Illness or Intellectual/Developmental Disability meets the criteria for a nursing home and their needs are met) Level I (3877) was completed for one resident (R4) out of two residents reviewed for PASARR screening.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely pain management for one resident (R120) out of five residents reviewed for pain management, resulting in a shortened therapy session and resident pain and discomfort.

Inspectors wroteBased on interview and record review, the facility failed to provide morning meals for two residents (R62, R91) who attended dialysis out of three residents sampled for dialysis services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper cleaning and disposal of loose medications were conducted per professional standards of practice for one medication cart (Cherry Hall Cart) of three medication carts observed for medication storage and cleanliness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the dignity of one (R402) of three residents reviewed for dignity and respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were administered in accordance with professional standards of practice for one (R403) of four residents reviewed for medication administration resulting in inaccurate medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medications were administered via the correct route via PEG Tube (percutaneous endoscopic gastrostomy tube, a feeding tube inserted through the abdominal wall into the stomach, used for patients who cannot eat normally) for one (R403) of four residents reviewed for medication administration resulting in the potential for silent aspiration (when food, liquid, or other materials are inhaled into the airway without the individual realizing it, potentially leading to serious health issues like aspiration pneumonia and even death).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records were accurate for one (R403) of six residents reviewed for accurate medical records.

Inspectors wroteThis citation pertains to intake MI000149346. Based on observation, interview, and record review the facility to provide shower linens (towels and washcloths) for two residents (R112 and R113) resulting in an unclean, uncomfortable environmental where residents went without shower linens and had to purchase and share personal items. This deficient practice affected all 107 residents residing in the facility. Review of an anonymous intake, dated 1/6/25, noted the following on 1/24/25, Complainant states for at least the past 2 weeks the facility has been without towels and washcloths for the residents. The complainant states staff have been instructed to cut up gowns to use to wash and dry residents. Complainant states they have a loved one at the facility and staff left feces on the resident after attempting to clean them up with a gown. [...]

Inspectors wroteThis citation pertains to intake MI00149294. Based on interview and record review, the facility failed to ensure that private property was protected from theft by an employee for one resident (R102) of five reviewed for misappropriation of property, resulting in an employee's deliberate removal of R102's earbuds from possession.

Inspectors wroteThis citation pertains to intakes MI00149008 and MI00148990. Based on interview and record review, the facility failed to ensure proper transfer assistance for two residents (R102 and R103) out of four residents reviewed for accidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the correct amount of TPN (total parenteral nutrition used to provide complete nutrition directly into the bloodstream) was administered for one resident (R102), out of three residents reviewed for altered methods of receiving required nutrients.

Inspectors wroteBased on interview and record review, the facility failed to consistently change the PICC (peripherally inserted central catheter) line tubing according to physician's order for one resident (R102) out of three residents reviewed for altered methods of feeding. (The parenteral method delivers nutrition intravenously which increases the risk of infection).

Inspectors wroteThis citation pertains to intake MI00147516. Based on interview and record review the facility failed to inform a cognitively impaired resident's representative of a change in condition for one resident (R902) out of three residents reviewed for resident's rights, resulting in a missed opportunity for R902's representative to participate in medical decisions.

Inspectors wroteThis citation pertains to intake MI00147516. Based on interview and record review the facility failed to identify a resident with dentures and implement adequate oral care for one resident (R902) out of three residents reviewed for Activities of Daily Living (ADLs).

Inspectors wroteThis citation pertains to intake MI00146875. Based on interview and record review the facility failed to follow a physician's order in a timely manner to insert an indwelling urinary catheter for one (R805) of three residents reviewed for quality of care resulting in the potential for the resident to develop a urinary tract infection.

Inspectors wroteThis citation pertains to intakes MI00144625 and MI0014484. Based on observation, interview, and record review the facility failed to provide sufficient nursing staff to meet the needs of residents' dependent upon staff for care needs. This deficient practice has the potential to affect all 72 residents that reside at the facility. On 7/9/24 at 9:52 a.m. during the Entrance Conference, it was confirmed the resident census was 72 (32 residents on the second floor; 40 residents on the first floor). On 7/09/24 at 10:46 a.m. during the initial pool process, the second floor had two nurses and two nurse aides to provide care for 32 residents. On 7/9/24 at 10:50 a.m. Unit Manager H said there is usually two nurse aides for 32 long term residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse (excluding the Director of Nursing) was on duty for eight consecutive hours a day, seven days a week; resulting in the potential for inadequate coordination of emergent or routine care that could cause negative outcomes. This deficient practice had the potential to affect all 72 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide accurate and complete information for Advance Medical Directives (AMD), legal documents that allow a person to identify decisions about end-of-life care ahead of time, for eight residents (R12, R15, R16, R17, R19, R21, R40, and R55) of 12 residents reviewed for AMDs resulting in the resident or their Legal Guardian (LG) not being fully informed of how to formulate an AMD and their preferences for medical care not to be followed by the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dignity was maintained for one resident (R21) of three residents reviewed for dignity, resulting in the resident expressing feelings of embarrassment and humiliation.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide showers for one (R21) of five residents reviewed for Activities of Daily Living (ADL'S), resulting in the resident not receiving scheduled showers.

Inspectors wroteThis citation contains two Deficient Practice Statements. Deficient Practice Statement #1. Based on observation, interview, and record review the facility failed to effectively communicate and collaborate care with hospice staff for one resident (R28) reviewed for hospice services resulting in R28 not receiving an Alternating Pressure Relief Mattress (APM).

Inspectors wroteBased on observation, interview, and record review the facility failed to schedule an ophthalmologist (eye doctor) appointment for one resident (R12) reviewed for vision services resulting in R12 having delayed treatment for cataracts.

Inspectors wroteBased on observation, interview, and record review the facility failed to label tube feeding (liquid nutrition provided by a tube to stomach) container and hydration flush bag for one resident (R60) out of two residents reviewed for nutrition, resulting in the potential for receiving the incorrect product and dosage.

Inspectors wroteBased on interview and record review the facility failed to ensure that the facility responded to pharmacist Medication Regimen Review (MRR) recommendations timely for one resident (R8) of five residents reviewed for a medication regimen review, resulting in the potential for the continuance of unnecessary medications and lack of communication of recommended medication changes.

Inspectors wroteThis citation pertains to intake #144271 Based on interview and record review the facility failed to obtain blood glucose levels per physician orders effecting one resident (R901) out of three residents reviewed for change in condition, resulting in unmonitored blood glucose levels. Review of an admission Record revealed, R901 admitted to the facility on [DATE] and discharged on 4/30/24 with pertinent diagnosis which included Sepsis, Type 2 Diabetes, and Severe Sepsis with Septic Shock. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R901 had no cognitive impairment with a Brief interview for Mental Status (BIMS) score of 14 out of 15 and required parenteral nutrition. Review of Physician orders revealed R901 had orders which included: Blood Sugar check two times a day for DM (diabetes mellitus) with a starte date of 4/14/24 and an end date of 5/3/24. [...]

Inspectors wroteThis citation pertains to Intake MI00143275. Based on interview and record review, the facility failed to report an allegation of abuse for one resident (R502) of four residents reviewed for abuse.

Inspectors wroteThis citation pertains to Intake MI00143275. Based on interview and record review, the facility failed to investigate an allegation of abuse for one resident (R502) of four residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake MI00141653. Based on interview and record review the facility failed to administer intravenous fluids ordered by physician for one resident (R303) out of three residents reviewed for medication administration, resulting in R303 not receiving intravenous fluids as ordered by the physician.

Inspectors wroteThis citation pertains to MI00140483. Based on observation, interview, and record review, the facility failed to ensure the Cherry Hill shower room was maintained in a clean and sanitary manner, resulting in the potential to spread harmful pathogens and residents' environment not being clean and homelike.

Inspectors wroteThis citation pertains to MI00140483. Based on observation, interview, and record review, the facility failed to properly clean resident refrigerators, date-label opened food, and remove expired/undated food from two resident refrigerators, resulting in the potential for food borne illness.

Inspectors wroteThis citation pertains to intake MI00139751. Based on interview and record review, the facility failed to develop a skin alteration care plan for one resident (R420) of five residents reviewed for pressure ulcers, resulting in the potential for the resident to not receive the proper interventions/treatment.

Inspectors wroteThis citation pertains to MI00136584, MI00138968, MI00140212, and MI00140483. Based on interview and record review, the facility failed to provide showers according to resident's preference and/or on their scheduled shower days for three (R403, R416, and R426) of fifteen residents reviewed who were dependent on staff for performance of activities of daily living (ADLs), resulting in untimely and unmet care needs regarding personal hygiene.

Inspectors wroteThis citation pertains to MI00140212. Based on interview and record review, the facility failed to consistently document the provision of meal assistance for one resident (R426), deemed to be at nutrition risk, out of eleven residents reviewed for food intake/feeding assistance, resulting in the potential for additional nutrition concerns to go undetected and compromise in nutritional status.

Inspectors wroteThis citation has two deficient practices. Deficient Practice #1: Based on interview and record review, the facility failed to implement appropriate safety interventions for one resident (R71) out of eight residents reviewed for accidents, resulting in a fall with injury (femoral fracture), and an emergency hospital encounter.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary kitchen, plumbing, and an accessible hand sink, resulting in the potential contamination of food and equipment, and potential for discouragement of hand hygiene, affecting all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure staff adhered to contact precautions during meal pass; 2. Ensure a meal cart was properly cleaned and sanitized for meal distribution to the residents; and, 3. Educate residents on the risks of sharing electronic cigarettes. These deficient practices resulted in the potential for the spread of harmful pathogens among the residents in the building.

Inspectors wroteThis citation pertains to Intakes MI00134525, MI00134776, MI00135107, and MI00135738. Based on observation, interview, and record review, the facility failed to provide shaves, nail care, and scheduled showers for seven residents (R26, R73, R228, R248, R429, R480, and R487) out of ten residents reviewed for Activities of Daily Living (ADLs), resulting in unmet ADL needs, a feeling of frustration, and the potential for loss of dignity.

Inspectors wroteThis citation pertains to Intake MI00134180. Based on observation, interview, and record review, the facility failed to ensure meals were served at palatable temperatures for multiple residents on the Medbridge Unit, Resident #65, an unidentified resident, and four out of seven anonymous residents attending a Resident Council Meeting, resulting in resident hunger, dissatisfaction with the meal experience, and the potential for unmet nutritional needs.

Inspectors wroteThis citation pertains to Intake MI00135738. Based on interview and record review, the facility failed to conduct an initial care conference for one resident (R248) of two residents reviewed for choices, resulting in the missed opportunity for the resident and/or resident representative to participate in the care planning process and make choices about the resident's daily life.

Inspectors wroteThis citation pertains to Intake MI00133152. Based on observation, interview, and record review, the facility failed to administer medications timely and per physician's orders for one resident (R59) of six residents reviewed for medication administration, resulting in the potential for less than therapeutic effect of the prescribed medication when medications were not taken properly.

Inspectors wroteThis citation pertains to intake number MI00135633. Based on interview and record review, the facility failed to provide transportation for one resident (R431) scheduled for a follow up orthopedic appointment out of one resident reviewed for appointments, resulting in the potential for a delay and frustration in treatment due to multiple missed appointments by the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely PICC (peripheral inserted central catheter) line/dressing changes, label an IV (Intravenous, therapy that delivers liquid substances directly into a vein) bag, date an IV tubing, and obtain physician's order for PICC line maintenance for two residents (R43 and R485) reviewed for IV Parenteral fluid resulting in the potential for medication delay and error and a bacterial infection originating at the PICC line site.

Inspectors wroteBased on interview and record review, the facility failed to ensure a physician responded to a pharmacy recommendation for one resident (R26) out of five residents reviewed for pharmacy recommendations resulting in a missed opportunity for collaboration on a medication recommendation and the potential for unmet medical care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a smoking policy that addressed the use of electronic cigarettes (e-cigs) for residents of the facility. This deficient practice resulted in two residents (R128 and R230) using e-cigs on the property of a non-smoking facility and staff not being adequately educated about the use of e-cigs.