Optalis Canton: Missing Oxycodone Investigation Failures - MI
That finding sits at the center of a complaint inspection completed August 18, 2025, at Optalis Health and Rehabilitation of Canton, a skilled nursing facility in Canton, Michigan. Federal inspectors cited the facility for failing to conduct a timely, thorough, and objective investigation after a controlled substance went missing, a deficiency tagged at a level of harm described as minimal harm or potential for actual harm.
The sequence of events began on June 16, 2025, when a resident received a dispensed quantity of 60 Oxycodone 10-325mg tablets from the pharmacy. Six days later, on June 22, the pharmacy was called for a refill. The pharmacy told the nurse who called, identified in inspection records as Nurse AA, that the refill request was coming too soon. The resident had just received 60 tablets. That meant roughly 30 tablets were unaccounted for.
Nurse AA called the Director of Nursing about the missing Oxycodone.
What happened next is where the investigation broke down. Nurse AA told inspectors that at the beginning of their shift on June 22, they had counted the narcotic cart. The count matched the narcotic sheet. Nothing appeared to be missing. Thirty tablets of a Schedule II opioid were gone, and the count came back clean.
That is not a coincidence. That is a documentation problem, a counting problem, or something worse. The inspection report does not reach a conclusion about which. What it records is that the facility's own investigation did not resolve the question either.
When inspectors interviewed the Nursing Home Administrator on August 13, 2025, they asked about the facility's expectations around controlled substance compliance. The administrator's answer was direct about what the rules were supposed to be and equally direct about what was actually happening. "The nurse staff must adhere to policies and procedures around controlled substances," the administrator said. Then came the admission: "Sometimes nurses will leave before counting the cart if the incoming nurse is late. That is not how it should be."
That sentence, offered by the facility's own top administrator, describes a routine breakdown in one of the most basic safeguards a nursing home has against narcotic diversion. Narcotic counts exist precisely to catch discrepancies at the moment of shift change, when one nurse hands accountability to another. If the outgoing nurse leaves before the incoming nurse arrives, that handoff never happens. The count gets done by one person instead of two. The chain of custody breaks.
The administrator acknowledged this was happening. Not as a rare exception. As something that sometimes occurs.
The facility's abuse policy, last updated May 24, 2023, states that residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property. It also states that investigations must be timely, thorough, and objective, and that staff must identify and interview all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others with knowledge of the allegations.
The inspection record does not document that those steps were completed in the weeks between June 22, when the missing tablets were discovered, and August 13, when federal inspectors arrived and began asking questions. The gap between discovery and documented investigative action is nearly eight weeks.
Thirty tablets of Oxycodone 10-325mg is not a small amount to lose track of. Each tablet contains 10 milligrams of oxycodone combined with 325 milligrams of acetaminophen. It is a combination opioid prescribed for moderate to severe pain, commonly used in nursing home populations recovering from surgery or managing chronic pain conditions. Sixty tablets dispensed on June 16 should have lasted through the end of the prescription period. They did not.
The resident whose prescription was involved is not named in the inspection report, and the report does not describe what effect, if any, the shortage had on that person's pain management or care. What the report does describe is a facility that, when confronted with evidence that a controlled substance had gone missing from a resident's supply, did not complete the investigation its own policies required.
Nurse AA's account raises a specific problem that the investigation apparently did not resolve. If the narcotic sheet showed 30 tablets at the start of the June 22 shift, and the count matched that sheet, then either the sheet was wrong, the count was wrong, or the tablets had already been removed and the documentation had been adjusted to conceal that. Any of those possibilities points toward a more serious failure than a simple miscounting error. None of them were resolved, at least not in any way documented in the inspection record.
The administrator's comment about nurses leaving before counts are completed adds a second layer to the problem. If shift-change counts were being skipped with any regularity, then the narcotic sheets themselves may not accurately reflect what was actually in the cart on any given day. A count that matches a sheet is only meaningful if the sheet was accurate to begin with.
Inspectors cited the facility under F0610, which covers the requirement to report and investigate allegations of abuse, neglect, and misappropriation. The deficiency was cited at the "few residents affected" scope level, meaning inspectors identified the problem as isolated rather than widespread. The harm level was listed as minimal harm or potential for actual harm, the lower end of the deficiency scale.
That designation reflects where inspectors drew the line based on what they could document. It does not resolve the question of where 30 oxycodone tablets went, or whether the resident who needed them received adequate pain management during the period they were missing, or whether anyone at the facility was ever held accountable for their disappearance.
The Nursing Home Administrator said nurses must adhere to policies and procedures. The administrator also said nurses sometimes do not. Thirty tablets of Oxycodone are gone. The investigation the facility was required to conduct did not produce answers that satisfied federal inspectors eight weeks after the shortage was discovered.
The narcotic sheet said everything was fine.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Optalis Health and Rehabilitation of Canton from 2025-08-18 including all violations, facility responses, and corrective action plans.
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.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 3, 2026 · Our methodology
Optalis Health and Rehabilitation of Canton in Canton, MI was cited for violations during a health inspection on August 18, 2025.
The sequence of events began on June 16, 2025, when a resident received a dispensed quantity of 60 Oxycodone 10-325mg tablets from the pharmacy.
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.