Optalis Canton: Missing Oxycodone, Falsified Records - MI
"I don't know I don't know I don't know," she told inspectors. "It could be anyone at this point."
That answer, offered to federal investigators at a licensed nursing home responsible for the care of some of Michigan's most vulnerable residents, captures what inspectors found when they arrived at the facility on Lilley Road in August: a controlled substance had vanished, a key document had been destroyed, and a medication record had been falsified to conceal what happened.
The inspection, completed August 18, 2025, was triggered by a complaint. What inspectors documented was a cascade of failures — missing narcotics, a missing narcotic sheet, and a medication administration record that listed a dose of Oxycodone as given at 10 a.m. on June 22 when, by the director of nursing's own account and that of the nurse who worked that shift, no Oxycodone was available at 10 a.m. that day.
The drug didn't arrive until after noon.
On the morning of June 21, a nurse identified in the report as Nurse AA called the pharmacy. The resident the Oxycodone had been prescribed for, referred to in the report as R1, was out of medication. The pharmacy pushed back: they had delivered 60 tablets on June 16. R1 should have had plenty left.
The director of nursing then called the pharmacy herself and arranged for Oxycodone to be pulled from the Pyxis machine, the automated dispensing system the facility uses to manage and track medications. A report she later showed to inspectors showed the Oxycodone was removed from the Pyxis at 12:02 p.m. on June 22, 2025, and administered to R1.
But R1's Medication Administration Record told a different story. According to the record, the Oxycodone had been given at 10 a.m. — two hours before it was retrieved from the Pyxis, and two hours before it was physically possible for R1 to have received it.
Someone had documented a medication administration that could not have happened when the record said it happened.
The narcotic sheet that should have tracked every Oxycodone tablet since the June 16 delivery was gone. The director of nursing confirmed it had been removed from the narcotic book. Sixty tablets had been delivered. The sheet that would show how many were administered, to whom, and when had disappeared along with the tablets themselves.
The facility's own abuse and misappropriation policy, last updated in May 2023, requires that allegations of misappropriation of resident property be reported immediately to the administrator and to the state survey agency. Controlled substances prescribed to a resident are that resident's property. Their disappearance, under any reading of that policy, was something the facility was obligated to report.
The nursing home administrator, interviewed on August 12, was asked about expectations for controlled substance compliance. The response was a sentence about policy: "The nurse staff must adhere to policies and procedures around controlled substance."
What the administrator did not address, and what the inspection report does not resolve, is who took the Oxycodone, when, or why the narcotic sheet was removed. The report does not indicate that any staff member was identified as responsible. It does not indicate that law enforcement was contacted. It records only what inspectors found: missing drugs, a missing log, a falsified record, and a director of nursing who said she didn't know who was responsible.
Oxycodone 10-325mg is a Schedule II controlled substance. The 10 milligrams refers to oxycodone, an opioid. The 325 milligrams refers to acetaminophen. At that dose, prescribed to a nursing home resident, each tablet represents a meaningful pain management intervention for someone who likely has limited ability to advocate for themselves if their medication goes missing.
The resident in this case had a prescription for it. The pharmacy confirmed delivery. And then 60 tablets were gone, with no documentation of where they went and no one willing or able to say who took them.
The inspection cited the facility under F0609, which covers the obligation to report and investigate allegations of abuse, neglect, and misappropriation. The level of harm was assessed as minimal harm or potential for actual harm — a designation that reflects the regulatory framework's assessment of risk to the resident, not the severity of the underlying conduct. A resident going without prescribed pain medication because that medication has been stolen is not a paperwork problem. It is a person in pain.
The inspection report does not describe R1's diagnosis, age, or condition beyond the fact that they had a prescription for a strong opioid painkiller. It does not say whether R1 went without medication during the days between June 16 and June 21, when Nurse AA discovered there was nothing left in the cart. It does not say whether anyone told R1 what had happened to their prescription.
What it says is that 60 tablets were delivered on a Monday, and that by the following Sunday, a nurse was calling the pharmacy because there was nothing left, and the record of where the tablets went had been removed from the book where it was supposed to be kept.
The director of nursing's words in the inspection report are worth sitting with. Not the policy language, not the administrator's answer about adherence to procedures, but the actual human response of the person who runs nursing at this facility when asked who took a controlled substance from a resident's medication supply: "I don't know I don't know I don't know."
That repetition is not a transcript error. It is what she said.
Optalis Health and Rehabilitation of Canton operates at 7025 Lilley Road. The inspection was conducted by the Centers for Medicare and Medicaid Services. The plan of correction, if one has been submitted, is available through the nursing home or the Michigan state survey agency.
R1's Oxycodone was eventually administered on June 22, after noon, once the Pyxis machine provided a replacement supply. Whether the pain was managed in the days before that, and what happened to the original 60 tablets, the inspection report leaves unanswered.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
Optalis Health and Rehabilitation of Canton in Canton, MI was cited for violations during a health inspection on August 18, 2025.
"I don't know I don't know I don't know," she told inspectors.
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.