Optalis Canton: Missing Oxycodone, Falsified Records - MI
The 30 missing tablets were part of a larger delivery. On June 16, 2025, Nurse Manager E signed for three controlled substance cards from the pharmacy: one card containing 30 tablets of Clonazepam and two cards each containing 30 tablets of Oxycodone, 60 Oxycodone tablets in total. By June 21, five days later, a nurse identified in the inspection report as Nurse AA called the pharmacy because a resident identified only as R1 had run out of Oxycodone. The pharmacy told her they had delivered 60 tablets on June 16. R1 should have had enough.
They didn't.
The Director of Nursing, when asked by inspectors to explain the discrepancy, said she ordered Oxycodone pulled from the facility's Pyxis machine, an automated dispensing system, to cover the gap. Records show that Oxycodone 10-325mg was removed from the Pyxis at 12:02 p.m. on June 22. But R1's Medication Administration Record shows the drug documented as administered at 10 a.m. that same day, two hours before it was physically available according to both the Director of Nursing and Nurse AA.
Someone recorded giving a controlled narcotic that did not yet exist in the medication supply.
Inspectors reviewed the facility's own investigative report during the August 18 visit. That document named an agency nurse, identified in the inspection report as Agency Nurse V, as the staff member who had access to the medication cart during the relevant shift and who was the alleged person responsible for removing the Oxycodone. When inspectors asked the Director of Nursing about that finding, her answer shifted.
"I'm not sure who took the Oxycodone," she said. "It could be anyone at this point. I don't know, I don't know, I don't know."
She also confirmed that the narcotic tracking sheet had been removed from the narcotic book. That sheet is the paper record of every controlled substance dispensed from the cart, who gave it, to whom, and when. Without it, there is no way to reconstruct what happened to the 30 tablets between June 16 and June 21.
The Nursing Home Administrator was interviewed on August 12, six days before the inspection formally concluded. Asked about the facility's expectations around controlled substance compliance, the administrator said nurse staff must adhere to policies and procedures. The facility's own abuse policy, last updated in May 2023, states that residents have the right to be free from misappropriation of their property and that the facility will provide ongoing oversight and supervision of staff to ensure its policies are carried out.
What the inspection record shows is something different. A card of 30 Oxycodone tablets went missing. The document that would have tracked those tablets was removed from the book. A medication administration record was completed for a drug that hadn't been dispensed yet. And two months after the discovery, the Director of Nursing told inspectors she had no idea who was responsible, even as her own investigative report had named a suspect.
Oxycodone is a Schedule II controlled opioid, prescribed for pain serious enough that 10-325mg tablets, a combination of oxycodone and acetaminophen, are among the stronger formulations in routine nursing home use. R1's prescription for it suggests a resident managing significant pain. Whether R1 received every dose they were supposed to receive between June 16 and June 21 cannot be determined from what remains of the records, because the records that would show it are gone.
The Pyxis machine, which the Director of Nursing turned to once the shortage became apparent, is designed specifically to prevent this kind of gap. It logs every removal with a timestamp and a user credential. The June 22 record at 12:02 p.m. is precise. The handwritten medication administration record showing 10 a.m. is not. That two-hour difference is the kind of discrepancy that, in a facility with intact narcotic records and a functioning oversight system, would have been caught and explained. Here, it appears in the inspection report without any explanation from staff.
Inspectors cited the facility under F0602, which covers misappropriation of resident property and resident rights protections. The level of harm was cited as minimal harm or potential for actual harm, affecting few residents. That classification reflects the regulatory framework's assessment of documented impact, not necessarily the full scope of what occurred. Thirty tablets of a controlled opioid are unaccounted for. The tracking sheet is gone. The person the facility's own investigation identified as having had access to the cart during the relevant shift was never definitively named by the Director of Nursing when inspectors asked her directly.
What R1 experienced during the days that Oxycodone was missing from the cart, before Nurse AA called the pharmacy on the morning of June 21, is not recorded in the inspection report. The report notes only that Nurse AA called because R1 was out of medication. It does not say how long R1 had gone without it, or whether anyone at the facility had noticed before the nurse made that call.
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: July 21, 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 30 missing tablets were part of a larger delivery.
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.