Optalis Troy Sent Blind Dementia Resident to Appointments Alone - MI
The resident, identified in inspection records only as R303, was admitted to Optalis Health and Rehabilitation of Troy in April 2025. Her diagnoses included dementia, convulsions, and blindness in her right eye. A physician and a licensed psychologist had both signed a formal capacity assessment in March 2025 concluding she lacked the ability to make reasoned medical decisions or provide informed consent. The document cited impaired insight, impaired reasoning, and impaired thinking and memory. Her care plan, initiated the same month she arrived, stated plainly that her power of attorney had determined she required long-term placement and 24-hour care and supervision.
On August 14, 2025, a physician order confirmed she had an appointment at 2:00 p.m. The facility arranged wheelchair transportation through an outside company and sent her alone. According to the complaint that triggered the inspection, she was left in the lobby of the doctor's office with no caretaker from the facility.
It was not the first time.
When inspectors interviewed the unit clerk responsible for scheduling and arranging transportation on September 4, she explained that until a couple of weeks earlier, staff had been told they did not accompany residents to appointments. The policy had recently changed, she said, so that a staff member now went along if a resident was incompetent. Asked how she determined whether a resident was incompetent, she said she would go talk to the resident herself, or ask other staff. She confirmed R303 had been sent alone.
The unit manager, asked the same questions minutes later, said it depended on whether the resident was competent. When the conversation turned specifically to R303, she said she could not answer and would need to speak with the Director of Nursing.
The Director of Nursing told inspectors she had thought R303's family was going to meet her at the appointment. She confirmed the facility used outside wheelchair transportation companies, not a staff-driven van. When an inspector asked directly why a resident whose care plan required 24-hour supervision had been placed in a transportation van and sent out of the facility alone, the Director of Nursing acknowledged the concern.
The administrator, interviewed that afternoon, was presented with the same contradiction: a care plan mandating round-the-clock supervision, a resident sent repeatedly to medical appointments without anyone from the facility present. The administrator also acknowledged the concern.
Neither offered an explanation for why the July 30 physician note, the one with the underlined demand, had not changed anything before August 14.
The inspection was triggered by a complaint and completed September 4, 2025. CMS classified the violation under the standard requiring facilities to prevent accidents, with a harm level of minimal harm or potential for actual harm.
R303's power of attorney had been designated as the responsible party for both her finances and her medical care precisely because she could not manage those things herself. The physicians who evaluated her in March had put it in writing. The consulting physician who saw her twice without records or a staff escort had put it in writing again, in capital letters, with emphasis. Her care plan had put it in writing from the beginning.
She was sent alone anyway, left in a lobby, unable to explain to anyone in that office why she had come.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Optalis Health and Rehabilitation of Troy from 2025-09-04 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Optalis Health and Rehabilitation of Troy in Troy, MI was cited for violations during a health inspection on September 4, 2025.
The resident, identified in inspection records only as R303, was admitted to Optalis Health and Rehabilitation of Troy in April 2025.
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.