Optalis Troy: Wrong Address Sent Wound Patient to Wrong Doctor - MI
The resident, identified in inspection records only as R302, was a patient at Optalis Health and Rehabilitation of Troy, a rehabilitation facility at 925 W. South Blvd. He had a wound to his right fifth digit, the small toe, and was under the care of an outside wound surgeon, Dr. K. On July 31, 2025, staff arranged transportation to see Dr. K. He was sent to the wrong location.
Unit Clerk G, who handles transportation scheduling, told inspectors she had been instructed to send R302 to see Dr. K and had the order in front of her documenting location A. She arranged the ride, and only afterward learned he was supposed to go to location B. She rescheduled the appointment for August 7, a week later.
The Director of Nursing said she was aware R302 had been sent to the wrong office but was not certain why it happened.
During that week, and for much of his stay, R302 was treating the wound himself. The wound nurse assigned to his care, WN I, confirmed the wound was declining from the time he arrived at the facility until his discharge. Staff knew about the self-treatment. The problem was communication.
R302 had a language barrier. The facility had a system to address exactly that, a real-time remote translation service called MARTTI, which stands for My Accessible Real Time Trusted Translator. WN I told inspectors she did not use it. The Director of Nursing said she did not believe any staff used it with R302.
Instead, staff relayed information through R302's daughter.
WN I said she and another wound nurse, WN H, had both been assigned to R302's care. She said she was not certain she was the person who provided the wrong address for the transportation. When asked what the wound treatment consisted of, she said she was not certain of the specifics but knew a change had been made from betadine to Medihoney as the wound continued to worsen. The switch was an attempt to reverse the decline.
It did not work. The wound kept deteriorating.
The question of whether R302 should have been on the antibiotic vancomycin added another layer of uncertainty. A note from the facility's nurse practitioner, identified as NP M, referenced starting R302 on Vanco on July 14, 2025. No order for the drug existed in the chart. The Director of Nursing told inspectors the written reference to remaining on Vanco was most likely a documentation error. Inspectors attempted to reach NP M on September 4 at approximately 1:26 p.m. A message was left. No return call came.
The inspection, a complaint survey, was conducted September 4, 2025. Inspectors cited the facility under federal tag F0684, which covers the standard of care residents receive, noting the level of harm as minimal or potential. The citation covered a few residents.
The facility's own wound care policy calls for weekly evaluation of skin changes and an individualized care plan with specific interventions. Its change-in-condition policy states that residents will be routinely monitored and evaluated to determine the need for additional health services, and lists changes in skin color or condition as among the signs requiring attention.
R302's wound met that description from the day he arrived. He was discharged before inspectors finished their review.
Whether the week's delay in reaching Dr. K, the self-treatment that staff could not effectively address without a translator, or the uncertainty about the vancomycin order contributed to the final condition of his toe, the inspection report does not say. What it records is a wound that worsened throughout his stay, a translation tool that went unused, and an appointment that sent him to the wrong place.
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.
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 Troy in Troy, MI was cited for violations during a health inspection on September 4, 2025.
The resident, identified in inspection records only as R302, was a patient at Optalis Health and Rehabilitation of Troy, a rehabilitation facility at 925 W.
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.