The October 12 incident began when one resident directed profanity at another in the hallway. The confrontation escalated when the first resident physically attacked the other, grabbing her hair and slamming her on the floor, according to an incident note reviewed by state inspectors.
The injured resident was transferred to the emergency room at her family's request. But the facility's transfer form listed a fall as the reason for hospitalization, not the assault.
Licensed Practical Nurse and Unit Manager I told inspectors on November 25 that the purpose of the transfer form "was to ensure that the hospital has accurate information regarding the transfer of a resident in order to provide correct treatment."
The nurse acknowledged the facility gave incorrect information to the hospital. She noted that "a physical exam and assessment for a fall would be different than a physical exam and assessment following a physical altercation."
This wasn't the first incident between the same residents. On September 14, staff witnessed one resident pushing the other during morning medication rounds. The injured resident told staff "she was hit and pushed by another resident, and she is too old to fight other people."
That September incident was documented only on an internal incident report marked "Privileged and Confidential. Not part of the Medical Record." The Director of Nursing confirmed to inspectors that the assault was never entered into the resident's medical record.
Facility policy requires staff to document all treatments, services, and care in medical records. The policy states documentation "should be factual, objective, and resident centered" and "accurate, relevant, and complete."
During the December 1 exit conference, the nursing home administrator and director of nursing offered no additional documentation when asked by inspectors.
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 2025-12-01 including all violations, facility responses, and corrective action plans.