The attack happened on October 11 when Resident 104 directed profanity toward Resident 105 in the hallway. Resident 105 verbally confronted her, then physically assaulted her by grabbing her hair and slamming her on the floor. Family requested hospital evaluation.
But the transfer form sent to the emergency room listed "fall" as the reason for hospitalization, not assault.
Licensed Practical Nurse and Unit Manager I told federal inspectors the purpose of transfer forms 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 correct information wasn't given to the hospital. "A physical exam and assessment for a fall would be different than a physical exam and assessment following a physical altercation," the nurse said.
This wasn't the first incident between the same residents. On September 14, Nurse L witnessed Resident 105 pushing Resident 104 during morning medication rounds. Resident 104 told staff "she was hit and pushed by another resident, and she is too old to fight other people."
Staff wrote an incident report but marked it "Privileged and Confidential. Not part of the Medical Record."
The Director of Nursing confirmed during inspection that the September incident was never documented in the medical record, calling this "a necessary step to ensure a complete medical record and effective communication among staff."
Facility policy requires all treatments, services, and care to be documented factually and completely in medical records by the end of each shift. The policy states documentation should be "accurate, relevant, and complete."
During the exit conference, administrators offered no additional documentation when asked.
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.