The violent October 12 altercation at Optalis Health and Rehabilitation of Canton began when one resident directed profanity at another in the hallway. The confrontation escalated when the first resident grabbed the other's hair and threw her to the ground.
Staff transferred the injured resident to the emergency room at her family's request. But the hospital transfer form listed a fall as the reason for the visit, not the physical assault.
"The correct information on R104's eINTERACT form was not given to the hospital," the facility's licensed practical nurse and unit manager told inspectors on November 25. She explained that "a physical exam and assessment for a fall would be different than a physical exam and assessment following a physical altercation."
The same two residents had fought before. On September 14, a nurse witnessed one resident pushing the other during morning medication rounds. The pushed resident told staff "she was hit and pushed by another resident, and she is too old to fight other people."
Staff completed an incident report for the September fight but never documented it in the resident's medical record. The facility's director of nursing confirmed to inspectors that this violated their own policy requiring complete documentation of all incidents.
The nursing home's documentation policy states that records "should be factual, objective, and resident centered" and "accurate, relevant, and complete." The policy requires staff to document incidents "at the time of service or by the end of the shift."
During the December 1 inspection exit conference, administrators offered no additional documentation when inspectors asked for more information about the incidents.
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.