Optalis Health And Rehabilitation Of Canton

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

discharged on 9/28/25 and upon return to the facility on [DATE REDACTED], Resident R105 returned to the second-floor [NAME] Hill South unit.- On 10/11/25, Resident R105 was moved to the first-floor MedBridge unit. On 11/24/25 at 2:16 PM, Resident R104's Concerned Family Member (CFM) F reported that Resident R104 had been attacked by Resident R105 on two separate occasions. R104A review of the clinical record documented Resident R104 was admitted to the facility on [DATE REDACTED]. Resident R104's diagnoses included cerebral infarction, vascular dementia, and bipolar disorder. A MDS assessment dated [DATE REDACTED] documented intact cognition. A review of Resident R104's care plans documented in part:

The resident has a behavior problem r/t (related to) patient continuously yells at staff and others. Date initiated 6/13/25. A 9/14/25 incident report for Resident R104 documented in part the following: While doing the morning med pass, I saw (Resident R105) and (Resident R104) arguing and shouting to one another. Nurse L verbalized that

he saw (Resident R105) pushing (Resident R104). (Resident R104) verbalized that she was hit and pushed by another resident, and

she is too old to fight other people. Denies pain and discomfort. A 10/11/25 incident report for Resident R104 documented in part the following: A verbal and physical altercation occurred between (Resident R105) and (Resident R104) in

the hallway. The incident began when (Resident R104) directed profanity toward (Resident R105). (Resident R105) verbally confronted (Resident R104) which escalated into (Resident R105) physically assaulted (Resident R104). (Resident R104) said (Resident R105) pulled her hair. A 10/12/25 progress/incident note for Resident R104 documented in part the following: A verbal and physical altercation occurred between (Resident R105) and (Resident R104) in the hallway. The incident began when (Resident R104) directed profanity toward (Resident R105). (Resident R105) verbally confronted (Resident R104) which escalated into (Resident R105) physically assaulted (Resident R104) by grabbing her hair and slamming her on the floor. (Resident R104) was assisted back to her room, assessment completed. Family, MD (Medical Doctor), DON (Director of Nursing) and Administrator were notified. (Resident R104) was transferred to ER (emergency room) for evaluation per family request. During an

interview on 12/1/25 at 11:42 AM, the Nursing Home Administrator (NHA) acknowledged that the resident-to-resident verbal and physical altercation between Resident R104 and Resident R105 on 10/11/25 could have been prevented had Resident R105 remained on the first-floor MedBridge unit, rather than being moved back to the second-floor Cherry Hill South unit. The facility policy titled, Abuse, dated 5/24/23 was reviewed and documented in part the following:Residents have the right to be free from abuse.Prevention (of abuse) consists of facility systems designed to detect, identify, correct, and prevent the occurrence of abuse.Completing ongoing assessments and care planning for appropriate interventions, and monitoring of residents with behaviors, including but not limited to: verbally aggressive behaviors (screaming, cursing, demanding, insulting, etc, physically aggressive behaviors (hitting kicking, biting, spitting, throwing objects, threatening gestures, etc.)The facility will educate the staff in identifying abuse .Possible indicators of abuse include, but are not limited to: physical abuse of a resident observed.Any allegation of abuse must be immediately reported to the supervisor and the Abuse Prevention Coordinator. The Administrator initiates investigating any allegation of abuse against a patient.If a resident is the alleged perpetrator, the facility will ensure other residents are protected as determined by the circumstances, which may include but are not limited to resident room changes, increased supervision, or immediate transfer or discharge, if indicated.

On 12/1/25 at 12:30 PM during the exit conference, the NHA and DON did not offer additional documentation or information when asked.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Canton

7025 Lilley Road Canton, MI 48187

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

disease, immunodeficiency, type two diabetes mellitus, heart failure, and dependence on renal dialysis. Resident R103's quarterly MDS, dated [DATE REDACTED], indicated Resident R103 was cognitively intact with a BIMS score of 15/15. Resident R103 was dependent with assistance with Activity Daily Living Care.

The facility's Nursing Home Administrator (NHA) was interviewed on 11/25/2025 at 4:45 p.m. regarding the verbal altercation between Resident R102 and Resident R103. The NHA was asked when the resident-to-resident verbal altercation happened. The NHA stated, The nurse did not notify me until October 6, 2025. I should have been notified of the day it happened on October 2, 2025. I already in-serviced my staff on reporting abuse timely. Resident R104 and Resident R105

A review of the clinical record documented Resident R104 was admitted to the facility on [DATE REDACTED]. Resident R104's diagnoses included cerebral infarction, vascular dementia, and bipolar disorder. A Minimum Data Set assessment dated [DATE REDACTED] documented intact cognition.

A review of Incident/Accident reports for Resident R104 documented in part the following: September 14, 2025: While doing the morning med pass, I saw (Resident R105) and (Resident R104) arguing and shouting to one another. Nurse L verbalized that he saw (Resident R105) pushing (Resident R104). (Resident R104) verbalized that she was hit and pushed by another resident, and she is too old to fight other people. Denies pain and discomfort.

A review of the clinical record documented Resident R105 was initially admitted on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident R105's diagnoses included chronic obstructive pulmonary disease, adjustment disorder with mixed anxiety and depressed mood. A MDS assessment dated [DATE REDACTED] documented intact cognition.

During an interview on 12/1/25 at 11:42 AM, the Nursing Home Administrator (NHA) confirmed that the 9/14/25 incident between Resident R104 and Resident R105 was reportable to the State Agency but was not reported due to

an internal failure to notify her of the event.

The facility policy titled, Abuse, dated 5/24/2023, was reviewed and documented in part the following:

The facility will ensure that all allegations involving abuse .are reported immediately to the Administrator and: Reported to the State Survey Agency immediately but not later than two hours after the allegation is made if the allegation involves abuse or results in serious bodily injury .or Reported to the State Survey Agency no later than 24 hours if the allegation does not involve abuse an does not result in serious bodily injury.

On 12/1/25 at 12:30 PM during the exit conference, the NHA and Director of Nursing did not offer additional documentation or information when asked.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Canton

7025 Lilley Road Canton, MI 48187

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

LPN/UM I. Resident R111 said he wanted to be shaved on days he gets cleaned up. Resident R111 was just shaved while receiving care and was smiling and grinning during the interview. On 11/25/25 at 1:17 PM, CNA K said Resident R111 had a full beard, and it did not look like he had been shaved since admission. CNA K said Resident R111's beard was thick, and it took five to six razors to shave him. A facility policy titled, Activities of Daily Living (ADL), dated 12/7/23 was reviewed and documented in part:- Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal, and oral hygiene.- Appropriate care and services will be provided for residents who are unable to carry out ADL independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care).- The amount of assistance the resident needs to complete their ADL care will be documented in the resident's care plan. On 12/1/25 at 12:30 PM during the exit conference, the Nursing Home Administrator and DON did not offer additional documentation or information when asked.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Canton

7025 Lilley Road Canton, MI 48187

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

recovering from an acute stroke. PT E added that Resident R101 could not speak and had zero strength. He could not express himself or talk. His care plan should have reflected that he was dependent for bed mobility. On 11/25/25 at 4:12 PM, during a demonstration of the bed positions that Resident R101 was observed in during the survey, the Director of Nursing (DON) said that neither position would be considered a low position but instead would be considered a transfer position. The DON said keeping Resident R101's bed in a low position while

in it was an intervention for someone that had a fall. The DON acknowledged that a two-person assist for bed mobility was not initiated for Resident R101 until 9/22/25 and that dependence on bed mobility indicated he was

a two-person assist. The DON indicated that had Resident R101 been a two-person assist upon admission, his falls

on 7/12/25 and 9/20/25 may have been prevented. A review of the facility policy titled, Fall Management Guidelines, dated 12/13/23, documented in part the following:- Fall management goals: Reduce the risk of falls by intervening in modifiable risk factors. Reduce the risk of injuries as a result of a fall.- The facility staff, with input of the attending physician, will implement a resident-centered comprehensive care plan that addresses the fall management program, the goal for fall management, individualized interventions to address the resident's modifiable fall risk factors, interventions to try to minimize the consequences of risk factors that are not modifiable, and the plan for reduction of risk and or risk for injury related to falls. On 12/1/25 at 12:30 PM during the exit conference, the NHA and DON did not offer additional documentation or information when asked.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Optalis Health and Rehabilitation of Canton

7025 Lilley Road Canton, MI 48187

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

- 10/12/25 incident note: A verbal and physical altercation occurred between (Resident R105) and (Resident R104) in the hallway. The incident began when (Resident R104) directed profanity toward (Resident R105). (Resident R105) verbally confronted (Resident R104) which escalated into (Resident R105) physically assaulted (Resident R104) by grabbing her hair and slamming her on

the floor. Patient was assisted back to her room, assessment completed. Family, doctor, DON and Administrator were notified. (Resident R104) was transferred to ER (emergency room) for evaluation per family request. Resident R104's eINTERACT Transfer Form dated 10/11/25, documented that a fall was the reason for Resident R104's transfer to the hospital. On 11/25/25 at 12:15 PM, Licensed Practical Nurse (LPN)/Unit Manager (UM) I said the purpose of the eINTERACT form was to ensure that the hospital has accurate information regarding the transfer of a resident in order to provide correct treatment. LPN/UM I indicated the correct information on Resident R104's eINTERACT form was not given to the hospital. LPN/UM I indicated Resident R104 was transferred to the hospital following a resident-to-resident altercation. LPN/UM I added that a physical exam and assessment for a fall would be different than a physical exam and assessment following a physical altercation. A review of an incident report dated 9/14/25 involving Resident R104 documented in part the following: While doing the morning med pass, I saw Resident R105 and Resident R104 arguing and shouting to one another. Nurse L verbalized that he saw Resident R105 pushing Resident R104. Resident R104 verbalized that she was hit and pushed by another resident, and she is too old to fight other people. Denies pain and discomfort. Immediate action taken: Observed patient, conducted skin assessment to Resident R104, no bruises nor injury noted. Resident R104 denies pain and discomfort. The verbiage at the bottom of the incident report documented, Privileged and Confidential.Not part of the Medical Record. During an interview on 12/1/25 at 11:17 AM, the DON confirmed that the 9/14/25 incident, in which Resident R104 was pushed by another resident, was not documented in the medical record. The DON indicated this was a necessary step to ensure a complete medical record and effective communication among staff. A review of the facility policy titled, Documentation in the Medical Record, dated 1/8/25 revealed the following:- The following information is to be documented in the resident medical record: Physicians, nurses, and other licensed professionals progress notes. Medication administration.

Treatments or services performed.- Principles of documentation include, but are not limited to: Documentation should be factual, objective, and resident centered.- Documentation should be accurate, relevant, and complete.- Documentation should be completed at the time of service or by the end of the shift in which the evaluation, observation, or care service occurred. On 12/1/25 at 12:30 PM during the exit conference, the NHA and DON did not offer additional documentation or information when asked.

Event ID:

Facility ID:

If continuation sheet