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F0609
D

Failure to Timely Report Alleged Sexual Abuse Between Cognitively Impaired Residents

St. Louis, Michigan Survey Completed on 08-13-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to timely report an allegation of sexual abuse involving two residents, both with severe dementia and significant cognitive impairment. A certified nurse aide discovered a female resident pulling up her pants and a male resident, naked and with an erection, in the same room. The incident was reported to the floor nurse, who then contacted the Clinical Care Coordinator/Registered Nurse (CCC/RN). The CCC/RN assessed both residents and found no physical signs of sexual intercourse or injury but did not report the incident to the abuse coordinator as required. The Nursing Home Administrator/Abuse Coordinator (NHA/AC) was not informed of the incident until the following morning during a routine meeting and only became fully aware of the details after a concerned staff member called later that day. The incident was not reported to the State Agency, despite both residents being unable to consent due to cognitive impairment and the situation meeting the definition of an alleged violation. The failure to report the suspected abuse in a timely manner constituted the deficiency.

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