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F0609
D

Failure to Timely Report Suspected Abuse Allegation

Marshall, Michigan Survey Completed on 08-21-2025

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 ensure timely reporting of an abuse allegation to the State Agency involving a resident with severe cognitive impairment. A resident with a low BIMS score, indicating severe cognitive impairment and inability to consent, was alleged by their roommate to be involved in sexual activity with another person. The initial allegation was reported by a CNA to an LPN, but the LPN did not follow up to gather more information. The CNA reported the allegation again to the charge nurse and an RN during a subsequent shift, but the RN delayed action, waiting for the LPN to arrive before proceeding. The Nursing Home Administrator was not notified until the following morning. The incident was ultimately reported to the State Agency, but not until several hours after the initial allegation was made. The delay in reporting was due to a lack of immediate follow-up and communication among staff, including the LPN not investigating further and the RN waiting for confirmation from the LPN before taking action. The facility's failure to promptly report the suspected abuse as required resulted in a deficiency.

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