F0600

G

Failure to Protect Cognitively Impaired Residents From Sexual Abuse by a Known Wanderer

Troy, Michigan Survey Completed on 03-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to protect cognitively impaired residents from sexual abuse by another resident with known wandering and sexually focused behaviors. One resident with Parkinson’s disease and dementia, who had a BIMS score of 5 and a court-appointed guardian due to legal incapacity, had multiple documented episodes of wandering into other residents’ rooms, entering roommates’ space, and looking for his spouse, which upset other residents. Nursing notes over several months described this resident stumbling into another resident’s room, being threatened by another resident to leave, flooding a bathroom, entering a roommate’s space, and urinating on the floor. Staff also documented that this resident grabbed a nurse’s breast multiple times while laughing and yelling, hit a nurse on the rear end, made sexual remarks to female staff, and tried to get into bed with a neighboring resident while that resident attempted to push him away by shaking and pulling the blanket.

Despite these repeated behaviors, the facility did not implement effective care plan interventions for wandering or sexually focused behaviors until shortly before the sexual abuse incident. The care plan did not address these behaviors from admission through multiple documented episodes of room entry and inappropriate sexual contact with staff and attempts to get into bed with another resident. The Administrator later stated that, after one incident, the interdisciplinary team decided to move the resident to another unit, which was identified as the unit where the majority of the facility’s most vulnerable residents with Alzheimer’s disease and dementia resided. The Administrator also stated they believed the resident’s wandering was not repetitive or primarily at night and that the resident was easily redirectable, and acknowledged relying on staff reports rather than reviewing the progress notes that documented multiple wandering incidents.

The sexual abuse incident occurred when a CNA, during rounds, turned on the light in a female resident’s room and observed the male resident in bed with her, with his hand down the front of her brief. The female resident had dementia, anxiety, adult failure to thrive, severely impaired cognitive skills for daily decision making, and a court-appointed guardian, and was non-verbal and unable to respond during the post-incident assessment. Camera footage showed that no staff were stationed outside the male resident’s room as care-planned, that he left his room in a wheelchair, looked up and down the hallway, and entered the female resident’s room, remaining there for over an hour before being discovered. The CNA initially left both residents in the bed together while going to get assistance, and neither the CNA nor the LPN who responded used translation tools they typically used to communicate with the male resident, who had a language barrier, to obtain his account of the incident. The female resident’s guardian and spouse later reported they were told only that a man had been found in bed with her and were not informed that his hand had been down her brief.