Optalis Troy: Sexual Incident Unreported for 9 Days - MI

The incident happened on October 28, 2025, around 2:00 in the afternoon at Optalis Health and Rehabilitation of Troy, a rehabilitation and long-term care facility on West South Boulevard. A CNA identified in inspection records as CNA L had just finished rounds when a coworker yelled for her to come to a shared room. She walked in to find the resident, identified as R108, standing near the curtain that divided the room, pants down, brief removed, looking confused.

R108 then sat down on the bed belonging to R104.

The other resident in the room, R103, walked toward R108. R108 became combative. R103 began shooing him away with a house shoe.

CNA L told inspectors she wasn't alone. LPN E and CNA H were also present when it happened.

The police report tells a starker version. Filed on November 6, 2025, nine days after the incident, it describes R108 opening his gown, dropping his underwear, and fondling himself in R104's room. The nursing home administrator was the one who finally made the call. The report was classified as a suspicious circumstances incident.

The facility's own abuse policy, last updated in May 2023, requires that any allegation involving abuse be reported to the state survey agency immediately, and no later than two hours after the allegation is made. If the incident doesn't rise to the level of abuse or serious bodily injury, the outer limit is 24 hours. A final investigation report goes to the state no later than five working days after discovery.

None of those windows were met. Nine days passed between the incident and the police report. Inspectors arrived on November 21, 2025, as part of a complaint investigation.

What makes the delay harder to explain is who was in the room. This wasn't a situation where a single aide caught a glimpse of something ambiguous and wasn't sure what to report. A licensed practical nurse and two certified nursing assistants witnessed R108 standing with his pants around his ankles, sitting on another resident's bed, and becoming combative when approached. The incident was documented. It was remembered in detail weeks later when CNA L was reached by phone.

The question inspectors were left with, and that the record doesn't fully answer, is what happened in the nine days between October 28 and November 6. Who knew? Who decided not to report? Who decided, eventually, that a call needed to be made?

The inspection report identifies the deficiency under F0609, which covers the obligation to report and investigate allegations of abuse, neglect, and crimes. The level of harm was cited as minimal harm or potential for actual harm. That language is regulatory shorthand. What it describes, in plain terms, is a room where one resident sat on another resident's bed with his underwear removed, where a third resident had to defend herself with a shoe, and where the staff who witnessed it did not trigger the reporting chain their employer's own policy required.

R104, whose bed R108 sat on, is present in the police report but largely absent from the inspection narrative. What the experience was like for that resident, or for R103, who was close enough to R108 to reach him with a house shoe, the record does not say.

The facility's abuse policy uses language about residents having the right to be free from abuse, neglect, exploitation, and mistreatment. It describes a reporting structure that moves from the floor to the administrator to the state within hours. It includes protections for staff who report. On October 28, that structure didn't activate. It took more than a week, and the record suggests it was the administrator, not the staff on the floor, who eventually made contact with law enforcement.

CNA L's phone interview, conducted on November 7, the day after the police report was filed, captures the scene with the kind of specificity that comes from a memory that hasn't faded. The curtain area. The confusion on R108's face. R103 and the house shoe. She remembered it clearly. She had apparently not reported it in a way that triggered the two-hour clock.

The inspection covered a facility that serves residents in various stages of rehabilitation and long-term care. R108's behavior, described in the report as occurring while he appeared confused, raises questions about his cognitive status that the inspection record doesn't resolve. What the record does establish is that whatever his condition, the incident was witnessed, remembered, and not reported for nine days.

Inspectors cited the deficiency as affecting some residents. The plan of correction, if one was submitted, is not included in the publicly available inspection document. For information on how the facility responded, CMS directs the public to contact the nursing home or the state survey agency directly.

The facility has not been identified in the inspection record as having taken any action against the staff members who were present and did not report. Whether any referral was made to the state nurse aide registry, which the facility's own policy identifies as a required step when an employee is found unfit for service, is not addressed in the inspection findings.

R103 was in her room on a Tuesday afternoon in late October. A confused man walked in, took off his pants, and sat on her neighbor's bed. She grabbed her shoe.

Nobody called the state for nine days.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Optalis Health and Rehabilitation of Troy from 2025-11-21 including all violations, facility responses, and corrective action plans.

Additional Resources

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