F0610

E

Failure to Thoroughly Investigate Abuse and Poisoning Allegations and Protect Residents

Farmington, Michigan Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to conduct timely, thorough, and accurately documented investigations into multiple allegations of staff-to-resident physical and sexual abuse and poisoning, and failure to implement adequate protections for residents during those investigations. For one resident with severe cognitive impairment and limited ability to communicate, an allegation was made that a CNA remained in the room for an unusually long period while providing care, was seen bent over the roommate, and was reported to have held the resident’s wrists down. Initial witness statements documented that the roommate observed the CNA bent over the resident, holding her wrists, and that the resident appeared upset. Another statement noted the resident seemed nervous and reluctant to speak and that her nails were not clipped, despite the CNA’s later claim that he had clipped and cleaned her nails during the extended care episode. These details, including the allegation of the CNA holding the resident’s wrists tightly and the discrepancy about nail care, were not included in the investigation summary or in the report submitted to the State Agency.

The facility’s documentation regarding this incident was inaccurate, disorganized, and inconsistent. Witness statements showed the incident was reported internally on one date and alleged to have occurred on an earlier date, while the FRI submitted to the State Agency listed different discovery and incident dates. Key allegations, such as the CNA holding the resident’s wrists down and the roommate’s detailed observations, were omitted from the investigation summary and the FRI. The facility’s investigation summary stated that a skin and pain assessment was completed immediately, but the only documented skin assessments for the cognitively impaired resident were dated before the alleged incident and then ten days later. Additionally, the CNA continued to work several shifts after the initial allegation was identified, and there was no evidence that law enforcement or other agencies were notified, despite the nature of the allegations.

For another resident with intact cognition and a diagnosis including schizoaffective disorder, the facility failed to fully investigate multiple serious allegations. One incident report documented that the resident told staff that a nurse aide raped her while providing care, yet the investigation summary submitted to the State Agency only described that the resident felt someone entered her room and did something to her, without mentioning rape. In separate incidents, the same resident alleged that another resident poisoned her coffee and that an LPN poisoned her coffee or otherwise poisoned her, contacted police, and was transferred to the hospital. The FRI for the allegation against the other resident was submitted 12 hours after discovery, and no investigation was submitted within the required five-day timeframe. For the poisoning allegations against the LPN, the facility’s investigation relied on interviews with the LPN and the roommate and review of surveillance video and lab work, but there was no documented interview of the resident for either poisoning allegation, and the investigation for a later poisoning allegation reused interviews from an earlier, different allegation. There was also no evidence that the LPN was suspended pending investigation of the poisoning allegations. The Administrator, serving as Abuse Coordinator, was unable to explain the omissions, lack of investigations, reuse of prior interviews, and failure to suspend staff or notify law enforcement in connection with these allegations.