STATE OF MICHIGAN GRETCHEN WHITMER
GOVERNOR DEPARTMENT OF LICENSING AND REGULATORY AFFAIRSLANSING
ORLENE HAWKS DIRECTOR
611 W. OTTAWA P.O. BOX 30664 LANSING, MICHIGAN 48909 www.michigan.gov/lara 517-335-1980
January 21, 2021 Nicholas Burnett Flatrock Manor, Inc. 2360 Stonebridge Drive Flint, MI 48532
RE: License #:
Investigation #: AM4403885172021A0501011 Elba North Dear Mr. Burnett:
Attached is the Special Investigation Report for the above referenced facility. Due to the violations identified in the report, a written corrective action plan is required. The corrective action plan is due 15 days from the date of this letter and must include the following:
How compliance with each rule will be achieved.
Who is directly responsible for implementing the corrective action for each violation.
Specific time frames for each violation as to when the correction will be completed or implemented.
How continuing compliance will be maintained once compliance is achieved.
The signature of the responsible party and a date.
If you desire technical assistance in addressing these issues, please feel free to contact me. In any event, the corrective action plan is due within 15 days. Failure to submit an acceptable corrective action plan will result in disciplinary action.
Please review the enclosed documentation for accuracy and contact me with any questions. In the event that I am not available and you need to speak to someone immediately, please contact the local office at (810) 787-7031.
Sincerely,
Crecendra Brown, Licensing Consultant Bureau of Community and Health Systems 4809 Clio Road
Flint, MI 48504 (810) 931-0965 enclosure
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MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF COMMUNITY AND HEALTH SYSTEMS
SPECIAL INVESTIGATION REPORT I. IDENTIFYING INFORMATION
License #: AM440388517
Investigation #: 2021A0501011
Complaint Receipt Date: 12/14/2020
Investigation Initiation Date: 12/14/2020
Report Due Date: 02/12/2021
Licensee Name: Flatrock Manor, Inc.
Licensee Address: 7012 River Road Flushing, MI 48433
Licensee Telephone #: (810) 964-1430
Administrator: Carrie Aldrich
Licensee Designee: Nicholas Burnett
Name of Facility: Elba North
Facility Address: 300 N. Elba Rd. Lapeer, MI 48446
Facility Telephone #: (810) 969-4442
Original Issuance Date: 09/05/2017
License Status: REGULAR
Effective Date: 03/05/2020
Expiration Date: 03/04/2022
Capacity: 12
Program Type: DEVELOPMENTALLY DISABLED
II. ALLEGATION(S)
III. METHODOLOGY
12/14/2020 Special Investigation Intake 2021A0501011
12/14/2020 Special Investigation Initiated - Letter
12/14/2020 APS Referral
APS Referral made to Centralized Intake.
12/15/2020 APS Referral
APS Referral was denied for investigation. 12/15/2020 Contact - Document Sent
Sent email to Licensee Designee Nick Burnett and Administrator Carrie Aldrich requesting paperwork in regard to investigation. 12/15/2020 Contact - Telephone call made.
Livingston County CMH Elizabeth Tincher. 12/23/2020 Contact - Telephone call made.
Guardian A.
12/23/2020 Contact - Telephone call made. Guardian B.
12/23/2020 Contact - Telephone call made. Staff Kennedy Coleman.
12/23/2020 Contact - Telephone call made. Staff Porsha McCullough. 12/23/2020 Contact - Telephone call made.
Staff Lara Montague.
12/23/2020 Contact - Telephone call made. Staff Mary Pyonk.
Violation Established?
On December 13, 2020, Resident A was sexually assaulted by Resident B while in the shower.
3 12/23/2020 Contact - Telephone call made.
Staff Jacquez Tucker.
12/29/2020 Contact - Telephone call made.
Lapeer County Adult Protective Services Rose Koss.
12/29/2020 Exit Conference
Licensee Designee Nick Burnett. 01/04/2021 Contact - Document Received
Received requested investigation paperwork. 01/20/2021 Contact – FaceTime Video Conference
Home Manager Nick Garcia, Resident A and Resident B.
ALLEGATION:
On December 13, 2020, Resident A was sexually assaulted by Resident B while in the shower.
INVESTIGATION:
No onsite was conducted due to COVID-19.
On December 15, 2020, I called Livingston County CMH Elizabeth Tincher. Ms. Tincher provided me with information on Resident A and Resident B. Ms. Tincher stated that Resident A receives services from Livingston County Community Mental Health. Ms. Tincher gave me the contact information for Guardian A.
On December 23, 2020, I conducted a phone interview with Guardian A. Guardian A stated that he caught Resident B in the shower with Resident A. Guardian A stated that he went to go see Resident A on December 13, 2020. Guardian A stated that Resident A was in a soiled diaper, so he asked staff for a clean diaper. Guardian A stated that staff put Resident A in the shower. Guardian A stated that he went to go check on Resident A and found Resident B in the shower with Resident A. Guardian A stated that Resident B looked directly at him and grabbed Resident A’s penis. Guardian A stated that he started yelling at Resident B and staff came into the bathroom. Guardian A stated that he told the staff to keep Resident B away from Resident A. Guardian A stated that Resident B is bigger than Resident A and Resident B is very aggressive. Guardian A stated that this kind of thing has happened before and Resident B attacked Resident A. Guardian A stated that now staff are not supposed to let this happen again when Resident A is taking a shower. Guardian A stated that Flatrock Manor has been trying to make him sign a form consenting to Resident A having sex at the facility, but he never signed the form. Guardian A stated that he contacted Community Mental
Health and they told him he did not have to sign the form. Guardian A stated that a year ago, Resident B pinned Resident A against a wall and tried to sexually assault him. Guardian A stated that Resident A does not want Resident B touching him. Guardian A stated that Resident A pulled away from Resident B when Resident B grabbed his penis. Guardian A stated that he is afraid Resident B will try to sexually assault Resident A again.
On December 23, 2020, I attempted to contact Guardian B. I left Guardian B a detailed voice message. On December 28, 2020, Guardian B returned my phone call. Guardian B stated that Resident B should not be left alone with any of the other residents.
Guardian B stated that this is the first time he is hearing the allegation. Guardian B stated that Resident B should be receiving “eyes on” supervision when he is not in his bedroom due to his behaviors, bleeding disorder and his seizure disorder. Guardian B stated that unless Resident B is in his room, staff should have Resident B “on line-of-sight supervision.”
On December 23, 2020, I conducted a phone interview with Staff Kennedy Coleman. Staff Kennedy Coleman stated that she does not know if Resident B fondled Resident A. Ms. Coleman stated that Guardian A told her that Resident B fondled Resident A in the shower while Guardian A was there on December 13, 2020. Ms. Coleman stated that Guardian A told her that when he walked into the bathroom Resident B grabbed Resident A’s genitals in the shower. Ms. Coleman stated that Resident B has always been in line-of-sight supervision, but she was not sure what his assessment plan says now. Ms. Coleman stated that she was in the kitchen helping another staff with dinner when Guardian A came to her to tell her what happened. Ms. Coleman stated that she is not sure who was supposed to be keeping an eye on Resident B, but all staff are aware that they are supposed to keep Resident B in their sight when he is out of his room.
On December 23, 2020, I conducted a phone interview with Staff Porsha McCullough. Staff Porsha McCullough stated that when Resident B went into the bathroom, she does not believe he knew Resident A was in the bathroom. Ms. McCullough stated that when Guardian A saw Resident B in the bathroom he started yelling. Ms. McCullough stated that when Resident B came out of the bathroom, he did not look wet and she does not believe he went into the shower. Ms. McCullough stated that she has never known Resident B to fondle any of the other residents.
On December 23, 2020, I conducted a phone interview with Staff Lara Montague. Staff Lara Montague stated that she saw Resident B when he went into the bathroom when Resident A was in there. Ms. Montague stated that residents are not normally in the shower together at the same time. Ms. Montague stated that she went in the bathroom to give Guardian A a towel for Resident A and Guardian A was yelling at Resident B to leave Resident A alone. Ms. Montague stated that she did not witness Resident B touch Resident A. Ms. Montague stated that she tried to get Resident B to leave the bathroom, but he refused. Ms. Montague stated that she asked Staff Mary Pyonk to come in the bathroom and assist her with Resident B. Ms. Montague stated that Staff
5 Pyonk came to the bathroom and asked Resident B to leave the bathroom. Ms.
Montague stated that Resident B left the bathroom after Staff Pyonk asked him. Ms. Montague stated that Guardian A did not tell her Resident B touched or fondled
Resident A. I asked her if she knew why Guardian A was yelling when she came in the bathroom. Ms. Montague stated that she thought he was yelling because Resident B was in the shower naked with Resident A. Ms. Montague stated that once Resident B calmed down, he went back in the restroom later that day when it was empty.
On December 23, 2020, I conducted a phone interview with Staff Mary Pyonk. Staff Mary Pyonk stated that she does not believe Resident B did anything to Resident A. Ms. Pyonk stated that Resident A has sensory issues and she believes he would have had a behavior if Resident B touched him. Ms. Pyonk stated that she was dealing with another resident when Staff Montague called her for help in the bathroom. Ms. Pyonk stated that when she went into the bathroom Resident B was wet and I asked him to leave the bathroom. Ms. Pyonk stated that it is not normal for two residents to be in the shower at the same time. Ms. Pyonk stated that Resident B was naked and in the shower with Resident A. Ms. Pyonk stated that Guardian A was yelling and upset. Ms. Pyonk stated that she does not know what happened in the shower. Ms. Pyonk stated that Resident B has sensory issues and likes the water.
On December 23, 2020, I attempted to contact Staff Jacquez Tucker. I left a voice message on Mr. Tucker’s phone requesting him to return my phone call for the investigation. To date, I have not received a return phone call from Mr. Tucker. On December 28, 2020, I called Lapeer County Adult Protective Services Rose Koss. Ms. Koss stated that she talked to Recipient Rights and Medical Coordinator Virginia Conger, Resident B is supposed to be on 1-on-1 supervision. Ms. Koss stated that Medical Coordinator Conger told her that it is not specifically stated anywhere that Resident B was a 1-on-1 supervision. Ms. Koss stated that Resident B’s mother has been trying to get guardianship of him even though Resident B physically attacked her and her daughter. Ms. Koss stated that when Resident B attacked his mother and sister, he ripped their clothing off. Ms. Koss stated that Resident B has also physically attacked other people according to his mother. Ms. Koss stated that Resident B
attacked a nurse at a doctor’s office and ripped her clothes off. Ms. Koss stated that the Adult Protective Services referral was denied for investigation because there was
already an open case on Resident B.
I reviewed Resident A’s assessment plan on January 4, 2020. The assessment plan was signed by Guardian A and dated December 11, 2020. Resident A has sensory issues and does not like large crowds. Staff are to monitor Resident A for anxiety or agitation to provide support. Staff will know Resident A’s location at all times and be able to assist as needed. When experiencing agitation or anxiety, Resident A can become aggressive with staff or other residents. Resident A has no history of sexual intimate behavior or relationships and nothing is indicated in regard to him being a target for sexual abuse. Staff are to provide Resident A with physical assistance with
cleaning, but Resident A enjoys independence in the shower due to it being calming and comes out when he is ready.
I reviewed Resident B’s assessment plan on January 4, 2020. The assessment plan was signed by Guardian B and dated November 9, 2020. Resident B requires close supervision due to his history of aggression, hitting, grabbing forcefully, and biting others unprovoked. Resident B is known to become aggressive with others, hitting, grabbing, and biting other residents or staff. Resident B’s behavior can be impulsive and unpredictable. Resident B very recently has bitten other residents several times causing them to have to go to the hospital and one had to have an infection treated from Resident B biting them. Under Controls Sexual Behavior on Resident B’s assessment plan, it is reported that Resident B masturbates frequently and may do so in the
presence of others. Staff are to provide Resident B with redirection to a private area. Resident B typically gets along with others, but he cannot be left alone with other residents due to his aggressive behaviors. Resident B is able to shower himself, but staff are to supervise to ensure efficiency. Resident B needs help with washing his hair and may require verbal prompting, preparation of items and supervision.
In Special Investigation 2021A0501004 dated December 21, 2020, Resident B bit another resident in October 2020 and in November 2020 when there was no staff supervision. The resident had to go to the hospital and is being treated for an infection caused from Resident B biting him. Resident B’s assessment plan states that he cannot be left alone with other residents due to his aggressive behaviors. Home
Manager Nicholas Garcia stated that the facility was short staffed during the days when Resident B bit another resident.
Corrective action plan dated December 28, 2020 and signed by Licensee Designee Nick Burnett for Special Investigation Report # 2021A0501004 states that Licensee will ensure that all residents receive adequate supervision. Resident B will receive staff supervision at all times when out of his bedroom and staff will be within arm’s length of Resident B when he is in the common areas of the facility. The Licensee will observe staff daily to ensure that residents’ behavior plans are being followed.
On January 20, 2021, I conducted a FaceTime Video Conference with Home Manager Nick Garcia, Resident A and Resident B. Mr. Garcia stated that all of the residents have their own rooms and staff keep their eyes on Resident B when he is out of his room. Resident A was in the common area and smiled when spoken to. Resident A did not understand the interview questions and was not appropriate for interviewing.
Resident A appeared to be content, clean, and dressed appropriately. Resident B is nonverbal. Resident B was in his room laying down. Resident B woke up when Mr. Garcia went in his room and sat up so he could see me on the phone. Resident B was in the bed, calm, and appeared to be clean.
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APPLICABLE RULE
R 400.14303 Resident care; licensee responsibilities.
(2) A licensee shall provide supervision, protection, and personal care as defined in the act and as specified in the resident's written assessment plan.
ANALYSIS: Guardian A, Staff Porsha McCullough, Staff Laura Montague, and Staff Mary Pyonk stated that on December 13, 2020, Resident B was alone with Resident A in the bathroom. Guardian A stated that on December 13, 2020, he went to go check on Resident A in the shower and found Resident B in the shower with Resident A. Guardian A stated that Resident B looked directly at him and grabbed Resident A’s penis.
Resident B’s assessment plan states that he will grab forcefully unprovoked and he cannot be left alone with other residents due to his aggressive behaviors.
CONCLUSION: REPEAT VIOLATION ESTABLISHED
Special Investigation Report # 2021A0501004 dated December 21, 2020.
On December 29, 2020, I conducted a phone exit conference with Licensee Designee Nick Burnett. I informed Mr. Burnett that I informed Mr. Burnett that a corrective action plan would be requested for the violation. Mr. Burnett stated that he would be
IV. RECOMMENDATION
Upon the receipt of an acceptable and approved corrective action plan, no change to the license status is recommended.
January 20, 2021 ________________________________________ Crecendra Brown Licensing Consultant Date Approved By: January 20, 2021 ________________________________________ Mary E Holton Area Manager Date
