State: Nursing home failed to report alleged abuse

ZEELAND, Mich. (WOOD) — One nursing home resident told a state investigator that a nurse aide broke her leg; a man claimed the same aide squeezed him so hard that he was sure his ribs broke; others said he was so rough that he left them with “skin tears.”

Some said they were afraid of him.

In state reports, they’re talking about “Certified Nurse Aide D” — a man working at the time at Providence Christian Healthcare & Rehab Center in Zeeland.

Then, there’s Certified Nurse Aide No. 13, who witnesses said got rough with a resident at Providence, said not to worry because bruises wouldn’t show up on him because he’s black, then reportedly called him a “stupid N-word,” according to state reports.

State investigators say the nurse aides at Providence either caused “actual harm” to residents or put them at immediate risk of being harmed last year.

But, investigators wrote, Providence failed to report the alleged mistreatment, according to state inspection reports listed on Medicare’s “Nursing Home Compare” website.

The state said the home also failed to investigate not only alleged abuse but unexplained injuries of patients.

The state started investigating only after anonymous tips.

The investigations by the state left Providence as the only nursing home in Kent and Ottawa counties rated on a Medicare website as “much below average” in both health inspections and in “overall” score.

Providence is one of eight nursing homes within 100 miles of Grand Rapids and one of 28 in the state with an overall rating of “much below average,” according to a Target 8 analysis.

In a statement, the home said the rating is based on 2013 reports but that it is now complying with state standards.



While one of the nurse aides is listed only as “Certified Nurse Aide D,” Target 8 identified him as Solomon Mulleta.

In reports, the state says he broke a woman’s thigh bone last July while pushing her down the hall in her wheelchair, apparently banging into a wall, then kept pushing her into the lunchroom, despite her cries.

A nurse aide said the woman was “shaking, crying and had a look on her face like she was terrified,” the state report says.

But the home did not investigate the broken bone and did not report it to the state as required, records show.

Two weeks later, a nurse aide heard crying in a room, then found Mulleta brushing a resident’s hair while blood poured from a long cut on her arm.

A nurse’s aide quoted by the state called it “the largest skin tear she had ever seen, which extended about half the length of Resident #30’s lower arm, and it was bleeding badly.”

Mulleta, 57, of Holland, denied wrongdoing.

“I have never been rough and it’s not my nature to be,” he said. “I didn’t do anything wrong. It’s false allegations, everywhere.”



In fact, Target 8 learned that the state Department of Licensing and Regulatory Affairs conducted a follow-up investigation into Mulleta to determine whether to “tag” his nurse aide certification, meaning he could no longer work as an aide at a home that accepts Medicaid or Medicare.

State investigators said that despite the allegations listed in state reports, his firing and the nursing home’s low scores, they found no “proof” that Mulleta abused or neglected residents.

Stephen Gobbo, deputy director of the Bureau of Health Care Services, said pursuing a nurse aide requires a greater burden of proof than finding a nursing home in violation. That’s in part because the penalty is so severe — ending an aide’s career, he said.

However, the state cited the home for failing to prevent abuse, failing to investigate allegations of abuse and failing to investigate unexplained injuries — placing all residents at “high risk for physical harm and/or injury.”

The state said it found four residents with injuries of “unknown origin” that weren’t investigated by the home or reported to the state. It also reported finding six residents who alleged abuse that also wasn’t investigated or reported.

The home’s administrator, Derek Weenum, refused to comment.

Providence is owned by Providence Life Services, a Chicago-based non-profit based in Chicago.

In a written statement, a spokesman said “the matters from state surveys in the fall of 2013 have long been addressed… if abuse is even suspected, we immediately address the circumstances and investigate.”

He said the home is now in compliance with state standards.

Providence fired Mulleta in November — four months after the first complaints — but only after the anonymous tip that led to the state investigation. He now works as a nurse aide at Grace of Douglas nursing home in Douglas. A source at that home said he has not caused any problems there.



Then there was Jami Bray, identified in state reports as Certified Nurse Aide No. 13, who allegedly got angry with a combative patient at Providence in September and knelt on top of him.

But what she allegedly said raised even more concern: “When it comes to black people, if they bruise, you can’t see it” — reportedly overheard by two other aides in the room.
Then, under her breath, according to an aide quoted by the state: “Stupid N-word.”

Providence fired Bray, but nursing home officials told the state they didn’t report the incident to the state because the statements caused the patient no harm. Even if he’d heard it, they told the state, he couldn’t process it. He has dementia.

Bray, 23, denied being rough with the resident.

“I only grabbed his arms because he was about to punch the wall and punch the other girls and then we stopped and then I let go, and then he calmed down and I walked away,” she said. “That was it.”


She also denied making racist remarks.

“It’s all about petty girls drama and there was no reason to fight it for my job because I didn’t want to work with those girls anyway,” Bray said.

Bray is now working as a nurse aide at Spectrum Health Rehab & Nursing Center at 750 Fuller Ave. NE in Grand Rapids. Spectrum officials said they won’t comment on specific employees, but said they wouldn’t hire anybody if they’d known that kind of history.

The state says it has taken steps to “flag” Bray’s nurse aide certification based on the allegations. If she doesn’t fight it, she would no longer be allowed to work as an aide at a home that accepts Medicare or Medicaid.

Two nurse aides who still work at Providence spoke with Target 8, but only if they weren’t identified.

“I don’t trust the place,” one said. “I have a really, really hard time about that. I don’t trust with all the complaints and things that have happened, I don’t trust that if something happened that it’s going to be handled properly.”

Both blame management.

“When it comes down to everything else, it’s not about anything else but the residents,” the aide continued. “It’s about taking care of them, and that’s why we’re here, that’s what it’s all about, and it doesn’t feel that way; it doesn’t feel like that anymore.”

Providence Christian Healthcare & Rehab Center released the following statement:

“As a non-profit, faith-based organization, our first priority is always the health, safety and wellbeing of our residents. The matters from the state surveys in the fall of 2013 have long been addressed with the department of licensing and regulatory affairs. If abuse is even suspected we immediately address the circumstances and investigate. We have trained all our staff to recognize and report any instance that fails to meet our quality standards. Since 2013, Providence Zeeland remains in compliance with state standards. Surveys of our residents and family members indicate 96% of our clients are satisfied with the services they received and would recommend Providence to their friends. We will continue to do everything we can to serve them with every resource available to us.”

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