Springs at Rochester Hills: Resident-on-Resident Abuse - MI
That conclusion is now the subject of a federal deficiency citation against The Springs at Rochester Hills Rehab and Nursing Center, following a complaint inspection completed October 7, 2025. Inspectors rated the violation as causing actual harm to a small number of residents.
The incident happened on September 26, 2025, in the evening, after dinner, while it was still light outside. Three nurses gave accounts to inspectors. Their accounts did not match what the facility put in its investigation file.
Nurse B worked on the first floor that day. She had come upstairs, she told inspectors, and that's when she saw the interaction. Resident 802, who the report identifies as the aggressor, "got mad," and Nurse B watched her hit Resident 803 on the arm. Then she kept hitting her. Nurse B said she intervened verbally, telling Resident 802 to stop, explaining that Resident 803 "just doesn't understand."
Nurse E was in the middle of a medication pass when it escalated. Resident 802 was her assigned patient. Resident 803 was not. She turned and saw Resident 803 on the ground. Resident 802, she told inspectors, had been "thinking another resident was her husband," and knocked Resident 803 to the floor. Nurse E described Resident 802 as having a recent mental status change, something new for her. She had also heard, from another nurse on another shift, that Resident 802 had a history of being aggressive with other residents. She was careful about that: "I don't want to speak on something I overheard."
Nurse T was assigned to Resident 803. She was down the hall at the medication cart when she heard another nurse call her name and then heard a bump. She looked down the hall and saw Resident 803 on the floor, both hands on the ground, head against the wall. Resident 802 was in her wheelchair, kicking at her. "It wasn't hard," Nurse T said, "only so much she can do in a wheelchair." She ran down to separate them.
The hospice nurse came to the facility to evaluate Resident 803. There was a small area of injury near her eyebrow.
When inspectors sat down with the administrator and the director of nursing on the afternoon of October 7, the administrator deferred. Asked to explain the details of the incidents, she pointed to the documentation in the investigation file and what had been reported to the state agency. Asked how the facility determined it could not substantiate abuse, she pointed to the same file. Asked specifically about the discrepancies between what the nurses witnessed and what ended up in the investigation, the administrator acknowledged the discrepancies existed. She could not explain them.
The administrator was also the facility's designated abuse coordinator.
The facility's own abuse and neglect policy, dated June 28, 2025, defines physical abuse to include hitting, slapping, kicking, squeezing, grabbing, pinching, punching, poking, twisting, and roughly handling. It states that willfulness, for purposes of that definition, does not require that someone intended to cause harm, only that they acted deliberately. It states that abuse causes physical harm, pain, or mental anguish, regardless of a resident's mental or physical condition.
Three nurses told inspectors they saw Resident 802 hit Resident 803, knock her to the floor, and kick her while she was down. One of them ran the length of the hall to pull them apart. A hospice nurse documented an injury. The facility's own written policy described exactly what happened as physical abuse.
The facility said it could not substantiate that abuse had occurred.
What inspectors found was a gap between the witness statements nurses gave and what the investigation recorded. The administrator, who ran that investigation, sat across from inspectors and confirmed the gap was real. She offered nothing to account for it.
The inspection report does not describe what happened to Resident 802 after the incident, whether she was separated from Resident 803, whether her care plan was updated to address the aggression, or whether staff on the unit received any additional guidance. It does not say whether Resident 803 received any follow-up beyond the hospice nurse's visit that evening.
What it records is this: a resident with a documented mental status change and a history of aggression toward other residents knocked a fellow resident to the floor and kicked her while she lay there. At least two nurses witnessed part or all of it. A third had seen the hitting that preceded it. The facility opened an investigation and closed it without a finding.
Resident 803 was on the floor with her head against the wall. Nurse T ran down the hall to reach her. The hospice nurse noted the injury near her eyebrow and left.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Springs At Rochester Hills Rehab and Nursing C from 2025-10-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 26, 2026 · Our methodology
The Springs at Rochester Hills Rehab and Nursing C in Rochester Hills, MI was cited for abuse-related violations during a health inspection on October 7, 2025.
Inspectors rated the violation as causing actual harm to a small number of residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.