West Hickory Haven: Failed to Report Resident Escapes - MI
Federal inspectors discovered the notification failures during an August complaint investigation. Both residents had severely impaired cognition and diagnoses including Alzheimer's disease and dementia, according to their medical records.
The first incident involved a resident with Alzheimer's disease, adjustment disorder, mood disorder, and delirium. On May 3, the resident exited through the facility's front doors before staff spotted him and brought him back inside. Seven days later, on May 10, the same resident walked out again.
Staff witnessed both incidents entirely, according to nursing notes. A May 16 entry by Nurse B stated the resident "is alert to self and often ambulates throughout the facility" and noted that on both dates "he did exit the facility through the front doors and staff saw him and redirected him into the facility. He was visualized by staff the entire time."
The second resident also walked out the front doors on May 3. This resident had been diagnosed with dementia, traumatic brain injury, falls, and muscle weakness. Despite using a walker, the resident was independently mobile, medical assessments showed.
Nurse B's May 16 documentation described this resident as someone who "is alert to self and often ambulates throughout the facility with walker" and confirmed that "on 5/3/25 he did exit the facility through the front doors and staff saw him and redirected him into the facility."
Neither family received notification about the escapes.
When inspectors interviewed the first resident's family member in August, they asked directly whether the family had been informed about the elopement incidents. The family member said they had not been made aware.
Documentation reviews found no evidence that responsible parties for either resident were contacted about the exits, despite facility policy requiring such notification.
West Hickory Haven's own policy on wandering residents explicitly addresses this requirement. The "Wandering Resident Exit Seeking Management" policy states that "upon return of an eloped resident" the "resident's family/legal representative shall be notified of the resident's status."
The facility admitted both residents with significant cognitive impairments that made unsupervised exits potentially dangerous. Medical records showed the first resident had severely impaired cognition alongside multiple psychiatric conditions. The second resident also had severely impaired cognition, compounded by brain injury and physical weakness that required walking assistance.
Both residents remained independently mobile despite their cognitive limitations. Their ability to walk to and through the facility's front entrance demonstrated they retained enough physical capability to leave the premises, even while lacking the mental capacity to understand the risks of doing so.
The May incidents occurred within a week of each other, with one resident attempting to leave twice in that period. Staff response appeared consistent across all three exit attempts - they observed the residents leaving and redirected them back inside without apparent delay or difficulty locating them.
However, the facility's failure to communicate these incidents to families violated federal regulations requiring immediate notification of responsible parties when situations affect residents. The regulation specifically mandates that facilities "immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident."
Inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The August 26 complaint investigation examined three residents' records for changes of condition and found notification failures for two of them.
The citation represents a breakdown in the facility's communication protocols during incidents involving vulnerable residents with severe cognitive impairments. Both residents' diagnoses and assessment scores indicated they lacked the mental capacity to safely navigate outside the facility independently.
West Hickory Haven's documented policy acknowledged the importance of family notification following resident elopements, yet the facility failed to implement its own procedures. The gap between written policy and actual practice left families unaware that their cognitively impaired relatives had walked out of the building and required staff intervention to return safely.
The incidents occurred during daytime hours when the front entrance was apparently accessible to residents. Staff visibility of the exits suggested the facility maintained some level of monitoring, but not enough prevention to stop the departures from happening.
Federal regulations require nursing homes to immediately inform families when incidents affect their relatives. At West Hickory Haven, two families remained in the dark about their loved ones walking out the front door.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for West Hickory Haven from 2025-08-26 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 20, 2026 · Our methodology
West Hickory Haven in Milford, MI was cited for violations during a health inspection on August 26, 2025.
Federal inspectors discovered the notification failures during an August complaint investigation.
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.