West Hickory Haven: Resident Elopement, No Investigation - MI
That is what federal inspectors documented at West Hickory Haven on August 26, 2025, following a complaint inspection that resulted in a finding of actual harm.
The resident, identified in inspection records as Resident 202, had eloped from the facility. A nurse, identified only as Nurse L, observed the resident outside near a hallway emergency exit. That detail, on its own, should have started a clear trail. There are doors. There are alarms. There are cameras. None of it was followed.
When inspectors asked staff which door Resident 202 had used to get outside, they said they did not know. Their best guess was the front door. That guess was not verified. Inspectors asked whether anyone had pulled camera footage from the front lobby to check. They had not. Inspectors asked whether anyone had interviewed the staff members involved in the incident. They had not done that either.
The investigation, in other words, did not happen.
The facility's own written policy, reviewed by inspectors that afternoon, described exactly what was supposed to occur. The policy required that any accident or incident with injury or the potential for injury be documented and investigated, with the explicit goal of understanding how the event occurred and preventing it from happening again. The same policy addressed door alarms specifically: when an exit alarm sounds, staff are required to visually check the area around that exit, including outside the building, and to evaluate the cause before resetting the alarm, only after the resident's safety is confirmed.
Resident 202 was found in a parking lot. That is outside the building. That is past any door alarm. That is the outcome the alarm and the visual check and the investigation process exist to prevent.
None of those steps produced answers. Staff could not say which door alarmed. They could not say who, if anyone, responded to that alarm at the moment it sounded. They could not say what the resident did between leaving the building and being found in the parking lot, or how long that took.
The finding was cited under F0689, the federal tag covering accidents and supervision, and was assigned a level of actual harm. That distinction matters. Inspectors did not classify this as a near miss or a potential problem. They determined that harm had already occurred.
What inspectors documented at the end of their inquiry was a facility that responded to a serious safety failure by doing almost nothing to understand it. No footage reviewed. No staff questioned. No reconstruction of what happened. The only thing confirmed was that a resident ended up outside, in a parking lot, and the people responsible for that resident's safety could not explain how.
The facility's own policy described the purpose of incident investigations plainly: to make every effort to decrease the likelihood of a recurrence. That work requires knowing what went wrong. Without reviewing the cameras, without talking to the staff who were present, without tracing which door was used, there is no way to know. And without knowing, there is no way to prevent it from happening again.
Resident 202 was found outside. The door they used remains unidentified.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 4, 2026 · Our methodology
West Hickory Haven in Milford, MI was cited for violations during a health inspection on August 26, 2025.
The resident, identified in inspection records as Resident 202, had eloped from the facility.
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.