West Hickory Haven: Resident Physically Restrained - MI
The resident, identified in inspection records as R801, was on hospice care and largely immobile. When staff provided any kind of care, she would sometimes try to hold her gown or a blanket. She didn't strike out. She didn't yell. A nursing assistant who worked with her described it plainly: R801 was resistive, but in the quiet way of someone in pain reaching for the only thing within her reach.
On October 14, 2025, a certified nursing assistant identified in the report as CNA 'C' physically restrained her anyway.
The facility's own unit manager, RN 'A', told inspectors exactly what staff were supposed to do when R801 showed signs of resistance or discomfort. Stop care. Wait a moment. Reapproach. Let a nurse know in case she was in pain. Typically, one staff member would hold R801's hand while the other provided care.
None of that happened on October 14.
CNA 'C' was fired after the incident. The administrator confirmed that to inspectors during an interview on October 29, the day the survey was completed. She also confirmed she had been made aware of the restraint. What the inspection report documents is the gap between what the facility knew and what had been put in place to prevent it.
R801 had no individualized care plan entry addressing her resistive behaviors before October 14. There was no documented behavioral intervention tailored to her. There was no protocol specific to her that said: here is what to do when this woman, who is dying and cannot move freely, tries to hold her blanket. Inspectors found that a targeted care plan addressing her behaviors wasn't created until after she had already been restrained.
The facility had a written restraint policy, revised in November 2008, that stated residents had the right to be free from physical restraints imposed for discipline or staff convenience. A physical restraint, the policy defined, is any manual method or physical or mechanical device attached or adjacent to a patient's body that the person cannot remove easily and that restricts their freedom of movement or normal access to their own body.
R801 could not remove it easily. She could barely move.
CMS rated the deficiency at the level of actual harm.
The nursing assistant who worked regularly with R801, identified as CNA 'G', told inspectors that R801's resistance during care wasn't aggression. It was pain. She'd reach for her gown. She'd hold a blanket. CNA 'G' understood what that meant. The care plan, until after October 14, did not reflect that understanding in any documented, actionable form.
The administrator, during her interview at 2:06 in the afternoon on the day of the survey, told inspectors she was not the facility's Abuse Coordinator. That role belonged to the Director of Nursing, who was not available during the inspection. The administrator said she was still kept informed of abuse situations at the facility and had been informed about what happened to R801.
RN 'A', the unit manager, was interviewed about 40 minutes later. She described the standard approach clearly. The expectation was well understood among at least some staff. Hold her hand. Stop if she's uncomfortable. Check for pain. The gap wasn't in what the facility's nurses knew. The gap was in whether that knowledge had been formalized into R801's care before the night CNA 'C' decided not to follow it.
Inspectors reviewed R801's clinical record and found no documented behaviors for October 14, the day of the restraint. That absence matters. It means the incident, and whatever led up to it, was not recorded in the behavioral record the way it should have been. A hospice patient was physically restrained, the aide who did it was fired, and the clinical record for that day showed nothing.
The inspection was a complaint survey, meaning someone reported what happened before federal inspectors arrived. The report does not identify who filed the complaint.
West Hickory Haven sits at 3310 West Commerce Road in Milford, a small city in Oakland County about 35 miles northwest of Detroit. The facility's CMS certification number is 235262.
What the record shows is a woman on hospice, at the end of her life, who reached for a blanket when someone touched her because she was in pain. The people who knew her understood that. The care plan didn't say so until it was too late. And on October 14, someone held her down.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for West Hickory Haven from 2025-10-29 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 23, 2026 · Our methodology
West Hickory Haven in Milford, MI was cited for violations during a health inspection on October 29, 2025.
The resident, identified in inspection records as R801, was on hospice care and largely immobile.
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.