West Hickory Haven: Resident Restrained by Tied Shirt - MI
Nobody from the previous shift had mentioned it.
The two aides who had just finished their shift, identified in inspection records as CNA 'C' and CNA 'D', told the incoming staff there was nothing special to report. They walked from room to room before leaving. They said everyone was fine.
CNA 'H' was the one who found R801. She brought in her colleague CNA 'G' to see it. Both agreed it was not right. CNA 'H' then waited, standing by, until the floor nurse finished the narcotic count before saying anything. When RN 'E' was finally free, CNA 'H' brought her to the room. RN 'E' and CNA 'H' untied the sleeves together.
What happened next is the second failure layered on top of the first.
RN 'E' did not file an abuse report. She did not suspend the aides from the outgoing shift. She did not call anyone. CNA 'G', who had witnessed the tied sleeves and understood what she was looking at, assumed the nurse would hand her an incident report to fill out. No report came. CNA 'G' assumed the nurse had made the call up the chain. She finished her shift and went home and slept.
She woke up and realized nobody had called her.
At that point, roughly nine to ten hours after R801 was found with her arms bound, CNA 'G' contacted the Director of Nursing herself.
By then, CNA 'C' and CNA 'D' had already come back to work. Time records reviewed by inspectors showed CNA 'C' punched in at 6:40 AM on October 14, worked until 10:41 PM, then returned the next morning at 6:35 AM and worked until 9:49 PM, nearly two full consecutive days. CNA 'D' punched in at 6:27 AM on October 14, worked until 10:42 PM, and was back at 6:27 AM on October 15, finishing out the entire day shift. The two aides suspected of physically restraining a resident with her own clothing spent the following day working inside the same facility, on the same floor, around the same residents.
Neither was suspended. Neither was removed while an investigation was conducted.
The administrator at West Hickory Haven told inspectors on October 29, 2025, that she was aware of what had happened to R801. She explained that the proper protocol required staff to report immediately to the Abuse Coordinator, and that any alleged perpetrator was to be suspended immediately pending investigation. She said RN 'E' should have reported it as soon as she found out. She said CNA 'G' and CNA 'H' should have reported it too.
RN 'E's employment was eventually terminated. The administrator told inspectors it was for other reasons.
CNA 'G' and CNA 'H', the aides who found R801 and untied her sleeves, received education about abuse reporting along with the rest of the staff. They received no disciplinary action.
The administrator said the Director of Nursing was the facility's designated Abuse Coordinator. The DON was not available during the survey.
CNA 'C' and CNA 'D', the two aides who left the shift without disclosing the restraint, denied doing it when CNA 'G' raised it with them directly. Inspectors were unable to reach CNA 'H' for a phone interview before the survey closed. Her written statement, included in the facility's own investigation file, described arriving to find R801 with her sleeves tied at the ends, confirming what CNA 'G' had also described: a woman whose arms were bound by her own clothing, left that way through an entire shift handoff, discovered only when the next crew started their rounds.
The facility's written abuse policy, revised in February 2023, stated that anyone with knowledge of potential or actual abuse must report it immediately to the administrator or designee, and that reports involving abuse must be submitted within two hours. Inspectors noted that the same policy also included language giving the facility 24 hours to report mistreatment, and flagged that the 24-hour language does not meet the regulatory requirement.
The facility reported the incident to the state, but the timeline of that report, and what it contained, is not detailed in the inspection record. What the record does show is that the internal response moved slowly, that the people most directly responsible for what happened to R801 kept working while the clock ran, and that the nurse who stood in the room and untied the sleeves and then said nothing to anyone with authority was eventually let go, but for something else.
What was done to R801 is not ambiguous. Her shirt sleeves were tied together. She could not move her arms. She was left that way by the people caring for her, and when those people handed off to the next shift, they said there was nothing to report.
She was not found by a supervisor making rounds. She was not found because someone reported a concern. She was found because a nursing assistant started her shift and went room to room and happened to look.
The inspection, conducted as a complaint survey, cited the facility at the F0609 level, covering the requirement to report and investigate allegations of abuse. The finding was rated as causing minimal harm or potential for actual harm, affecting a small number of residents. CMS uses that language as a regulatory category. It describes where the violation sits on a compliance scale.
It does not describe what it is like to be a person who cannot lift her arms.
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.
Nobody from the previous shift had mentioned it.
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.