West Hickory Haven: Physical Restraint Cover-Up - MI
Federal inspectors documented the incident during a complaint inspection on October 29, 2025. What they found was not just a case of physical restraint, but a cascading failure of reporting at nearly every level of the facility's staff.
The restraint happened on October 14, 2025. According to inspection records, CNA 'C' and CNA 'D' were the aides on duty when R801, the resident, was physically restrained with her own clothing. Time records reviewed by inspectors showed CNA 'C' had punched in at 6:40 AM that morning and did not punch out until 10:41 PM, a shift of more than sixteen hours. She returned the next morning at 6:35 AM and worked until 9:49 PM. CNA 'D' punched in at 6:27 AM on October 14 and left at 10:42 PM. She was back the following morning at 6:27 AM and stayed until 2:43 PM.
Both aides worked the day after the restraint. Neither, according to the inspection record, was suspended pending investigation.
CNA 'H' was the aide who found R801. She had just come on shift as CNA 'C' and CNA 'D' were leaving. The departing aides told her there was nothing special to report. CNA 'H' began her rounds and found R801 with her shirt sleeves tied together at the ends, her arms unable to move freely. CNA 'H' went and got CNA 'G'. The two aides agreed it was not right. Then CNA 'H' waited for RN 'E' to finish the narcotic count before reporting it to her.
RN 'E' and CNA 'H' went to R801's room and untied the sleeves.
That should have been the beginning of the facility's response. It was closer to the end of it.
CNA 'G' told inspectors she thought the nurse had reported the incident and that the facility would contact her for a statement. She finished her shift, went home, and slept. When she woke up, nobody had called. It was approximately nine to ten hours after she had first seen R801 restrained. At that point, CNA 'G' contacted the Director of Nursing herself.
The inspection report does not describe what RN 'E' did in those hours between untying R801's sleeves and CNA 'G' making that call. What the record does say is that RN 'E's employment was later terminated, though the administrator told inspectors it was for other reasons, not specifically for the failure to report the restraint.
The administrator, interviewed at 2:06 PM on October 29, described the process clearly enough. Staff were required to report immediately to the Abuse Coordinator. The alleged perpetrator was to be suspended immediately, pending investigation. RN 'E' should have reported it as soon as she found out. So should CNA 'G' and CNA 'H'.
The administrator said all of that. She also said that CNA 'G' and CNA 'H', the aides who found the restrained resident and waited, received no disciplinary action. They were educated about abuse reporting, along with the rest of the staff.
The facility's own written policy, titled Abuse/Suspected Abuse; Crime Investigation and Reporting and revised in February 2023, stated that any person witnessing or having knowledge of potential or actual abuse must immediately report it to the administrator or designee. The policy required reports to be submitted within two hours when the alleged violation involved abuse. Inspectors noted the policy also referenced a 24-hour window for reporting mistreatment, and flagged that timeline as failing to meet regulatory requirements.
The Director of Nursing, who served as the facility's Abuse Coordinator and would have been the central figure in any proper response to what happened to R801, was not available during the survey.
What the inspection report captures, detail by detail, is how a physical restraint of a nursing home resident moved through a facility's staff and encountered, at each step, a decision not to act urgently. CNA 'H' found R801 and waited for a narcotic count to finish before saying anything. CNA 'G' assumed someone else had handled it and went to sleep. RN 'E' untied the sleeves and, based on the record, did not report the incident in the two-hour window the facility's own policy required. The two aides who tied the sleeves in the first place told the incoming shift there was nothing special to report and came back the next day and worked.
The inspection report does not describe R801 beyond what was necessary to document the violation. Her arms could not move freely. She was found that way by someone coming on shift, not by anyone who had been there when it happened.
The administrator's account of what followed is precise in one respect and vague in another. She was precise about what the policy required: immediate reporting, immediate suspension of the alleged perpetrator, investigation. She was vague about why none of that happened with CNA 'C' and CNA 'D', who were, by the time the incident was reported up the chain, already most of the way through another full day of work.
The inspection was classified as a complaint survey. The level of harm was documented as minimal harm or potential for actual harm, affecting few residents. That classification sits alongside the specific facts: a resident whose arms were bound by her own knotted shirt, a staff that closed ranks through silence or inattention for the better part of a day, and two aides who physically restrained her and were back at work the following morning.
CNA 'H' was not available for an interview before inspectors finished their survey. The statement she gave during the facility's internal investigation was reviewed instead. In it, she described finding R801, getting CNA 'G', the two of them agreeing it was not right, and then waiting until RN 'E' was free. The statement ends with the sleeves being untied.
It does not say what happened to R801 after that, or who told her what had been done to her, or whether anyone did.
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.
Download the official CMS inspection PDF from Medicare.gov
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: September 23, 2026 · Our methodology
West Hickory Haven in Milford, MI was cited for violations during a health inspection on October 29, 2025.
Federal inspectors documented the incident during a complaint inspection on October 29, 2025.
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.