The Village Of East Harbor
The Village of East Harbor in Chesterfield Township, MI — inspection on December 22, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of R901's Activities of Daily Living (ADL) care plan revealed the resident required direct assistance with all ADLs including transfers.Review of R901's physician orders revealed an order dated 11/20/25 stating Transfer with (name of) Lift and 2 persons assist.
The (name of) lift is also known as a Sit to Stand lift and refers to a mechanical transfer assistance device that brings the individual from a seated to/from a standing position with mechanical support and assistance and requires the presence and assistance of staff. On 12/22/25 at 1:45 PM, R901 was observed in the common area sitting in the wheelchair.
The resident was not able to respond to questions regarding the reported situation in a coherent manner.On 12/22/25 at 2:03 PM, Licensed Practical Nurse (LPN) and Unit Manager B was interviewed and reported they were aware that on 11/30/25 Certified Nursing Assistant (CNA) A did complete a one-person manual transfer onto the toilet with R901, then requested assistance of another CNA to complete another manual transfer from the toilet.
LPN B reported their understanding was that CNA A was aware of the physician ordered transfer status and chose to complete the transfer manually because they felt the resident was safe to do so that day and added but that would still not be appropriate. LPN B confirmed residents should always be transferred according to the current physician order. On 12/22/25 at 2:15 PM, CNA A was interviewed and reported during the incident in question, they transferred the resident manually to the toilet without assistance from other staff. CENA A indicated they realized they were supposed to have used the mechanical lift after R901's daughter commented about the lack of the lift. CNA A reported they did receive assistance from another CNA to transfer the resident off the toilet but did so manually rather than using the lift. On 12/22/25 at 2:55 PM, the facility Director of Nursing (DON) was interviewed and reported the expectation is staff will complete resident transfers according to the physician order.
Review of the facility policy Transfer Activities, with a most recent review date of 11/15, revealed the policy statement To transfer the resident from the bed to chair, toilet or tub safely.
Review of the facility disciplinary report related to the incident revealed the statement [CENA A] failed to follow the ordered transfer status of a resident that requires a [NAME] lift and two persons assist.
For safety reasons, it is imperative that residents are transferred per their ordered transfer status.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
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