The Village Of East Harbor
Inspection Findings
F-Tag F0677
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake 2688079.Based on observation, interview, and record review, the facility failed to ensure two persons assisted with toileting assistance for one (Resident R901) resident of three transfer-dependent residents reviewed for assistance. Findings include: Review of a complaint called into the State Agency revealed a concern from Resident R901's family member that on 11/30/25, after the family member requested toileting assistance for the resident, the resident was manually transferred to the toilet by one staff person then manually transferred from the toilet by two staff rather than via two-person assistance using a mechanical lift as physician ordered.Review of the facility record for Resident R901 revealed they were admitted into the facility
on [DATE REDACTED] with diagnoses including Dementia, Anxiety Disorder, and Osteoarthritis. Review of Resident R901's Activities of Daily Living (ADL) care plan revealed the resident required direct assistance with all ADLs including transfers.Review of Resident 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, Resident 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 Resident 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 Resident 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.
Residents Affected - Few
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
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
The Village of East Harbor in Chesterfield Township, MI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Chesterfield Township, MI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Village of East Harbor or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.