West Hickory Haven
West Hickory Haven in Milford, MI — inspection on August 26, 2025.
Found 2 citations. 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
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY This citation pertains to intake #2581294Based on interview and record review the facility failed to notify the resident's responsible parties of an elopement for two residents (R#'s 201 and 202) of three residents reviewed for changes of condition.
Findings include:A complaint received by the State Agency alleged two resident's eloped from the facility and their responsible parties were not notified.On 8/26/25 at 9:30 AM, a review of R201's progress notes revealed an Interdisciplinary Team Note entered into the record on 5/16/25 by Nurse ‘B' that read, (R201) is alert to self and often ambulates throughout the facility.On 5/3/25 and 5/10/25 he did exit the facility through the front doors and staff saw him and redirected him into the facility. He was visualized by staff the entire time.A review of R201's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, adjustment disorder, mood disorder, and delirium. R201's Minimum Data Set (MDS) assessment dated [DATE] was reviewed and revealed R201 had severely impaired cognition and was independent with mobility.
Documentation in the record did not indicate R201's responsible party had been notified of the elopement.On 8/26/25 at 10:25 AM, a review of R202's progress notes revealed an Interdisciplinary Team Note entered into the record on 5/16/25 by Nurse ‘B' that read, (R202) is alert to self and often ambulates throughout the facility with walker.On 5/3/25 he did exit the facility through the front doors and staff saw him and redirected him into the facility.A review of R202's clinical record revealed they admitted to the facility on [DATE] with diagnoses that included: dementia, traumatic brain injury, falls, and muscle weakness. R202's MDS assessment dated [DATE] revealed R202 had severely impaired cognition and was independent with mobility with a walker.
Documentation in the record did not indicate R202's responsible party had been notified of the elopement.On 8/26/25 at 12:35 PM, an interview was conducted with R201's family member/responsible party and they were asked if they had been made aware R201 had eloped through the front door of the facility and said they had not been made aware.A review of a facility provided policy titled, Wandering Resident Exit Seeking Management was conducted and read, .7.
Upon return of an eloped resident:.c.
The resident's family/legal representative shall be notified of the resident's 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
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
08/26/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
West Hickory Haven
3310 W Commerce Rd Milford, MI 48380
SUMMARY STATEMENT OF DEFICIENCIES
in the parking lot, to which they had no explanation.
They were then asked what door R202 eloped from since they were observed by Nurse ‘L' outside of the [NAME] hallway emergency exit and said they did not know but thought it was the front door.
They were asked if they reviewed any camera footage from front lobby door to aid their investigation and said they did not.
Finally, they were asked if they interviewed any involved staff members regarding the incident and said they did not.On 8/26/25 at 3:20 PM, a review of a facility provided policy titled, Accident/Incident Reports was conducted and read, Policy: It is the policy of this facility to complete an accident/incident report for.accidents or incidents where there is injury or the potential to result in injury.Purpose: To establish a standard accident/incident completion and to ensure the facility meets the responsibility to make every effort to decrease the likelihood of a recurrence by investigating incidents, understand how they occur and take appropriate preventive action.3. RESPONSE TO A SOUNDING DOOR ALARM.b.
Check the exit door for any exiting residents by means of a visual check. A visual check means observing the area around the exit and may require leaving the building and checking the grounds. c. If an exit door alarm is triggered, the cause is evaluated and re-set after the resident is re-directed and their safety is assured.
Facility ID: