West Hickory Haven

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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 Resident R201's progress notes revealed an Interdisciplinary Team Note entered into the record on 5/16/25 by Nurse ‘B' that read, (Resident 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 Resident R201's clinical record revealed they admitted to the facility on [DATE REDACTED] with diagnoses that included Alzheimer's disease, adjustment disorder, mood disorder, and delirium. Resident R201's Minimum Data Set (MDS) assessment dated [DATE REDACTED] was reviewed and revealed Resident R201 had severely impaired cognition and was independent with mobility. Documentation in the record did not indicate Resident R201's responsible party had been notified of the elopement.On 8/26/25 at 10:25 AM, a review of Resident R202's progress notes revealed an Interdisciplinary Team Note entered into the record on 5/16/25 by Nurse ‘B' that read, (Resident 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 Resident R202's clinical record revealed they admitted to the facility on [DATE REDACTED] with diagnoses that included: dementia, traumatic brain injury, falls, and muscle weakness. Resident R202's MDS assessment dated [DATE REDACTED] revealed Resident R202 had severely impaired cognition and was independent with mobility with a walker.

Documentation in the record did not indicate Resident R202's responsible party had been notified of the elopement.On 8/26/25 at 12:35 PM, an interview was conducted with Resident R201's family member/responsible party and they were asked if they had been made aware Resident 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

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/26/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

West Hickory Haven

3310 W Commerce Rd Milford, MI 48380

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

in the parking lot, to which they had no explanation. They were then asked what door Resident 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.

Event ID:

Facility ID:

If continuation sheet