West Hickory Haven
West Hickory Haven in Milford, MI — inspection on October 29, 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
care and reapproach after a moment and notify the nurse in case the resident was experiencing any
care.A review of a facility policy titled, Restraint Protocol, revised November 2008, revealed, in part,
.restraints used for the purpose of discipline or for staff convenience .Physical Restraints: Is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body .
235262 10/29/2025
West Hickory Haven 3310 W Commerce Rd Milford, MI 48380
given her an incident report to fill out, but she did not. CNA 'G' reported she thought the nurse reported
contacted the DON, approximately 9-10 hours after she initially saw R801 restrained. On 10/29/25 at
interview prior to the end of the survey.A review of a statement given by CNA 'H' that was included in the facility's investigation revealed CNA 'H' said, I came in as (CNA 'C' and CNA 'D') were leaving (on 10/14/25).
They said there was nothing special to report. I started rounds and found (R801) with her shirt sleeves tied together at the end. I got (CNA 'G') and we both agreed it was not right .could not move her arms freely. I waited until (RN 'E') was done with narcotic count to report to (RN 'E') .(RN 'E') and I went to (R801's) room and untied her sleeves .On 10/29/25 at 2:06 PM, an interview was conducted with the Administrator.
The Administrator reported she was not the Abuse Coordinator for the facility and that was the Director of Nursing (DON) who was not available during the survey.
The Administrator reported she was still made aware of any abuse situations in the facility and was made aware of R801 being physically restrained.
When queried about the process for reporting any alleged or actual abuse, the Administrator reported staff were required to report immediately to the Abuse Coordinator and the alleged perpetrator was suspended immediately pending investigation.
The Administrator reported RN 'E' should have reported it as soon as she found out, as well as CNA 'G' and CNA 'H'.
The Administrator reported RN 'E's employment was terminated, but explained it was for other reasons. CNA 'G' and CNA 'H' were educated about abuse reporting with the rest of the staff but did not receive any disciplinary action. A review of CNA 'C's time punches revealed she punched in at 6:40 AM on 10/14/25 and punched out at 10:41 PM. CNA 'C' punched in at 6:35 AM and punched out at 9:49 PM which indicated she worked almost two whole shifts the following day after she physically restrained R801.A review of CNA 'D''s time punches revealed she punched in at 6:27 AM on 10/14/25 and punched out at 10:42 PM. CNA 'D' punched in at 6:27 AM on 10/15/25 and punched out at 2:43 PM which indicated she worked the entire day shift on 10/15/25, the day after R801 was found to be restrained. A review of a facility policy titled, Abuse/Suspected Abuse; Crime Investigation & Reporting, revised February 2023, revealed, in part, the following, .Any person(s) witnessing or having knowledge of potential or actual abuse or crime must immediately report the incident to the Administrator and/or designee .the facility will report all alleged violations to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigations .Reports are submitted online into the (SSA electronic reporting system) .Immediately but no later than 2 hours if the alleged violation involves abuse .
The policy noted the facility had 24 hours to report mistreatment, however, that does not meet regulatory requirements for abuse reporting.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.