West Hickory Haven

F 0604 Level of Harm - Actual harm Residents Affected - Few

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

CNA 'G' reported Resident R801 was on hospice and can't really move. CNA 'G' explained that when anyone does any kind of care, Resident R801 was kind of resistive, but does not strike out or yell or anything. She tries to hold her gown or a blanket. CNA 'G' felt Resident R801 did that because she had pain. Further review of Resident R801's clinical

record revealed no documented behaviors for 10/14/25. A review of Resident R801's care plans revealed no specific or individualized targeted behaviors or interventions until after Resident R801 was physically restrained on 10/14/25.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 Resident R801 being physically restrained. The Administrator reported CNA 'C''s employment with the facility was terminated after the incident. On 10/29/25 at 2:44 PM,

an interview was conducted with Unit Manager, RN 'A'. When queried about Resident R801 and what staff should do if she became resistive to care or had any combative behaviors, RN 'A' reported staff should stop care and reapproach after a moment and notify the nurse in case the resident was experiencing any pain. RN 'A' reported typically one staff member held Resident R801's hand while the other one provided the care.A review of a facility policy titled, Restraint Protocol, revised November 2008, revealed, in part, the following, It is the policy of this facility to ensure the residents right to be free from physical .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 .

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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

10/29/2025

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

walked from room to room prior to leaving, but they said everyone was fine and left. CNA 'G' began rounds when CNA 'H' came to her and showed her that Resident R801's shirt sleeves were tied together. CNA 'G' described

it as both sleeves were tied together so when Resident R801 lifted her hands it formed a circle. CNA 'G' reported Resident R801 was unable to move her arms. CNA 'G' explained CNA 'H' got the nurse (RN 'E') and CNA 'H' and the nurse untied Resident R801's sleeves. CNA 'G' reported when she left for her shift, the same CNAs (CNA 'C' and CNA 'D') arrived for their shift (day shift) and she brought up how she found Resident R801 restrained and they denied that they did it. When queried about whether she reported Resident R801 being physically restrained to anyone other than RN 'E', CNA 'G' reported she thought the nurse would have given her an incident report to fill out, but she did not. CNA 'G' reported she thought the nurse reported the incident and the facility would contact her for a statement. CNA 'G' explained she left her shift and went home and slept and when

she woke up realized nobody called her. At that time, she contacted the DON, approximately 9-10 hours

after she initially saw Resident R801 restrained. On 10/29/25 at 1:26 PM, an interview was attempted via the telephone with CNA 'H'. CNA 'H' was not available for an 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 (Resident 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 (Resident 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 Resident 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 Resident 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 Resident 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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