South Haven Nursing and Rehabilitation Community

In the surveyor’s words

From the most serious findings on record at South Haven Nursing and Rehabilitation Community, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 18, 2025

  This citation pertains to intake: MI00151221 Based on observation, interview, and record review the facility failed to ensure the safety and prevent an elopement of 1 (Resident #1) of 2 residents who were assessed to be at risk for elopement, resulting in an Immediate Jeopardy when Resident #1 left the premises alone, unbeknownst to staff, and was later observed (by a staff member who happened to drive by) walking along the road on 2/28/25, and was returned to the facility at approximately 3:30 pm. The elopement placed Resident #1 at risk serious harm, serious injury, and/or death. […]

• Immediate jeopardy, isolatedF600Jun 8, 2022

  This citation pertains to Intake # MI 728 & # MI 892. Based on observation, interview, and record review, the facility failed to prevent a resident-to-resident incident involving sexual abuse in 2 of 13 residents (Resident #6 & #7) reviewed for abuse, resulting in an Immediate Jeopardy when on 5/21/21 at approximately 5:45 p.m., Resident #7 (a cognitively impaired female) was found in Resident #6's bed (a cognitively intact male). Both residents were noted to be naked from the waist down. […]

• Immediate jeopardy, isolatedF608Jun 8, 2022

  This citation pertains to Intake # MI 728 & # MI 892. Based on interview, and record review, the facility failed to report a reasonable suspicion of a crime to the police in a timely manner in 2 of 13 residents (Resident #6 & #7) reviewed for abuse, resulting in an Immediate Jeopardy when on 5/21/21 at approximately 5:45 p.m., Resident #7 (a cognitively impaired female) was found in Resident #6's bed (a cognitively intact male). Both residents were noted to be naked from the waist down. The police were not notified upon identification of the incident, evidence was not collected, and the scene was not preserved. […]

• Actual harm, isolatedF689Nov 2, 2022

  This citation pertains to intake MI 216 Based on observation, interview, and record review, the facility failed to ensure a safe environment and implement safety interventions for 1 (R51) of 23 residents reviewed for accidents and hazards, resulting in a fall with a cervical spine fracture and facial laceration, and the increased potential for further falls with injuries. Findings include: According to www.ncbi.nlm.nih.gov, The first vertebra (C1), also called the atlas, is a ring-shaped bone that begins at the base of your skull. The atlas holds the head upright. […]

• No harm, potential for more than minimal, widespreadF880Dec 17, 2025

  Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility.Findings include:On 12/16/2025 starting at 9:25 AM, a tour of the kitchen found possible stagnant domestic water lines. One hot water fixture was capped off, by the coffee area, with no evidence of routine flushing. Two other water lines were protruding from the wall back by the walk-in cooler door, with no evidence the lines were regularly flushed. When asked if the maintenance director was here today, [NAME] KK stated that he has been off a couple weeks. […]