The Village of East Harbor

In the surveyor’s words

From the most serious findings on record at The Village of East Harbor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 4, 2023

  This citation pertains to Intake: MI00136749. Based on interview, and record review, the facility failed to provide adequate monitoring and supervision to prevent an elopement for one resident (R901) who had a severe cognitive impairment, was a known elopement risk, and wore a WanderGuard (a bracelet used to set off an alarm restricting a resident from walking out of the door). R901 eloped from the facility on 5/15/2023 at approximately 3:25pm without facility staff being aware of the resident's whereabouts. R901 was allowed to exit the facility by a staff member that was unfamiliar with the resident at approximately 3:25pm. […]

• No harm, potential for more than minimal, widespreadF812Jun 11, 2026

  Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety, resulting in the potential to spread food borne illness among all residents that consume food from the kitchen. Findings include:On 06/09/2026 between 9:05 AM-9:35 AM, during an initial observation of the kitchen with Dietary Manager (DM) F, the following items were observed: There was a personal cell phone and a portable speaker on the food preparation counter, directly next to a pan of uncovered pastries. When queried about the cell phone, DM F immediately removed the phone and speaker from the food preparation table but provided no further explanation. […]

• No harm, potential for more than minimal, widespreadF727Apr 2, 2025

  Based on interview and record review, the facility failed to provide eight consecutive hours of Registered Nurse (RN) coverage for five days of the period from 10/01/24 until 04/01/25 potentially affecting all 92 residents that residen in the facility. Findings include: Review of the Payroll-Based Journal (PBJ) data submission revealed the facility had been identified as having four or more days without adequate RN coverage for the most recent annual quarter. Review of the facility daily nursing staff postings revealed a total of 39 days during the quarter showing no RN hours for the day. […]

• No harm, potential for more than minimal, widespreadF812Apr 2, 2025

  Based on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen. Findings include: In the dry storage room, there was a buildup of trash on the floor underneath the racks, and the ceiling vent cover was coated with dust. According to the 2017 FDA Food Code section 6-501.14 Cleaning Ventilation Systems, Nuisance and Discharge Prohibition, (A) Intake and exhaust air ducts shall be cleaned and filters changed so they are not a source of contamination by dust, dirt, and other materials. In the walk-in cooler, there was raw beef and raw chicken stored next to fully cooked ham. […]

• No harm, potential for more than minimal, widespreadF727Feb 10, 2022

  Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, affecting all residents residing in the facility, resulting in the likelihood of inadequate coordination of emergent or routine care that could cause negative resident outcomes. Findings include: A review of 18 months of daily staffing postings were completed and revealed numerous dates where there was no RN coverage in the facility. On 2/10/2022 at 11:26 AM, Staffing Coordinator C was asked about RN staffing on numerous dates, and she indicated that she would get back with the surveyor as there was some confusion related to who could be considered counted as an RN. […]