West Hickory Haven

In the surveyor’s words

From the most serious findings on record at West Hickory Haven, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Mar 9, 2023

  This citation pertains to intake MI00133977. Based on observation, interview, and record review the facility failed to protect residents' right to be free from sexual abuse by another resident involving four (R40, R63, R10, and R4) of nine residents reviewed for abuse, resulting in Immediate Jeopardy to health and safety of residents when R40, a male resident, engaged in repeated inappropriate sexual contact with R4, R10, and R63, all of whom were severely cognitively impaired females who were unable to consent. […]

• Immediate jeopardy, isolatedF689Dec 20, 2022

  This citation pertains to Intake Number(s): MI00133117 and MI00132321. Based on observation, interview, and record review the facility failed to respond to an alarming door after one (R801) of three residents reviewed for elopement who had exit seeking behaviors and severely impaired cognition, exited the front door, held open by a visitor, without staff knowledge. This resulted in an Immediate Jeopardy (IJ) to the health and safety of the resident when R801 was found by an off-duty staff member crossing a heavily trafficked road with no sidewalks and was eventually found walking on the side of the road toward oncoming traffic approximately a quarter mile away from the facility. This had the likelihood to cause serious harm, serious injury, and/or death. […]

• Actual harm, isolatedF689Jan 20, 2026

  This citation pertains to Complaint #2709480.Based on observation, interview, and record review, the facility failed to appropriately evaluate the placement of the bed to prevent accident hazards for one (R901) of one resident reviewed for accident hazards, resulting in R901 sustaining a thermal burn to their right great toe after it made contact with the baseboard heater which was directly next to the bed. Findings include: A review of complaints submitted to the State Agency revealed an allegation that R901's foot had direct and prolonged contact with an exposed Hydronic (water) baseboard heat. Due to R901 having neuropathy (damaged nerves), they were unaware they were being burned. […]

• Actual harm, isolatedF604Oct 29, 2025

  This citation pertains to Complaint #2649116 and Incident #2652020.Based on observation, interview, and record review, the facility failed to ensure physical restraints were not utilized for staff convenience to restrict movement of the resident's arms for one (R801) of three residents reviewed for abuse, resulting in a severely cognitively impaired resident's shirt sleeves being tied together to prevent them from grabbing onto staff causing psychosocial harm using the reasonable person concept. […]

• Actual harm, isolatedF689Aug 26, 2025

  This citation has two deficient practices.Deficient Practice #1This citation pertains to intake #2581294Based on interview and record review the facility failed to prevent an avoidable accident for one resident (R203), of three residents reviewed for accident hazards, resulting in injury requiring transfer to the emergency room. Findings include:Based on interview and record review the facility failed to prevent an avoidable accident for one resident (R203), of three residents reviewed for accident hazards, resulting in injury requiring transfer to the emergency room. […]