West Hickory Haven

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include: On 06/01/2026 at 9:00 AM during a kitchen tour with dietary manager (DM) J observed the walk-in cooler gasket soiled with black build up. When queried, DM J indicated she concurred it was soiled and in need of cleaning and would ensure it was cleaned or possibly changed. According to the 2022 FDA Food Code section 4-602.13 Nonfood-Contact Surfaces. NonFOOD-CONTACT SURFACES of EQUIPMENT shall be cleaned at a frequency necessary to preclude accumulation of soil residues. On 06/01/2026 at 9:03 AM Observed 2 in-use juice guns visibly soiled with dried red build up inside the nozzles. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an effective infection prevention and control program that included a system for identifying, water management, hand hygiene and mapping.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an effective infection prevention and control program that included a system for an ongoing antibiotic stewardship program

Inspectors wroteThis citation pertains to complaint 2797202. Based on interview and record review, the facility failed to permit a resident to return to the facility following a transfer to hospital for one (R902) of four residents reviewed for discharge.

Inspectors wroteThis citation pertains to complaint 2797202. Based on interview and record review, the facility failed to provide the legal representative a written notice of transfer/discharge and send a copy to the Ombudsman for one (R902) of four residents reviewed for discharge.

Inspectors wroteThis 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.

Inspectors wroteThis citation pertains to intake 2615411Based on record review and interview, the facility failed to secure medication storage in an unlocked medication cart (Sapphire Cart) allowing one resident (R904) to gain access to another resident's medications resulting in one medication, Namenda (medication to treat moderate to severe dementia) never recovered. Findings Included:A Facility Reported Incident (FRI) received by the State Agency revealed on 9/1/25 at 9:30 AM, R904 was observed with three pill packets and several loose pills in their left pant pocket. All medications were reconciled apart from the Namenda. Clinical record review revealed R904 was admitted to the facility on [DATE] for long term care and had a medical history of diabetes, urinary retention, and falls related to muscle weakness. [...]

Inspectors wroteThis 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.

Inspectors wroteThis citation pertains to Complaint #2649116 and Incident #2652020. Based on observation, interview, and record review, the facility failed to report an allegation of abuse to the Abuse Coordinator and State Survey Agency within the required timeframe for one (R801) of three residents reviewed for abuse, resulting in a delay in investigation and the alleged perpetrators continuing to work with the victim.

Inspectors wroteThis 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.

Inspectors wroteThis citation pertains to intake #2581294Based on interview and record review the facility failed to notify the resident's responsible parties of an elopement for two residents (R#'s 201 and 202) of three residents reviewed for changes of condition.

Inspectors wroteThis citation relates to Intake: 1195243. Based on observation, interview, and record review, the facility failed to provide a safe, comfortable homelike environment for six Residents (R400, R401, R402, R403, R404, R405) of six residents reviewed for resident rights.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents personnel clothing was routinely returned to them from laundry for three residents (R39, R57 and R56) and multiple residents who asked to remain anonymous at the resident council meeting. This had the potential to affect all residents who relied on the facility to care for their laundry.

Inspectors wroteBased on observation, interview and record reviews the facility failed to ensure all staff, including agency staff could timely identify a resident's code status (R72) in the event of an emergency, failed to ensure the physician orders reflected the resident's wishes regarding their code status for four (R's 72, 51, 56 & 174 of four residents reviewed for code statuses. This deficient practice had the ability to affect all 74 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview and record review, the facility failed to appropriately transfer a resident per their assessed needs for two (R51 and R64) of six residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review, the facility to provide adequate care coordination related to hospice services for one Resident (R52) of two residents reviewed for hospice services.

Inspectors wroteThis citation pertains to intake #MI00148743. Based on observation, interview, and record review the facility failed to ensure a sanitary kitchen, food items past their use date were discarded, and food was labeled with an open and use-by date. This deficient practice had the potential to affect all residents who consume meals from the kitchen.

Inspectors wroteThis citation pertains to intake #MI00148257. Based on observation, interview and record review, the facility failed to ensure monitoring and documentation of specific targeted symptoms/behaviors and attempts and non-pharmacological interventions prior to the use of PRN (as needed) anti-anxiety medications for one resident (R#501) of three residents reviewed for psychotropic medications.

Inspectors wroteThis citation pertains to Intake Number: MI00146312 Based on interview and record review, the facility failed to protect the residents' right to be free from physical abuse by a resident for two (R805 and R808) of five residents reviewed for abuse, resulting in R806 punching R808 in the head and six days later R806 punching R805 in the face, neck and chest causing psychosocial harm using the reasonable person concept.

Inspectors wroteThis citation pertains to Intake Number(s): MI00146702. Based on observation, interview, and record review, the facility failed to thoroughly assess a resident with a change in condition and notify the physician for one (R801) of two residents reviewed for changes in condition.

Inspectors wroteThis citation pertains to Intake #MI00146039 Based on observation, interview and record review the facility failed to ensure a resident received proper care to prevent a fall for one (R807) of two reviewed for falls.

Inspectors wroteThis citation pertains to intake #MI00143690. Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for two (R905 & R906) of nine residents reviewed for abuse resulting in R906's right arm fracture when R906 was pushed to the floor by R905 as heard by (R909).

Inspectors wroteR906 On 4/10/24 at 11:35 AM, R906 was observed in their room with a sling on their right arm. R906 was asked about their arm. R906 explained it was broken, and it was very painful, but they had a difficult time getting pain medications when they asked for them. Review of the clinical record revealed R906 was admitted into the facility on [DATE] and readmitted [DATE] with diagnoses according to the face sheet that included: 3-part fracture of surgical neck of right humerus (right upper arm), dementia with anxiety and insomnia. According to the Minimum Data Set (MDS) assessment dated [DATE], R906 had moderately impaired cognition. [...]

Inspectors wroteThis Citation pertains to intake MI00143562. Based on interview and record review, the facility failed to provide and document evidence of prompt resolution to grievances identified by family for one (R907) resident of one resident reviewed for activity of daily living(ADLs) resulting in unresolved grievances and the potential for the resident not be assisted with meals.

Inspectors wroteThis citation has two deficient practice statements Deficient Practice #1 Based on observation, interview and record review the facility failed to ensure effective interventions to reduce injury from falls were in place for one resident (R19) at risk of falling, of seven residents reviewed for accidents/hazards, resulting in R19 sustaining a non-displaced nasal fracture and diffuse bruising to bridge of nose and surrounding left eye.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were removed from two of three medication carts and one medication storage room and the appropriate locked storage of a Schedule IV medication. Findings Include: On 02/07/2024 at 09:35 AM, An observation of the medication cart stationed on the Sapphire Unit was conducted with Nurse N. Upon review of the resident's daily medication drawer, this surveyor identified a bag from an outside healthcare system pharmacy containing one bottle of Lorazepam 0.5 milligram (mg) tablets. This Surveyor inquired to Nurse N what is the facilities protocol for Lorazepam storage. Nurse N stated Lorazepam should not be stored in the location where it was found by this surveyor. Record review of the facilities Controlled Medication Storage, Security & Disposition Policy (Effective June 2006, Revised: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dignified dining experience for two (R29 and R53) residents reviewed during the dining observation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (R56) of six residents who attended the resident council interview, was allowed to retain possession of their personal property after a temporary room change.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assessments were made following a resident's request to use their personal electronic wheelchair at the facility for one resident (R47) of three residents reviewed for choices.

Inspectors wroteBased on interview and record review the facility failed to appropriately coordinate/update and submit a Level one PASARR (Preadmission screening/annual resident review) form to the LCMHSP (local community mental health services program) for two (R2 and R56) of two residents reviewed for PASARR's.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered and medical treatments were signed as completed appropriately according to professional standards of practice for two (R20 and R3) residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate assistance with eating for one (R41) resident observed during dining observation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly assess a resident who had new onset of pain, contact the physician in a timely manner, and provide treatment according to physician's orders for one (R3) of two residents reviewed for changes in condition.

Inspectors wroteBased on interview and record review the facility failed to ensure timely nutritional assessments and interventions were completed/implemented for one resident (R63) of four residents reviewed for Nutrition.

Inspectors wroteBased on interview and record review the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of a PRN (as needed) anti-anxiety medication for one resident (R6) of five residents reviewed for unnecessary psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident food preferences were honored for four of six anonymous residents who attended the confidential resident council interview.

Inspectors wroteBased on observation, interview, and record review, the facility failed to utilize appropriate hand hygiene during dining assistance for three (R29, R45, and R41) residents observed during the dining observation.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide 80 square feet per resident in multiple resident rooms for 6 of 37 resident rooms (#s: 60, 61, 62, 63, 67 and 70), resulting in the potential for inadequate space. Findings Include: On 02/05/2024, a review of the facility's bed count information sheets, and observation of Medicare/Medicaid resident rooms revealed the following: ROOM SQ. FT. # OF BEDS 60 236 3 61 237 3 62 237 3 63 314 4 67 237 3 70 300 4 The health and safety of the residents were not affected by the room size, and there were no complaints regarding the size of the rooms.