Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Village Of East Harbor during CMS and state inspections, most recent first.
A resident requiring total assistance for transfers, including a physician order for a two-person mechanical lift, was manually transferred to and from the toilet by a CNA, with a second CNA assisting only for the return transfer. Staff interviews confirmed knowledge of the required protocol, but the transfer was not performed as ordered.
The facility failed to provide eight consecutive hours of RN coverage on five days, affecting all 92 residents. A review of PBJ data and daily nursing staff postings revealed multiple days without RN hours. The DON acknowledged the difficulty in securing RN coverage and noted the issue is being addressed in the QAPI process. The facility lacked a policy on RN coverage.
The facility failed to maintain food safety and sanitation standards, with issues such as improper storage of raw and cooked meats, unclean equipment, and inadequate pest control. Observations included a buildup of trash and dust in the dry storage room, improper storage of raw meats in the walk-in cooler, and unsanitary conditions in the dish machine room. Additionally, a staff member was observed preparing food without a beard restraint, and the dish machine in the Ontario kitchenette was not reaching proper sanitization temperatures.
The facility failed to provide a safe and comfortable environment for two residents due to a malfunctioning heating unit, leading to the use of space heaters in their room. A resident with multiple sclerosis and another with hemiplegia reported that the heating unit had been broken for months, and staff confirmed the use of space heaters. The Maintenance Director and Nursing Home Administrator were aware of the issue, with the latter stating that space heaters were for short-term use only.
The facility failed to properly apply orthotic devices for two residents, leading to discomfort and potential ineffectiveness. One resident had a misaligned cervical collar, allowing unwanted head movement, while another had a TLSO improperly positioned and was missing a wrist splint. Staff acknowledged the correct application methods, but the physician's orders were not followed.
The facility failed to properly label and store medications, as observed in a medication cart and a resident's room. Brimonidine Tartrate Ophthalmic eye drops were found unlabeled on a resident's overbed table without a physician order for self-administration. Additionally, an opened bottle of Nuplazid 34 was found in a medication cart without an open date. Interviews with LPNs confirmed that medications should not be at the resident's bedside and should be labeled and dated when opened.
The facility failed to document and include residents and their representatives in care conferences, affecting six residents. Despite having intact cognition and needing assistance with ADLs, these residents were not invited or included in their care planning, contrary to the facility's policy.
The facility failed to provide six residents with the grievance procedure or document the resolution of concerns identified during resident council meetings. Residents reported unmet care needs, long call light wait times, poor staff attitudes, and issues with dining, housekeeping, and laundry services. Despite recurring complaints, there was no documentation of follow-up or resolution.
The facility failed to implement fall care plan interventions for a high fall risk resident with a history of a fractured right femur, muscle weakness, and difficulty in walking. Despite the care plan specifying the use of a landing strip, anti-roll back on the wheelchair, and a Dycem nonskid pad, these interventions were not in place when observed. The DON confirmed that the interventions should have been implemented, but they were missing after the resident moved to a new room.
The facility failed to ensure that inhalers were labeled with a resident identifier and dated when opened in one of four medication carts. The DON confirmed that the expectation was to date and initial the inhalers with the date opened and resident initials. The facility's policy and the manufacturer's prescribing information both require proper labeling and dating of inhalers.
Failure to Follow Physician-Ordered Two-Person Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dementia, anxiety disorder, and osteoarthritis, who was dependent on staff for all activities of daily living and had a physician order requiring transfer with a mechanical sit-to-stand lift and two-person assistance, was manually transferred to and from the toilet by staff. On the date in question, a certified nursing assistant (CNA) manually transferred the resident onto the toilet without assistance from another staff member and without using the required mechanical lift. The CNA then requested help from another CNA to manually transfer the resident off the toilet, again not using the mechanical lift as ordered. Interviews with staff confirmed awareness of the physician's order for two-person mechanical lift transfers, and the unit manager acknowledged that the transfer should have been performed according to the order. The facility's policy also required safe transfers per ordered status. The incident was reported by the resident's family member, and facility documentation confirmed that the staff did not follow the ordered transfer protocol for the resident.
Failure to Provide Adequate RN Coverage
Penalty
Summary
The facility failed to provide eight consecutive hours of Registered Nurse (RN) coverage for five days during the period from October 1, 2024, to April 1, 2025, potentially affecting all 92 residents. A review of the Payroll-Based Journal (PBJ) data submission identified the facility as having four or more days without adequate RN coverage for the most recent annual quarter. Further examination of the facility's daily nursing staff postings revealed a total of 39 days during the quarter with no RN hours recorded. Upon request, the Director of Nursing (DON) provided documentation, including timeclock punch records, which confirmed five specific days with no RN coverage: October 13, 2024, October 26, 2024, November 23, 2024, December 25, 2024, and January 4, 2025. The DON acknowledged the difficulty in securing RN coverage and noted that the issue is being addressed in the facility's Quality Assurance and Performance Improvement (QAPI) process. Additionally, the facility did not have a policy addressing RN coverage.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations during the survey. In the dry storage room, there was a significant accumulation of trash on the floor beneath the racks, and the ceiling vent cover was coated with dust, violating the FDA Food Code's requirements for clean ventilation systems. In the walk-in cooler, raw beef and chicken were improperly stored next to fully cooked ham, posing a risk of cross-contamination. Additionally, the flooring beneath the juice machines was covered with a thick layer of brown, syrupy sludge, and the drip pans on the juice machines contained a thick layer of gelatinous juice. The dish machine room had a leaking pipe under the soiled drainboard, resulting in standing water and a black, slimy substance on the tiles, along with a leaking drain pipe for the garbage grinder, which attracted swarms of gnats. Further deficiencies were noted in the Ontario kitchenette, where the interior of the microwave was soiled with splattered food, and the wall behind the counter had large areas of peeling paint. A dietary aide was observed operating the dish machine, which was not reaching the proper sanitization temperature, leading to the decision to clean dishes in the main kitchen instead. Additionally, a staff member was observed preparing food without a beard restraint, contrary to FDA Food Code requirements. The [NAME] kitchenette's microwave was heavily soiled, and there was no dish machine log available, although the machine was reportedly used for cleaning coffee pots. These observations indicate a failure to maintain cleanliness and proper food safety protocols, as required by the FDA Food Code.
Use of Space Heaters Due to Malfunctioning Heating Unit
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for two residents, as space heaters were used in their room due to a malfunctioning heating unit. Resident 49 was observed with a space heater near the room's heating and cooling unit, which was not functioning. The resident reported that space heaters had been used since the fall because the room's heating was not working properly, and maintenance staff had provided the heaters. Interviews with staff, including a Licensed Practical Nurse and a Certified Nursing Assistant, confirmed that the room's heating unit had not been working for at least two months, and space heaters were being used to heat the room. Resident 49 was admitted with diagnoses of multiple sclerosis and muscle weakness, and had intact cognition with a Brief Interview for Mental Status (BIMS) score of 15/15. Resident 51, who shared the room, reported that the heating unit had been broken since early winter, and space heaters had been used throughout the winter. Resident 51 was admitted with hemiplegia and hemiparesis following a stroke, with a BIMS score of 11/15, indicating moderately impaired cognition. The Maintenance Director acknowledged the problem with the heating unit but could not provide an exact timeline for the issue. The Nursing Home Administrator was aware of the malfunctioning heater and stated that space heaters were intended for short-term and emergency use only.
Improper Application of Orthotic Devices for Two Residents
Penalty
Summary
The facility failed to ensure proper application of protective orthotic devices for two residents, leading to discomfort and potential ineffectiveness of the devices. Resident R261 was observed with a misaligned rigid cervical collar, which was not snugly positioned under the chin, allowing for unwanted head movement. Despite the resident's intact cognition and ability to express discomfort, the collar remained improperly fitted. The staff, including a therapist and a registered nurse, acknowledged the correct application method but did not ensure it was followed. The physician's orders required the collar to be worn at all times, yet the improper application persisted. Resident R256 was observed with a Thoracic Lumbar Support Orthotic (TLSO) improperly positioned high on the torso while sitting in a recliner, which was not recommended. This misplacement was attributed to the resident sliding down in the chair, as noted by a Physical Therapy Assistant. Additionally, the resident was not wearing a required wrist splint, with no explanation provided for its absence. The resident had moderately impaired cognition and required substantial assistance with daily activities. The physician's orders specified the use of the TLSO when out of bed and the wrist splint at all times, but these directives were not adhered to. The facility's policy did not provide guidance on the application of devices accompanying residents upon admission.
Improper Medication Labeling and Storage
Penalty
Summary
The facility failed to properly label and store medications, as observed in one of four medication carts and in a resident's room. On March 31, 2025, Brimonidine Tartrate Ophthalmic eye drops were found on the overbed table of a resident, R3, without a label indicating R3's name, and there was no physician order for self-administration. This medication was accessible to anyone passing by. Additionally, on April 1, 2025, a previously opened bottle of Nuplazid 34 was found in the top drawer of Cart 2 on the 300 Hall without an open date. Interviews with LPN H and LPN I confirmed that medications should not be at the resident's bedside and should be labeled and dated when opened.
Failure to Include Residents in Care Conferences
Penalty
Summary
The facility failed to document and include residents and their representatives in care conferences for six residents. Resident #50, who has Type 2 diabetes and Schizoaffective disorder with moderately impaired cognition, was not invited to care conferences on three separate occasions. The resident expressed a desire to be included, but the Social Worker could not provide documentation of any invitations or participation. The Director of Nursing confirmed that residents and their representatives should be invited and given opportunities to attend care conferences, but this was not done for Resident #50. During a group meeting, six residents reported they were not routinely included or invited to their care conferences and were not provided with copies of their care plans. One resident only became aware of their care conference through their representative. Specific reviews of records for Residents #47, #26, #1, #4, and #21 revealed similar issues, with many instances of care conferences being held without the residents or their representatives being documented as present. Some residents had intact cognition and expressed a need for assistance with all Activities of Daily Living (ADLs), yet they were still not included in their care planning. The facility's policy, last reviewed in 2016, states that residents and their representatives should be invited to care conferences. The Social Worker is responsible for maintaining a calendar and informing participants, but this procedure was not followed. The lack of documentation and inclusion of residents and their representatives in care conferences indicates a failure to adhere to the facility's own policy and regulatory requirements for person-centered care planning.
Failure to Address Resident Grievances and Document Resolutions
Penalty
Summary
The facility failed to provide six residents with the grievance procedure or document the resolution of concerns identified during the resident council meetings. The residents reported a lack of knowledge about the grievance process and stated that all complaints had been verbal with no written follow-up or resolution provided. The residents voiced repeated concerns about various issues, including staffing agency and nighttime staff not wearing name badges, unmet care needs, extended periods on the toilet, damaged clothes, long call light wait times, and poor staff attitudes. Additionally, there were complaints about dining services, housekeeping, and laundry services, with specific examples of cold food, sticky floors, and unreturned laundry. A review of the Resident Council notes from multiple dates revealed consistent complaints about CNA behavior, such as not answering call lights, turning off call lights without returning, talking on personal phones during patient care, and not wearing name badges. There were also issues with dining services, such as cold food, inconsistent condiments, and running out of certain food items. Housekeeping and laundry services were also criticized for not maintaining cleanliness and not returning laundry promptly. Despite these recurring issues, there was no documentation of follow-up or resolution in the meeting minutes. The Wellness Coordinator (WC) and the Director of Nursing (DON) confirmed the use of agency staff, mostly on the night shift, and acknowledged the residents' preference for house staff. The WC reported that copies of the resident council minutes were sent to the appropriate departments for resolution, but there was no evidence of a documented plan or response brought back to the residents. The facility's policies on complaint assistance and resident council meetings outlined procedures for addressing concerns, but these procedures were not effectively implemented, leading to unresolved grievances and ongoing resident dissatisfaction.
Failure to Implement Fall Care Plan Interventions
Penalty
Summary
The facility failed to implement the fall care plan interventions for a resident (R32) who was identified as a high fall risk. R32, who had a history of a fractured right femur, muscle weakness, and difficulty in walking, required one-person assistance with bed mobility and transfers. Despite the care plan specifying the use of a landing strip next to the bed, an anti-roll back on the wheelchair, and a Dycem nonskid pad on the wheelchair, these interventions were not in place when observed by the surveyor. R32 mentioned that they often transferred themselves and that staff reminded them to use the call light, but the necessary safety measures were not implemented in their new room after moving from another side of the facility. During an interview, the Director of Nursing (DON) confirmed that the expectation was for fall interventions from the care plan to be implemented. However, the observations on 4/18/2024 revealed that the specified interventions were missing. The facility's policy on Comprehensive Fall Risk Reduction Program mandates that the resident environment should be free of accident hazards and that residents should receive adequate supervision and assistive devices to prevent falls. The failure to implement these interventions directly contradicts this policy, leading to a deficiency in the care provided to R32.
Failure to Label and Date Inhalers
Penalty
Summary
The facility failed to ensure that inhalers were labeled with a resident identifier and dated when opened in one of four medication carts. During an observation on 04/17/24, it was found that one Trelegy inhaler in the Michigan 2A medication cart did not have the name or the date opened on the inhaler. Additionally, two of the three other Trelegy inhalers did not have the name, and the third did not have a date on the inhaler. The Director of Nursing (DON) confirmed that the expectation was to date and initial the inhalers with the date opened and resident initials. The facility's policy on medication storage, last reviewed in 04/24, requires that inhalers be labeled with the resident's name and stored in the original box from the pharmacy. The manufacturer's prescribing information for the Trelegy inhaler also specifies that the inhaler should be thrown away 6 weeks after opening or when the counter reads 0, whichever comes first, and that the date of opening should be written on the label.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chesterfield Township
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Michigan Veterans Home Of Chesterfield Township | 2.9 mi | — | 1 | 0 |
| Martha T Berry Mcf | 7.2 mi | — | 7 | 0 |
| Lakepointe Senior Care And Rehabilitation Center | 8.6 mi | — | 0 | 0 |
| Medilodge Of Richmond | 9.4 mi | — | 1 | 0 |
| Church Of Christ Care Center | 9.7 mi | — | 1 | 0 |
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