Faith Haven Senior Care Centre

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

for not following through with a doctor's order. It also noted a prior written warning on 6/2/25 with no substantial improvement since. An Employee Warning Record dated 7/25/25 cited disciplinary action for the 6/25/25 incident. The summary noted that RN C communicated a verbal physician's order in a way that made the resident feel threatened, though the investigation did not find intent to threaten. It recommended better tone, body language, and communication during stressful situations. It further stated that when an order needs clarification, the provider must be contacted immediately and documentation must reflect all steps taken to process or delay a physician's order.In an interview on 8/21/25 at 10:11 AM, RN C stated that on 6/25/25, she assisted staff with addressing Resident R1's change in condition. RN C felt that the medication that Resident R1 was taking and her recent diagnosis of bronchitis had affected her respiratory status. RN C reported calling PA T and receiving a verbal order to hold all narcotic medication, however when asked why RN C did not document this order, RN C admitted that she did not and per best standards of practice, RN C should have. RN C stated that she applied 2L oxygen via nasal cannula, and Resident R1 perked back up and returned to baseline. RN C reported that Resident R1 repeatedly refused transport to the Emergency Department, however, RN C felt she should go because of her unstable vital signs. Regarding the verbal Physician order for Resident R1's pain medication, RN C admitted that she did not put the order in timely because she felt it required provider clarification, however, made no timely attempts to obtain provider clarification. Of note, per the EMS prehospital summary, Resident R1's vital signs were as follows:6/25/25 at 10:41 AM (seven minutes after arrival) Blood pressure 139/75 Pulse 54 SPO2 93%. At 11:06 AM (while still at the facility) blood pressure 127/67 Pulse 77 SPO2 92%. The vitals show that Resident R1 was hemodynamically stable.When asked, RN C stated that she did not call back PA T after resolution of Resident R1's symptoms and notify PA T that the acute change in condition had resolved and to inquire of holding Resident R1's medications would still be necessary.In an

interview on 8/21/25 at 10:11 AM, covering NHA E stated that after reviewing the grievances dated 7/5/25,

it was clear that these concerns were allegations of abuse and should have been reported to the State Agency within the two-hour time frame. The Facility Reported Incident was not reported until 7/25/25, 20 days later. As a result of these practices, Resident R1 stated that she experienced significant psychological distress, humiliation, and fear for her safety. She reported being targeted, made to feel insignificant, and described RN C as emotionally and verbally abusive, triggering symptoms of Post-Traumatic Stress Disorder (PTSD).

Multiple staff corroborated that RN C threatened to withhold Resident R1's pain medications, coerced her into transferring to the hospital, told her you're going to die because of her prescriptions, and openly ridiculed her while she was crying in pain.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Faith Haven Senior Care Centre

6531 W Michigan Avenue Jackson, MI 49201

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

calling PA T and receiving a verbal order to hold all narcotic medication, however when asked why RN C did not document this order, RN C stated that she did not and per best standards of practice. Regarding the verbal Physician order for Resident R1's pain medication, RN C stated that she did not put the order in timely because she felt it required provider clarification. RN C stated that she did not call back PA T after resolution of Resident R1's symptoms and notify PA T that the acute change in condition had resolved and to inquire of holding Resident R1's medications would still be necessary.In an interview on 8/21/25 at 10:11 AM, covering NHA E stated that after reviewing the grievances dated 7/5/25, it was clear that these concerns were allegations of abuse and should have been reported to the State Agency within the two-hour time frame. The Facility Reported Incident was not reported until 7/25/25, 20 days later.As a result of these practices, Resident R1 stated that

she experienced significant psychological distress, humiliation, and fear for her safety. She reported being targeted, made to feel insignificant, Multiple staff corroborated that RN C threatened to withhold Resident R1's pain medications, coerced her into transferring to the hospital, told her you're going to die because of her prescriptions, and openly ridiculed her while she was crying in pain.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Faith Haven Senior Care Centre

6531 W Michigan Avenue Jackson, MI 49201

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited Faith Haven Senior Care Centre in Jackson, MI for a deficiency under regulatory tag F-F0609 during a complaint investigation conducted on 2025-08-21.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 3 deficiencies cited during this inspection of Faith Haven Senior Care Centre.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-08-28.