Faith Haven Senior Care Centre

Inspectors wroteThis citation pertains to Intake: 3011032Based on observation, interview, and record review the facility failed to prevent the development of pressure ulcers for one resident (R1) out of two residents with pressure ulcers reviewed, resulting in the development of R1 facility acquired stage 4 pressure ulcer that required hospital transfer for sepsis related to wound infection and surgical debridement. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that a substantial HS (evening) snack was consistently offered and appropriately distributed to a group of confidential residents that attended the Resident Council Meeting, potentially affecting all residents who receive meals in the facility with 14 or more hours between last evening meal and breakfast the following day, resulting in resident dissatisfaction, frustration and potential for uncontrolled blood sugars, signs and symptoms of hypoglycemia, feeling of hunger, and weight loss.

Inspectors wroteThis Citation Pertains to Intake 2795434Based on observation, interviews and record review, the facility failed to protect the residents' right to be free from abuse verbal and physical from a staff member (CNA D) for one resident (resident #33) of two reviewed.

Inspectors wroteThis Citation Pertain to Intake # 2795434 Based on observation, interview and record review, the facility failed to thoroughly investigate allegations of abuse for one resident (resident #33) of two residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake 2575924Based on interview and record review, the facility failed to protect the resident's right to be free from mental abuse and verbal abuse by a staff member. Findings Include:Review of the medical record reflected that R1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic pain syndrome, carpal tunnel syndrome, jaw pain, muscle spasms, restless legs syndrome, opioid dependence, intervertebral disc disorders (a condition that affects the disc between the vertebrae of the spine), adjustment disorder with mixed anxiety and depression, temporomandibular joint disorder (causing pain and dysfunction of the jaw), migraine, post-traumatic stress disorder, dental caries, anxiety disorder, depression, low back pain, and sciatica. [...]

Inspectors wroteThis citation pertains to intake 2575924Based on interview and record review, the facility failed to honor the residents right to refuse a hospital transfer in one (Resident one) out of three reviewed for resident rights.

Inspectors wroteThis citation pertains to intake 2575924Based on interviews and record review, the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. Findings Include:Review of the medical record reflected that R1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic pain syndrome, carpal tunnel syndrome, jaw pain, muscle spasms, restless legs syndrome, opioid dependence, intervertebral disc disorders (a condition that affects the disc between the vertebrae of the spine), adjustment disorder with mixed anxiety and depression, temporomandibular joint disorder (causing pain and dysfunction of the jaw), migraine, post-traumatic stress disorder, dental caries, anxiety disorder, depression, low back pain, and sciatica. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide restorative services for one residents (R67) of one residents reviewed for restorative care, resulting in the potential for all residents with Restorative Referrals, facility census 77, to decline in their current highest functioning level losing their independence and leading to withdrawal, depression and complications of immobility. Findings Include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R67 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included urinary tract infection, multiple sclerosis(chronic disease of the central nervous system that causes muscle weakness and vision changes), and anxiety disorder. [...]

Inspectors wroteDuring observation of meal service on 01/02/2025 at 11:29 a.m. Culinary Specialist Q was observed temping a cup of coffee. The cup of coffee was covered with plastic wrap. After temping the cup of coffee, Culinary Specialist Q instructed the dietary staff to dump out the four cups of coffee that were pre-poured and covered with a plastic film. Culinary Specialist Q explained that the staff should not pre pour the coffee before service but should obtain the coffee directly from the coffee machine and place the coffee cup on the resident's service food tray. Resident # 61 (R61) Review of the medical record revealed R61 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety, and depression. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to answer call light and provide timely care and services to one residents (R67) of one reviewed, resulting in frustration and embarrassment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that grievances were promptly resolved and/or responded to in a timely manner for 5 of 5 residents that participate in Resident Council (RC) meetings.

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three (R64, R66, R89) of 18 reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive resident-centered care plans for one out of 18 residents (R67), resulting in unmet care needs including restorative therapy within six months of right total shoulder replacement.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure for one out of 18 residents (Resident #41) care plan was revised as needed for changes in care needs. Findings Included: Review of R41's electronic medical record (EMR) revealed R41 was admitted to the facility on [DATE]. Record review of a wound evaluation dated 12/27/2024, revealed R41 had moisture associated skin damage (MASD) incontinence associate damage (IAD) to the sacrum (bone at the base of the spine) area. The MASD was documented to have developed in the facility. Further review of the wound evaluation dated 12/27/2024, revealed the interventions in place were a heel suspension/protection device, mattress with pump, positioning wedge, and a turning/repositioning program. [...]

Inspectors wroteResident #64 (R64) Review of the medical record revealed R64 was admitted [DATE] with diagnoses that included peripheral vascular disease (PVD), type 2 diabetes mellitus, atherosclerotic heart disease (buildup of cholesterol plaque in artery walls), hypertension, history of heart attack, depression, osteoarthritis (type of arthritis that occurs when flexible tissue at the end of bones wears down) bilateral hips, asthma, and schizoaffective disorder bipolar type. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/25/2024, revealed R64 had a Brief Interview of Mental Status (BIMS) of 15 (cognitively intact) out of 15. During observation and interview on 01/02/2025 at 01:36 p.m. R64 was observed lying down in bed. R64 explained that she has stayed at the facility several different times and that after the previous stay she was discharged home. [...]

Inspectors wroteBased observation, interview and record review the facility failed to provide daily oral hygiene for one resident (Resident #5) of two residents reviewed for activities of daily living.

Inspectors wroteBased on observation, interview and record review the facility failed to follow a physician's order, and appropriately position two residents, (R6 and R67), of 18 reviewed for quality of care, resulting in increased likelihood of unmet care needs and potential for worsening of contractors.

Inspectors wroteBased on interview and record review the facility failed to ensure for two of five residents (Resident 41 and 66) pharmacy medication recommendations were followed-up on by the Physician. Findings Included: Resident #41: Per R41's electronic medical record (EMR) R41 was admitted to the facility on [DATE]. Diagnosis included a fracture of the sacrum (bone at the base of the spine). Review of R41's Physician's orders revealed that on 10/5/2024 Tylenol was ordered as needed for pain, Oxycodone was ordered on 10/7/2024 for pain, and Tramadol was ordered on 11/4/2024 for pain. Review of R41's progress notes revealed a Pharmacy Recommendation dated 11/28/2024, of, PHARMACIST RECOMMENDS:: Patient is on three pain medications: Oxycodone, Tramadol and acetaminophen. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered within parameters for one (R66) and the appropriate antibiotic was administered for one (R45) of five reviewed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a gradual dose reduction (GDR) was attempted for one of five residents (Resident #47) in order to reduce the use a psychotropic. Findings Included: Review of Resident #47's electronic medical record (EMR) revealed R47 was admitted to the facility on [DATE]. Review of R47's medication administration record (MAR) for the month of April 2024, revealed R47 was ordered to received Prozac (a psychotropic medication) 40 mg one capsule in the morning for depression and bipolar disorder (a mental disorder of manic swings and depression). Review of behavioral notes dated 8/13/24 revealed Prozac will be attempted to be GDR and will be noted in R47's chart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure timely dental services to obtain dentures for one (R7) of one resident reviewed.

Inspectors wroteThis citation pertains to intake MI00144217. Based on interview and record review, the facility failed to ensure incontinence care was provided in a sanitary manner for one (Resident #6) of four reviewed for infection control.

Inspectors wroteResident #50 According to the clinical record including the Minimum Data Set (MDS) dated [DATE], Resident # 50 (R50) was a [AGE] year old female admitted to the facility with diagnoses that include cerebral vascular accident with right side hemiparesis and hemiplegia affecting the dominant right side. R50 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). During an interview with R50 on 01/10/24 11:38 AM, it was reported she required assistance from 2 staff persons for transfers with the use of a gait belt. R50 stated a few months ago during a weekend the facility was short staffed and Certified Nursing Assistant (CNA) L transferred her to the toilet without the assistance of another CNA. [...]

Inspectors wroteBased on interview and record review, the facility failed to address and resolve grievances reported in Resident Council Meetings as stated by seven of seven residents during a confidential Resident Council meeting resulting in unresolved concerns and unmet needs of residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a quiet homelike environment in the dining rooms and as reported by six of seven residents who attended the confidential Resident Council Meeting resulting in resident dissatisfaction and frustration from constant noise levels.

Inspectors wroteBased on interview and record review the facility failed to ensure the grievance process was explained to residents and where they were located as reported by seven of seven residents during a confidential Resident Council meeting, potentially resulting in unresolved concerns and unmet needs of residents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively maintain the physical plant effecting 75 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the privacy of one resident (Resident 24) of 1 reviewed for privacy, resulting in feelings of mistrust and frustration.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and resident's representative in writing of the reason for transfer/discharge to the hospital for one (Resident #75) of one reviewed for hospitalization, resulting the potential for residents and their representatives to be uninformed of the reason for transfer/discharge to the hospital.

Inspectors wroteBased on interview and record review, the facility failed to access medical equipment needs in one of one residents reviewed for death in facility (Resident #76), resulting in the potential for intermittent airflow blockage during sleep and sudden cardiac death. Findings Include: Resident #76 (R76) R76's history and physical referral from a previous nursing home dated [DATE] revealed she had diagnoses of obstructive sleep apnea (OSA), obesity and diabetes. The same document indicated the plan was to continue use of the continuous positive airway pressure (CPAP, (uses mild air pressure to keep breathing airways open during sleep) machine and monitor lung function. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide clinical rationale in one of five residents reviewed for medications (Resident #58), resulting in the potential for changes to the pH and flora of the gastrointestinal tract, increasing risk of clostridium difficile infections, pneumonias, iron-deficiency anemia, low magnesium levels and fractures.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper communication/documentation of Hospice services provided to one Resident (# 10) of two residents reviewed for Hospice services, resulting in the lack of coordination of comprehensive services and care provided with the potential for mismanagement of care.

Inspectors wroteBased on interview and record review the facility failed to inform and/or educate seven of seven residents who attended the confidential Resident Council meeting about the location of the survey book resulting in residents not being knowledgeable of the survey results occurring in the facility.

Inspectors wroteThis citation pertains to intakes MI110044 and MI00139379. Based on observation, interview and record review, the facility failed to prevent and treat pressure ulcers, in three of three residents reviewed for pressure ulcers (Resident #1, #2, and #3) resulting in worsening of pressure ulcers (Resident #3), facility acquired pressure ulcers, pain, and unmet needs.

Inspectors wroteThis Citation Pertains to Intakes MI00140304, MI00139998 Based on interview, and record review, the facility failed to provide an environment free from verbal abuse for one (#01) of one total sampled resident reviewed for abuse, resulting in the resident having worsened major depression, tearfulness when talking about it and lonely at times. Findings Include Review of the medical record revealed Resident #01 (R01) was admitted to the facility on [DATE] with diagnoses that included major depression, anxiety, obesity, chronic pain syndrome, and Polyosteoarthritis. According to Resident #01 (R01)'s Minimum Data Set (MDS) dated [DATE], revealed R01 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete Minimum Data Set assessments in one of three reviewed for pressure ulcers (Resident #3), resulting in inaccurate care plans and the potential for unmet needs. Findings Include: Resident #3 (R3) In review of R3's admission Nurse assessment dated [DATE], she had a Stage 1 pressure ulcer (alteration of intact skin) on her coccyx (tailbone) and had an indwelling catheter. Physical Therapy Evaluation dated 6/05/23 and diagnoses list revealed R3 fell at home walking to the bathroom with a cane, witnessed by her daughter and sustained a right hip fracture. R3's had the diagnoses of Dementia, diabetes, heart failure, osteoporosis, arthritis and macular degeneration (eye disease). [...]

Inspectors wroteThis citation pertains to MI00140044. Based on interview and record review, the facility failed to change a foley catheter according to Urology recommendations for one (Resident #2) of three reviewed for urinary catheters, resulting in the potential for catheter complications and infection.