A list of the most recent deficiencies for Faith Haven Senior Care Centre. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Meet other general requirements. | Fire Safety | 2024-01-11 | 2024-07-09 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2024-01-17 | 2024-02-02 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-01-17 | 2024-02-02 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-01-17 | 2024-02-02 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-01-17 | 2024-02-02 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-01-17 | 2024-02-02 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-17 | 2024-02-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-17 | 2024-02-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-17 | 2024-02-02 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-01-17 | 2024-02-02 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-01-17 | 2024-02-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-17 | 2024-02-02 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-01-11 | 2024-02-02 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-08 | 2023-11-28 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-08 | 2023-11-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-08 | 2023-11-28 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-11-08 | 2023-11-28 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-10-19 | 2022-11-14 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-10-19 | 2022-11-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-19 | 2022-11-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-10-19 | 2022-11-14 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-19 | 2022-11-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-19 | 2022-11-14 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-19 | 2022-11-14 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-10-19 | 2022-11-14 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-19 | 2022-11-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-19 | 2022-11-14 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-10-19 | 2022-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-10-19 | 2022-11-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-19 | 2022-11-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-10-19 | 2022-11-14 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-05-18 | 2022-07-08 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-05-18 | 2022-07-08 | Y |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2022-05-18 | 2022-07-08 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-05-18 | 2022-07-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-18 | 2022-06-17 | Y |
| Assess the resident when there is a significant change in condition | Health | 2022-05-18 | 2022-06-17 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-05-18 | 2022-06-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-18 | 2022-06-17 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-05-18 | 2022-06-17 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-18 | 2022-06-17 | Y |
| Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2022-05-18 | 2022-06-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-18 | 2022-06-17 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-05-18 | 2022-06-17 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-18 | 2022-06-17 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-09-21 | 2021-10-05 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-02 | 2021-10-01 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-09-02 | 2021-10-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-02 | 2021-10-01 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-09-02 | 2021-10-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-02 | 2021-10-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-09-02 | 2021-10-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-02 | 2021-10-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-09-02 | 2021-10-01 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2021-08-31 | 2021-10-01 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-08-31 | 2021-10-01 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-08-31 | 2021-10-01 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-08-31 | 2021-10-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-31 | 2021-10-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-31 | 2021-10-01 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-06 | 2021-05-07 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-03-04 | 2021-03-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-01 | 2021-03-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-01 | 2021-03-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-01 | 2021-03-31 | Y |
