Jackson, MI

Faith Haven Senior Care Centre

2-star overall rating with 2-star inspections with abuse icon flag with $15,872 in total fines with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

6531 W Michigan Avenue, Jackson, MI

(517) 750-3822

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

81

Certified beds

Average residents

76

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Nexcare Health Systems

Operator or chain grouping

Approved since

1978-03-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

20 facilities

Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.60

Registered nurse staffing · state 0.77 · national 0.68

LPN hours / resident day

0.81

Licensed practical nurse staffing · state 0.88 · national 0.87

Aide hours / resident day

2.18

Nurse aide staffing · state 2.38 · national 2.35

Total nurse hours

3.59

All reported nurse hours · state 4.03 · national 3.89

Licensed hours

1.41

RN + LPN hours · state 1.65 · national 1.54

Weekend hours

3.16

Weekend nurse staffing · state 3.52 · national 3.43

Weekend RN hours

0.32

Weekend registered nurse coverage · state 0.49 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.70

CMS adjusted RN staffing hours

Adjusted total hours

4.21

CMS adjusted total nurse staffing hours

Case-mix index

1.17

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 41% · national 45%

Total nurse turnover

54%

Annual nurse turnover · state 44% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,434

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

12.28

Composite VBP score used to determine payment impact.

Payment multiplier

0.9811

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 21.50% · Performance 21.61% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

1.75

Baseline 8.74% · Performance 7.90% · Measure score 1.75 · Achievement 0 · Improvement 1.75

Total nurse turnover

1.07

Baseline 72.46% · Performance 65.00% · Measure score 1.07 · Achievement 0 · Improvement 1.07

Adjusted total nurse staffing

2.09

Baseline 3.42 hours · Performance 3.67 hours · Measure score 2.09 · Achievement 2.09 · Improvement 0.58

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 9.79%
10.72%
0.9 pts better
No Different than the National Rate · Eligible stays 86 · Observed rate 9.3% · Lower 95% interval 6.85%
Discharge to community 41.53%
50.57%
9 pts worse
No Different than the National Rate · Eligible stays 70 · Observed rate 32.86% · Lower 95% interval 31.02%
Medicare spending per beneficiary 0.88
1.02
0.1 pts better
Drug regimen review with follow-up 97.62%
95.27%
2.4 pts better
Numerator 41 · Denominator 42
Falls with major injury 2.38%
0.77%
1.6 pts worse
Numerator 1 · Denominator 42
Discharge self-care score 68.18%
53.69%
14.5 pts better
Numerator 15 · Denominator 22
Discharge mobility score 54.55%
50.94%
3.6 pts better
Numerator 12 · Denominator 22
Pressure ulcers or injuries, new or worsened 2.38%
2.29%
0.1 pts worse
Numerator 1 · Denominator 42 · Adjusted rate 2.36%
Healthcare-associated infections requiring hospitalization 7.9%
7.12%
0.8 pts worse
No Different than the National Rate · Eligible stays 52 · Observed rate 11.54% · Lower 95% interval 4.37%
Staff COVID-19 vaccination coverage 25.6%
8.2%
17.4 pts better
Numerator 32 · Denominator 125
Staff flu vaccination coverage 33.16%
42%
8.8 pts worse
Numerator 62 · Denominator 187
Discharge function score 68.18%
56.45%
11.7 pts better
Numerator 15 · Denominator 22
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly.
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date Not Available
25.2%
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.8
1.7
0.1 pts worse
1.9
0.1 pts better
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.1 · Expected 2.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 0.9
1.5
0.6 pts better
1.8
0.9 pts better
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.9 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 97.4%
95.0%
2.4 pts better
93.4%
4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 98.6% · Q3 100.0% · Q4 95.7% · 4Q avg 97.4%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98.6%
95.0%
3.6 pts better
95.5%
3.1 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.6%
Percentage of long-stay residents experiencing one or more falls with major injury 1.5%
3.1%
1.6 pts better
3.3%
1.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 2.9% · Q3 1.5% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 0.4%
4.1%
3.7 pts better
11.4%
11 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4%
Percentage of long-stay residents who lose too much weight 5.7%
5.5%
0.2 pts worse
5.4%
0.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 8.1% · Q3 3.3% · Q4 6.2% · 4Q avg 5.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 17.3%
19.6%
2.3 pts better
19.6%
2.3 pts better
Long Stay · 2024Q4-2025Q3 · Q1 18.0% · Q2 18.8% · Q3 17.5% · Q4 15.2% · 4Q avg 17.3%
Percentage of long-stay residents who received an antipsychotic medication 10.8%
16.5%
5.7 pts better
16.7%
5.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 10.2% · Q3 8.3% · Q4 11.5% · 4Q avg 10.8% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.0%
0.1%
0.1 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened 16.6%
13.9%
2.7 pts worse
16.3%
0.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 15.0% · Q3 12.0% · Q4 15.1% · 4Q avg 16.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 9.2%
11.7%
2.5 pts better
14.9%
5.7 pts better
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q2 8.1% · Q3 8.3% · Q4 6.6% · 4Q avg 9.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
0.9%
0.9 pts better
1.0%
1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 1.1%
1.7%
0.6 pts better
1.7%
0.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.5% · Q4 2.9% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 3.6%
20.4%
16.8 pts better
19.8%
16.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 6.6% · Q4 6.2% · 4Q avg 3.6%
Percentage of long-stay residents with pressure ulcers 4.9%
5.6%
0.7 pts better
5.1%
0.2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 3.9% · Q3 5.5% · Q4 3.7% · 4Q avg 4.9% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 64.9%
82.8%
17.9 pts worse
81.7%
16.8 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 59.0% · Q2 57.3% · Q3 71.2% · Q4 70.9% · 4Q avg 64.9%
Percentage of short-stay residents who had an outpatient emergency department visit 8.9%
11.5%
2.6 pts better
12.0%
3.1 pts better
Short Stay · 20240701-20250630 · Adjusted 8.9% · Observed 9.5% · Expected 12.0% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 0.0%
1.3%
1.3 pts better
1.6%
1.6 pts better
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 85.2%
79.5%
5.7 pts better
79.7%
5.5 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 27.4%
24.2%
3.2 pts worse
23.9%
3.5 pts worse
Short Stay · 20240701-20250630 · Adjusted 27.4% · Observed 31.0% · Expected 26.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-06 · Fire 2025-01-06

17 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

2 fire-safety deficiencies

Top issue: Services (1 deficiency)

Cycle 2 Health 2024-01-17 · Fire 2024-01-17

12 health deficiencies

Top issue: Resident Rights (6 deficiencies)

2 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 3 Health 2022-10-19 · Fire 2022-10-19

15 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-01-06

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-03-24

D · Potential for more than minimal harm 2025-01-06

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-01-22

F · Potential for more than minimal harm 2024-01-17

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-02-02

E · Potential for more than minimal harm 2024-01-17

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2024-07-09

F · Potential for more than minimal harm 2022-10-19

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-11-14

E · Potential for more than minimal harm 2022-10-19

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-11-14

D · Potential for more than minimal harm 2022-10-19

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-11-14

Inspection history

Recent health citations

G · Actual harm 2025-08-21

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-08-28

D · Potential for more than minimal harm 2025-08-21

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-08-28

D · Potential for more than minimal harm 2025-08-21

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2025-08-28

E · Potential for more than minimal harm 2025-01-06

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2025-01-22

E · Potential for more than minimal harm 2025-01-06

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-01-22

D · Potential for more than minimal harm 2025-01-06

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2025-01-22

D · Potential for more than minimal harm 2025-01-06

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2025-01-22

D · Potential for more than minimal harm 2025-01-06

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-01-22

D · Potential for more than minimal harm 2025-01-06

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-01-22

D · Potential for more than minimal harm 2025-01-06

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-01-22

D · Potential for more than minimal harm 2025-01-06

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2025-01-22

D · Potential for more than minimal harm 2025-01-06

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-01-22

D · Potential for more than minimal harm 2025-01-06

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-01-22

D · Potential for more than minimal harm 2025-01-06

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-01-22

D · Potential for more than minimal harm 2025-01-06

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-01-22

D · Potential for more than minimal harm 2025-01-06

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2025-01-22

D · Potential for more than minimal harm 2025-01-06

F791 · Quality of Life and Care Deficiencies

Health

Provide or obtain dental services for each resident.

Corrected 2025-01-22

D · Potential for more than minimal harm 2024-05-03

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-05-17

G · Actual harm 2024-01-17

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2024-02-02

E · Potential for more than minimal harm 2024-01-17

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2024-02-02

E · Potential for more than minimal harm 2024-01-17

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2024-02-02

E · Potential for more than minimal harm 2024-01-17

F585 · Resident Rights Deficiencies

Health

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.

Corrected 2024-02-02

E · Potential for more than minimal harm 2024-01-17

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2024-02-02

D · Potential for more than minimal harm 2024-01-17

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2024-02-02

D · Potential for more than minimal harm 2024-01-17

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-02-02

D · Potential for more than minimal harm 2024-01-17

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-02-02

D · Potential for more than minimal harm 2024-01-17

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-02-02

D · Potential for more than minimal harm 2024-01-17

F849 · Administration Deficiencies

Health

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.

Corrected 2024-02-02

B · Minimal harm 2024-01-17

F577 · Resident Rights Deficiencies

Health

Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.

Corrected 2024-02-02

G · Actual harm 2023-11-08

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-11-28

D · Potential for more than minimal harm 2023-11-08

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-11-28

D · Potential for more than minimal harm 2023-11-08

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-11-28

D · Potential for more than minimal harm 2023-11-08

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2023-11-28

F · Potential for more than minimal harm 2022-10-19

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2022-11-14

E · Potential for more than minimal harm 2022-10-19

F585 · Resident Rights Deficiencies

Health

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.

Corrected 2022-11-14

E · Potential for more than minimal harm 2022-10-19

F625 · Resident Rights Deficiencies

Health

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.

Corrected 2022-11-14

E · Potential for more than minimal harm 2022-10-19

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2022-11-14

E · Potential for more than minimal harm 2022-10-19

F725 · Nursing and Physician Services Deficiencies

Health

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Corrected 2022-11-14

E · Potential for more than minimal harm 2022-10-19

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2022-11-14

D · Potential for more than minimal harm 2022-10-19

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2022-11-14

D · Potential for more than minimal harm 2022-10-19

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2022-11-14

D · Potential for more than minimal harm 2022-10-19

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2022-11-14

D · Potential for more than minimal harm 2022-10-19

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2022-11-14

D · Potential for more than minimal harm 2022-10-19

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2022-11-14

Penalties and ownership

What sits behind the stars

$15,872 2024-01-17

Fine

Fine · fine $15,872

Fine

Ownership

Nexcare Holdings, LLC

5% Or Greater Direct Ownership Interest · Organization

100% 15 facilities 2013-11-01
Branscum, James

5% Or Greater Indirect Ownership Interest · Individual

0% 27 facilities 2013-12-01
Eisenberg, Leo

5% Or Greater Indirect Ownership Interest · Individual

0% 26 facilities 2014-04-01
Nexcare Health Systems, LLC

Operational/Managerial Control · Organization

0% 26 facilities 2011-10-06
Perry, Michael

Operational/Managerial Control · Individual

0% 29 facilities 2015-08-01
Robin Eisenberg 2014 Family Trust

5% Or Greater Indirect Ownership Interest · Organization

0% 19 facilities 2014-04-01
Sangster, Todd

Corporate Officer · Individual

0% 27 facilities 2013-11-04
Smith, Williard

W-2 Managing Employee · Individual

0% 1 facilities 2020-11-06
Wronski, Frank

5% Or Greater Indirect Ownership Interest · Individual

0% 27 facilities 2014-04-01

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