Our Ladys Haven of Fairhaven Inc

In the surveyor’s words

From the most serious findings on record at Our Ladys Haven of Fairhaven Inc, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF809Nov 15, 2023

  Based on observations, interviews, and document review, the facility failed to offer a nourishing evening snack when there was greater than 14 hours between dinner and breakfast service. Findings include: Review of the facility's schedule for Meal Times, dated as revised 03/24/23, indicated there was 14.5 hours between dinner and breakfast service on all units. The Meal Times schedule indicated: Unit 1 Truck 1: Breakfast 7:30 A.M. Dinner 5:00 P.M. Unit 2 Truck 1: Breakfast 7:40 A.M. Dinner 5:10 P.M. A&B Breakfast 7:50 A.M. Dinner 5:20 P.M. Unit 2 Truck 2: Breakfast 7:55 A.M. Dinner 5:25 P.M. Unit 1 Truck 2: Breakfast 8:00 A.M. Dinner 5:30 P.M. […]

• No harm, potential for more than minimal, widespreadF812Nov 15, 2023

  Based on observation, interview, and policy review, the facility failed to ensure food stored in three of three nourishment kitchens, including food brought into the facility from family/visitors (including but not limited to leftovers) was stored in a safe and sanitary manner. Findings include: Review of the facility's policy titled Food Brought to Resident/Patients by Family and Other Visitors, dated ,d+[DATE], indicated but was not limited to: -Food brought to residents/patients by family or visitors will be handled and stored in a safe and sanitary manner. -Food items that require refrigeration must be labeled with patient's/resident's name and date the food was brought in and stored in a closed container to prevent contamination. […]

• No harm, potential for more than minimal, widespreadF812Jul 21, 2021

  Based on observations and interviews, the facility failed to implement safe food handling practices in the kitchen. Specifically, the facility failed to ensure: 1. one dietary staff member used proper hand hygiene during food preparation; and 2. one dietary staff member properly restrained her hair during meal preparation. 1. On 7/20/21 at 1:40 P.M., the surveyor observed Dietary Staff #2 in the kitchen chopping celery. He touched his mask and adjusted it several times while he prepared the food. He did not perform hand hygiene each time after touching his mask, but instead wiped his hands on a rag and then continued to chop the celery. During an interview on 7/20/21 at 1:42 P.M., Dietary Staff #2 said he should not have touched his mask and then touched the food. […]

• No harm, potential for more than minimal, widespreadF838Jul 21, 2021

  Based on record review, interviews, and observations, the facility failed to update the facility assessment to accurately reflect the staffing of licensed nurses and certified nursing assistants (CNA) on duty. Findings include: Review of the Facility Assessment Tool, updated 4/7/21 and reviewed at the Quality Assurance Performance Improvement (QAPI) committee on 4/21/21 indicated the facility had 117 licensed beds and the average daily census is 65-70 residents. The average age is [AGE] years old of the residents. Review of the current census during the survey was 72 with one resident on medical leave. […]

• No harm, potential for more than minimal, widespreadF881Jul 21, 2021

  Based on record review, policy review, and interviews, the facility failed to implement an Antibiotic Stewardship program that included antibiotic use protocols and a system to monitor antibiotic use in the facility as indicated by the facility's policies. The facility failed to adhere to their antibiotic use policies for one Resident (#68), out of 22 sampled residents. Findings include: Review of the facility's policy titled Antibiotic Stewardship Program 2016 Policy, revised November 2020, indicated the policy is aligned with the Centers for Disease Control and Prevention (CDC) Core Elements of Antibiotic Stewardship for Nursing Homes (2015), and the facility is to implement an Antibiotic Stewardship Program (ASP). […]