Royal of Fairhaven Nursing Center

In the surveyor’s words

From the most serious findings on record at Royal of Fairhaven Nursing Center, in the surveyor’s own words.

• Actual harm, isolatedF656Sep 27, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), whose Plan of Care indicated that he/she required the use of a hoyer lift (mechanical floor lift system used to transfer a medically dependent person from point A to point B), physical assistance of two staff members for transfers and was assessed by nursing at high risk for falls, the Facility failed to ensure nursing staff consistently implemented and followed interventions identified in his/her Plan of Care while meeting his/her transfer needs. On 9/08/23, Certified Nurse Aide (CNA) #1 transferred Resident #1 out of bed and then back into bed without the use of a hoyer lift and without another staff member present to assist her. […]

• Actual harm, isolatedF689Sep 27, 2023

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing to be at high risk for falls, and required the use of a hoyer lift (mechanical floor lift system used to transfer a medically dependent person from point A to point B) and physical assistance of two staff members for transfers, the Facility failed to ensure he/she was provided with the required level of staff assistance and an assistive device to maintain his/her safety, in an effort to prevent an accident resulting in an injury. On 9/08/23, Certified Nurse Aide (CNA) #1 transferred Resident #1 on two separate occasions, out of bed and then back into bed without the use of a hoyer lift and without another staff member present to assist her. […]

• Actual harm, isolatedF600Jul 26, 2022

  Based on observation, records reviewed and interviews, for one of three sampled residents (Resident #1), who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/29/22, in effort to get Resident #1 to agree to take a shower, Nurse #1 intentionally devised a plan with another staff member to make it look like she (Nurse #1) was accidentally bumped into while holding a glass of a chocolate type liquid, and once bumped by the other staff member, Nurse #1 could then spill (pour) the contents of the glass onto Resident #1. Nurse #1's was able spill (pour) the contents of the glass onto Resident #1 (who was seated in the unit dining room, in full view of others), getting it in his/her hair, as well as on his/her clothing. […]

• No harm, potential for more than minimal, widespreadF761Jan 9, 2024

  Based on observation, interview, document review, and policy review, the facility failed to ensure all medications were labeled in accordance with currently accepted professional principles, which included the appropriate accessory and cautionary instructions, and a date-opened when a shortened date of expiration was applicable. Specifically, the facility failed to: - Ensure all multi-dose bottles of eye drops and respiratory inhalers were labeled with a date-opened when first accessed and discarded per shortened date of expiration when applicable, affecting two of two Units and three of four medication carts within the facility; and - Ensure all drugs were properly contained in packaging with labeling to include appropriate accessory and cautionary instructions, affecting two of two Units… […]

• No harm, potential for more than minimal, patternF550Mar 3, 2025

  Based on interviews and observations, the facility failed to promote residents' rights to be treated with dignity, respect and was provided equal access to services for all residents. Specifically, the facility failed to ensure: 1. all 46 residents residing on one unit (Dementia Special Care Unit (DSCU)-a specialized nursing home unit that provides care for people with dementia designed to support residents' independence and well-being) of two units in the facility were provided equal access to television sets for their personal use, while 18 residents on the first-floor unit were each provided televisions sets by the facility (at no cost) for their personal use; 2. […]