Fairhaven Healthcare Center

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure they maintained a complete and accurate medical record that included nursing documentation related to assessments of a new area of skin alteration that had developed on his/her left thigh.

Inspectors wroteBased on record reviews and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure he/she was free from a significant medication error, when upon admission Resident #1's medications were not reconciled and transcribed accurately, resulting in him/her receiving two doses of Rifampin (powerful antibiotic) which had been discontinued at the hospital prior to his/her discharge.

Inspectors wroteBased on interview and record review the facility failed to ensure that all services provided for two Residents (#8 and #69), out of a total sample of 29 residents, met professional standards of quality. Specifically:1) For Resident #8 the facility failed to follow a physician-ordered hypoglycemic protocol by failing to re-check blood sugar or notify the physician when the Resident's blood sugar was less than 60 mg/dL (milligrams per deciliter).2) For Resident #69 the facility failed to follow Physician orders for offloading the Residents' heels.

Inspectors wroteBased on observation, record review and interview the facility failed to provide a dignified dining experience for two Residents (#49 and #107 ) out of a total sample of 29 residents. Specifically:1. For Resident #49, the facility failed to ensure a dignified dining experience.2. For Resident #107, the facility failed to ensure a dignified dining experience and referred to the Resident as a feeder, rather than by his/her preferred name.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one Resident, (#77 ) was free from unnecessary psychotropic medication, out of a total sample of 29 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure one Resident (#28) out of a total sample of 29 residents was provided with the correct physician ordered adaptive equipment with meals. Specifically, Resident #28 was not provided with a double handed mug for 5 of 5 observed meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise the care plan for one Resident (#102), following the completion of one comprehensive assessment. Specifically, facility staff failed to review and revise the care plan when Resident #102 started hospice and a comprehensive assessment for significant change in status (SCSA) was completed.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure assistance with Activities of Daily Ling (ADLs) was provided for one Resident (#49) out of a total sample of 29 residents. Specifically, for Resident #49 the facility failed to ensure assistance was provide with meals.

Inspectors wroteBased on observation, record reviews and interviews, the facility failed to provide treatment and services related to an indwelling urinary catheter (a thin flexible tube inserted into the bladder to drain urine outside the body), for two Residents (#3 and #92) out of a total sample of 29 residents. Specifically,1. For Resident #3, the facility failed to implement the physician's orders related to the correct indwelling catheter balloon and size.2. For Resident #92, the facility failed to implement the physician's orders related to the correct indwelling catheter balloon and size and empty the urinary drainage bag as ordered.

Inspectors wroteBased on observations record review and interviews, the facility failed to provide care and services consistent with professional standards for one Resident (#2) who required renal dialysis (a life sustaining treatment that helps the body remove extra fluids and waste products from the blood when the kidneys are not able to.) out of a total sample of 29 residents. Specifically, the facility failed to ensure clamps and pressure dressings were kept with the Resident in case of emergency related to a tunneled hemodialysis catheter (a plastic tube used for exchanging blood between a patient and a hemodialysis machine).

Inspectors wroteBased on records reviewed and interviews the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS) assessment (a test used monitor for adverse consequences of antipsychotic medication) was completed for one Resident (#13), who was receiving antipsychotic medications, out of a total sample of 29 residents.

Inspectors wroteBased on observations, interviews, and record review for one Resident (#62) out of three residents observed, the facility failed to ensure it was free from a medication error rate of greater than 5%. One out of three nurses observed made two errors out of 26 opportunities resulting in a medication error rate of 7.69%. Specifically, Nurse #4 administered the incorrect type of multivitamin and the incorrect type of eye drops.

Inspectors wroteBased on observations and interviews, the facility failed to ensure staff stored all drugs and biologicals in accordance with accepted professional standards of practice. Specifically, the facility failed to ensure two bottles of lorazepam (a Schedule IV controlled substance) was maintained in a separately locked compartment.

Inspectors wroteBased on observation and interview the facility failed to ensure proper food handling on 1 of 4 resident units. Specifically, on the Pawtucketville unit, 2 different staff handled resident's toast with their bare hands.

Inspectors wroteBased on observation, record review and interview, the facility failed to meet professional standards of quality for three Residents (#61, #40 and #78), out of a total of 24 residents. Specifically: 1. For Resident #61, the facility failed to apply wound care dressing per physician orders. 2. For Resident #40, the facility failed to apply hand rolls to both hands per physician orders. 3. For Resident #78, the facility failed to provide 15-minute checks and ensure a wanderguard was in place per physician orders.

Inspectors wroteBased on observations, record review and interview, the facility failed to provide respiratory care services in accordance with professional standards of practice for three Residents (#317, #77, #42) out of a total sample of 24 Residents. Specifically, the facility failed to: 1. Ensure oxygen filters were in use while Resident #317 was receiving oxygen via nasal cannula 2. Ensure oxygen filter was clean, oxygen tubing was dated and labeled and CPAP (continuous positive airway pressure) machine was clean and stored in a sanitary way. 3. Ensure oxygen filter was clean, oxygen tubing was dated and labeled, distilled water was changed and dated, and BIPAP (bilevel positive airway pressure) machine was clean and stored in a sanitary way.

Inspectors wroteBased on observation, record review and interview, the facility failed to follow infection control practices to prevent possible spread of infection by: 1. Failing to perform proper hand hygiene and failing to use Personal Protective Equipment (PPE) for an Enhanced Barrier Precaution room. 2. Failing to sanitize shared medical equipment between residents, specifically a glucometer (a machine used to test blood sugar). 3. Failing to follow infection control practices during a wound dressing change, specifically not performing hand hygiene after glove removal and storage of wound treatment supplies.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide a dignified existence for one Resident (#317) out of a total sample of 24 Residents. Specifically, the facility failed to utilize a privacy bag while Resident #317's urinary catheter bag was visible and in use.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure person-centered care plans with measurable goals and individualized interventions were developed and implemented for two residents (#58 and #94), out of 24 sampled residents. Specifically: 1. For Resident #58 the facility failed to develop a plan of care related to the prevention of pressure ulcers. 2. For Resident #94, the facility failed to develop comprehensive pacemaker care plan.

Inspectors wroteBased on observations, record review, policy review and interviews, the facility failed to provide supervision with meals for one Resident, (#44) out of a total sample of 24 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide the necessary treatment and services for two residents (#37 and #61) with pressure ulcers, out of a total sample of 24 residents. Specifically: 1. The facility failed to implement soft booties to Resident #37's feet in accordance to the medical plan of care. 2. The facility failed to implement the treatment orders for a pressure ulcer as recommended by the wound physician for Resident #61.

Inspectors wroteBased on observation, record review and interview the facility failed for one Resident (#76), out of a total sample of 24 residents, to ensure interventions to maintain his/her safety were implemented in accordance to the plan of care.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure services to maintain continence were implemented for one Resident (#58), out of a total sample of 24 residents. Specifically, for Resident #58 the facility failed to evaluate his/her incontinence and failed to develop a person-centered plan of care with individualized interventions for bladder incontinence.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure staff implemented interventions related to weight loss for one Resident (#13) out of a total of 24 sampled residents.

Inspectors wroteBased on observation, record review and interviews, the facility failed for one Resident (#11), out of a total sample of 24 residents, to ensure professional standards of care and treatment for hemodialysis (a treatment where a machine removes blood from your body, filters it through a dialyzer (artificial kidney) and returns the cleaned blood to your body). Specifically, the facility failed to adhere to emergency care practices for the use of a venous catheter, failed to have a person-centered care plan with individualized interventions and failed to ensure communication between the facility and dialysis treatment center was consistent according to the medical plan of care.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure it was free from a medication error rate of five percent or greater. Two out of four nurses observed made three errors in 28 opportunities on two of the three units resulting in a medication error rate of greater than 5%. These errors impacted two Resident (#317 and #44), out of nine residents observed.

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were labeled with open dates and failed to ensure outdated medications were not available for administration on two of four resident care units.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide the prescribed, therapeutic diet for one Resident (#317) out of a total sample of 24 Residents. Specifically, Resident #317 was prescribed a therapeutic Mechanical soft (Dental) Ground texture diet and did not receive ground textures during meals.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an accurate medical record for one Resident (#94) out of a total sample of 24 Residents.

Inspectors wroteBased on records reviewed, interviews and observations, the Facility failed to ensure they supported each residents' right to self determination which included facilitating the residents choice to eat meals in their rooms, when all facility residents were issued a notification letter indicating residents were required to eat in facility dining room, exceptions were made for illness and approvals by nursing, however in addition the residents were also notified that nursing staff would no longer deliver meal plates to residents rooms, therefore forcing some residents who were approved by nursing to eat in their rooms, to facilitate the process themselves.

Inspectors wroteBased on records reviewed and interviews for one of three sampled residents ((Resident #1) who was non-ambulatory, was dependent on staff for mobility and required an assistive device (mechanical lift) for all transfers, the Facility failed to ensure that in an effort to maintain Resident #1's safety to prevent an incident/accident while being transferred by staff, that he/she was provided with a mechanical lift that staff had been trained to use and was appropriate for him/her based on his/her physical limitations, which included an inability to weight bear or physically participate due to paralysis of his/her upper/lower extremities, therefore placing him/her at increased risk for injury.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure nutritional supplements were provided to one Resident (#15), after having sustained significant weight loss, out of a total of 25 sampled Residents. Subsequently, Resident #15 continued to lose weight.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that it is free of medication error rates of five percent or greater. Specifically, the medication error rate was 15.63%.

Inspectors wrote3. Resident #13 was admitted to the facility in July 2022 with diagnoses including osteoarthritis, iron deficiency anemia and B group vitamin deficiency. Review for the doctor's orders dated November 2023 indicated an order for Calcium 600 mg (milligrams) + D3 400 IU (international units) give one tablet by mouth one time a day for minerals. During medication pass on 11/14/23, at approximately 9:10 A.M., the surveyor observed Nurse #3 administer Calcium 600 mg + D3 200 IU one tablet to Resident #13. Review of the medication administration record dated November 2023 indicated that Nurse #3 documented that he gave 1 tablet of Calcium 600 mg + D3 400 IU. During an interview on 11/14/23, at approximately 9:45 A.M., Nurse #3 said that he didn't realize that the amount of the D3 was not what the doctor ordered. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure two Residents (#18 and #45) were assessed for the ability to self-administer medications, out of a total sample of 25 residents.

Inspectors wroteBased on record review and interview, the facility failed to notify the physician of a newly developed skin injury for one Resident (#102) out of a total of 25 sampled Residents.

Inspectors wroteBased on observations, record review, and interview, the facility failed to identify and assess the use of pillows placed underneath a fitted sheet below the side rails on both sides of the bed as a potential restraint for one Resident (#25), out of a total sample of 25 residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement the plan of care for two Residents (#25 and #102) out of a total of 25 sampled Residents.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide the necessary activities of daily living for dependent residents for one Resident (#76) out of a total sample of 25 residents. Specifically, the facility failed to provide continuous supervision during mealtimes for Resident #76.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that the resident's environment was free from accident hazards for two Residents (#56 and #82) out of a total of 25 sampled Residents. Specifically, the facility failed to ensure Resident #56's and Resident #82's cigarettes and cigarette lighters were kept in a secure location.

Inspectors wroteBased on observations, records review, interview and policy review, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (G-tube, a feeding tube in the abdomen used to provide nutrition) was provided in accordance with professional standards of practice for one Resident (#6) out of a total sample of 24 residents. Specifically, the facility failed to obtain a new tube feeding bag for water after the bag was observed to be in use for over three days.

Inspectors wroteBased on observations, record review and interview the facility failed to provide respiratory care services in accordance with professional standards of practice. Specifically, the facility failed to 1. For Resident #97 the facility failed to ensure nursing obtained a physician's order for oxygen use, and 2. failed to change the oxygen tubing as ordered and ensure a filter was being used on the oxygen concentrator for one Resident (#22) out of a total sample of 24 residents.

Inspectors wroteBased on observations, interviews, and record review the facility failed to implement a physician's order to give phosphate binders (a medication to absorb phosphate from the food you eat) at the appropriate time for one Resident (#11) out of a total sample of 24 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure the nursing staffing data was posted daily in a prominent area and readily accessible to residents and visitors as required.