Our Ladys Haven of Fairhaven Inc

Inspectors wroteBased on review of Resident Council Minutes, a resident group meeting, and interviews, the facility failed to ensure grievances/complaints brought forward from the Resident Council were addressed and resolved in a timely manner to ensure the residents felt their concerns were acted upon and included the facility response to the group.

Inspectors wroteBased on interview and document review, the facility failed to ensure residents had access to grievance forms to formulate grievances anonymously and implement their grievance process to ensure grievances were addressed, responded to promptly, residents were provided a resolution to their grievance, and the information was documented on the grievance forms in use by the facility. Specifically, the facility failed to:a. Ensure residents were able to formulate grievances anonymously and had grievance forms easily accessible to them to complete a grievance without having to rely on the staff to provide them with the form; andb. Ensure the facility provided follow up and resolution to a grievance of an excessively loud television verbally reported by two separate Residents (#20 and #73) from the AB unit out of a sample of 18 residents and three resident units.

Inspectors wroteBased on observations and interviews, the facility failed to properly follow sanitation and food handling practices to prevent the risk of foodborne illness in accordance with professional standards for food service safety. Specifically, the facility failed to:1. Handle ready to eat food (food which does not require cooking or further preparation prior to consumption) utilizing proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another);2. Ensure that dietary staff maintained and performed appropriate hand hygiene practices while preparing and serving meals for residents in the facility's main kitchen; 3. Reheat food according to safety standards to prevent food borne illness; 4. Ensure dietary staff wear hair coverings in the kitchen during food service; and5. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to follow infection control and prevention practices. Specifically, the facility failed to:1. Ensure staff removed personal protective equipment (PPE) appropriately when exiting the room of Resident #54, who was on transmission-based precautions (TBP);2. Implement remediation measures in response to positive Legionella (a type of bacteria that can grow in water systems and can cause Legionnaires' disease, a serious lung infection); and3. Ensure staff wore appropriate PPE in accordance with the TBP/ isolation precaution signs posted outside of Resident #74's room.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete medical records for one Resident (#64), out of a sample of 18 residents. Specifically, for Resident #64, the facility failed to ensure the medical record included the physician's documentation of encounters with the Resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it was free from a medication error rate of greater than five percent when one of two nurses made four errors out of 30 opportunities, totaling a medication error rate of 13.33%. These errors impacted two Residents (#38, #57), out of five residents observed. Specifically, 1. For Resident #38, Repaglinide (an oral antihyperglycemic medication used to help control high blood sugar), and Metformin (an oral antihyperglycemic medication used to help control high blood sugar) were not administered as ordered by the physician during the medication pass; and 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of care were met for one Resident (#57), out of five residents observed during medication administration and one Resident (#21), out of a total sample of 18 residents. Specifically, the facility failed: 1. For Resident #57, to ensure the Resident had taken all of his/her medications before leaving the Resident's room; and 2. For Resident #21, to ensure nursing performed pain assessments to determine, per physician's orders, which dosage of oxycodone (pain medication used to treat moderate to severe pain; opioid) to administer to the Resident.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure side rails were not implemented per the declination of consent from the Health Care Proxy (HCP) for one Resident (#121), of a total sample of 18 residents.

Inspectors wroteBased on records reviewed, policy review, and interview for two Residents (#4 and #26), of 18 sampled residents, the facility failed to ensure that each Resident's drug regimen was free from unnecessary psychotropic medications. Specifically, for Residents #4 and #26, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS, a clinical outcome checklist completed by a healthcare provider to assess the presence and severity of adverse outcomes, such as abnormal movements of the face, limbs, and body in patients) assessment was completed timely.

Inspectors wroteBased on record review and interview, the facility failed to maintain medical records that are complete, accurate, and systemically organized within accepted professional standards of practice for one Resident (#15) of 18 sampled residents. Specifically, the facility failed to document two administered doses of glucagon (an anti-hypoglycemic (low blood sugar) agent that increases blood glucose) on the Medication Administration Record (MAR).

Inspectors wroteBased on observation, interview, and policy review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to ensure: 1. For Resident #20, who has an indwelling urinary catheter, that staff implemented Enhanced Barrier Precautions (EBP-an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities); and 2. For Resident #32, who has an open wound, that staff implemented EBP.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure a dignified and homelike dining experience was provided for one Resident (#49), out of a total sample of 18 residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents in one of three dining rooms had a comfortable and homelike dining experience. Specifically, residents seated at the same table were not fed at the same time, resulting in them having to sit and watch others eating or being fed while waiting their turn to be fed by staff.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure an individualized plan of care was followed for Resident #5, in a total sample of 18 residents. Specifically, the facility failed to ensure a hand splint was applied for Resident #5 with decreased range of motion.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed to provide necessary respiratory care and services for one Resident (#276), out of a total sample of 18 residents. Specifically, the facility failed to ensure oxygen tubing was changed weekly.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure that all drug records were in order and that an account of all controlled drugs was maintained. Specifically, the facility failed to ensure for one Resident (#11), information was entered on the narcotic accountability record immediately after a schedule IV-controlled substance (low potential for abuse and low risk for dependence) was removed from the medication cart.