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Deficiency Records for Fair Havens Senior Living

A list of the most recent deficiencies for Fair Havens Senior Living. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Fair Havens Senior Living. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

Deficiency Type of Deficiency Deficiency Date Date Corrected Resulted from a Complaint?
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-08-30 2024-09-11 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-08-30 2024-09-11 Y
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2024-08-30 2024-09-11 Y
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2024-08-30 2024-09-11 Y
Ensure each resident receives an accurate assessment. Health 2024-07-08 2024-07-30 Y
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. Health 2024-07-22 2024-07-26 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2024-07-08 2024-07-24 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-06-24 2024-07-12 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-06-24 2024-07-12 Y
Respond appropriately to all alleged violations. Health 2024-06-24 2024-07-12 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2024-05-29 2024-05-31 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-05-29 2024-05-31 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-04-03 2024-04-04 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-03-21 2024-04-02 Y
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2024-03-21 2024-03-22 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-02-03 2024-02-05 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-02-03 2024-02-05 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-01-17 2024-02-05 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2024-01-17 2024-02-05 Y
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-09-13 2023-10-25 N
Conduct testing and exercise requirements. Fire Safety 2023-09-13 2023-10-24 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-09-13 2023-10-24 N
Provide properly protected cooking facilities. Fire Safety 2023-09-13 2023-10-06 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2023-09-13 2023-09-29 N
Establish emergency prep training and testing. Fire Safety 2023-09-13 2023-09-29 N
Establish staff and initial training requirements. Fire Safety 2023-09-13 2023-09-29 N
Provide a written emergency evacuation plan. Fire Safety 2023-09-13 2023-09-29 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-09-13 2023-09-26 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-09-13 2023-09-26 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-09-13 2023-09-26 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2023-09-13 2023-09-22 N
Develop a communication plan. Fire Safety 2023-09-13 2023-09-22 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2023-09-08 2023-09-19 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-09-08 2023-09-19 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-09-08 2023-09-18 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2023-09-13 2023-09-14 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-09-13 2023-09-14 N
Ensure operating rooms are properly protected and written records are maintained and available for inspection. Fire Safety 2023-09-13 2023-09-14 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-09-13 2023-09-14 N
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2023-09-08 2023-09-10 N
Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. Health 2023-09-08 2023-09-09 N
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Health 2023-06-24 2023-06-25 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-05-25 2023-06-07 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-05-25 2023-06-07 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-05-25 2023-06-07 Y
Provide properly protected cooking facilities. Fire Safety 2022-10-25 2023-04-21 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-02-17 2023-03-29 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2023-02-17 2023-03-28 Y
Allow residents to self-administer drugs if determined clinically appropriate. Health 2023-01-18 2023-02-07 Y
Provide care by qualified persons according to each resident's written plan of care. Health 2023-01-18 2023-02-07 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-01-18 2023-02-07 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-01-18 2023-02-07 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-10-25 2023-02-07 N
Provide and implement an infection prevention and control program. Health 2022-11-01 2022-12-23 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-11-23 2022-12-21 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-11-23 2022-12-21 Y
Allow residents to self-administer drugs if determined clinically appropriate. Health 2022-11-01 2022-12-21 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2022-11-01 2022-12-21 N
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. Health 2022-11-01 2022-12-21 N
Ensure each resident receives an accurate assessment. Health 2022-11-01 2022-12-21 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-11-01 2022-12-21 N
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Health 2022-11-01 2022-12-21 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-11-01 2022-12-21 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-11-01 2022-12-21 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-11-01 2022-12-21 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-11-01 2022-12-21 N
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Health 2022-11-01 2022-12-21 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2022-11-01 2022-12-21 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2022-11-01 2022-12-21 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2022-11-01 2022-12-21 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2022-11-01 2022-12-21 N
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. Health 2022-11-01 2022-12-21 N
Provide or get specialized rehabilitative services as required for a resident. Health 2022-11-01 2022-12-21 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2022-11-01 2022-12-21 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-11-01 2022-12-21 N
Perform COVID19 testing on residents and staff. Health 2022-11-01 2022-12-21 N
Conduct testing and exercise requirements. Fire Safety 2022-10-25 2022-11-28 N
Develop and maintain an Emergency Preparedness Program (EP). Fire Safety 2022-10-25 2022-11-22 N
Develop Emergency Preparedness policies and procedures. Fire Safety 2022-10-25 2022-11-22 N
Develop a communication plan. Fire Safety 2022-10-25 2022-11-22 N
Establish emergency prep training and testing. Fire Safety 2022-10-25 2022-11-22 N
Establish staff and initial training requirements. Fire Safety 2022-10-25 2022-11-22 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2022-10-25 2022-11-22 N
Follow proper procedures when the fire alarm was out of service for more than 4 hours. Fire Safety 2022-10-25 2022-11-22 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2022-10-25 2022-11-22 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2022-10-25 2022-11-22 N
Provide a written emergency evacuation plan. Fire Safety 2022-10-25 2022-11-22 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-10-25 2022-11-22 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2022-10-25 2022-11-22 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2022-10-25 2022-11-22 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2022-10-25 2022-11-22 N
Ensure proper usage of power strips and extension cords. Fire Safety 2022-10-25 2022-11-22 N
Ensure proper storage of liquid oxygen. Fire Safety 2022-10-25 2022-11-22 N
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-09-09 2022-09-30 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-09-09 2022-09-30 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-08-18 2022-09-30 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-06-22 2022-07-08 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-06-22 2022-07-08 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-06-22 2022-07-08 Y
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. Health 2022-04-20 2022-04-29 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-04-20 2022-04-29 Y
Ensure staff are vaccinated for COVID-19 Health 2022-04-20 2022-04-29 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-03-23 2022-04-05 Y
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2022-03-23 2022-04-05 Y
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2022-02-08 2022-02-18 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2022-02-08 2022-02-18 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-01-21 2022-02-01 Y
Address patient/client population and determine types of services needed. Fire Safety 2021-09-08 2021-09-24 N
Address subsistence needs for staff and patients. Fire Safety 2021-09-08 2021-09-24 N
Establish policies and procedures for sheltering. Fire Safety 2021-09-08 2021-09-24 N
Establish policies and procedures for volunteers. Fire Safety 2021-09-08 2021-09-24 N
Create arrangements with other facilities to receive patients. Fire Safety 2021-09-08 2021-09-24 N
List the names and contact information of those in the facility. Fire Safety 2021-09-08 2021-09-24 N
Provide emergency officials' contact information. Fire Safety 2021-09-08 2021-09-24 N
Provide primary/alternate means for communication. Fire Safety 2021-09-08 2021-09-24 N
Provide a means of sharing information on occupancy/needs. Fire Safety 2021-09-08 2021-09-24 N
Provide family notifications of emergency plan. Fire Safety 2021-09-08 2021-09-24 N
Establish staff and initial training requirements. Fire Safety 2021-09-08 2021-09-24 N
Conduct testing and exercise requirements. Fire Safety 2021-09-08 2021-09-24 N
Implement emergency and standby power systems. Fire Safety 2021-09-08 2021-09-24 N
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Fire Safety 2021-09-08 2021-09-24 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2021-09-08 2021-09-24 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2021-09-08 2021-09-24 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2021-09-08 2021-09-24 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2021-09-08 2021-09-24 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2021-09-03 2021-09-17 N
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Health 2021-09-03 2021-09-17 N
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. Health 2021-09-03 2021-09-17 N
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Health 2021-09-03 2021-09-17 N
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Health 2021-09-03 2021-09-17 N
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2021-09-03 2021-09-17 N

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