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 | 2024-01-17 | 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 |
| Provide and implement an infection prevention and control program. | Health | 2021-06-04 | 2021-08-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-20 | 2021-08-04 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-07-20 | 2021-08-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-06 | 2021-08-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-23 | 2021-08-04 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-10 | 2021-08-04 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-06-10 | 2021-08-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-10 | 2021-08-04 | Y |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-06-10 | 2021-08-04 | 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 | 2021-06-04 | 2021-08-04 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-06-04 | 2021-08-04 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-04 | 2021-08-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-19 | 2021-08-04 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-06-04 | 2021-06-23 | 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 | 2021-04-22 | 2021-05-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-07 | 2021-04-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-26 | 2021-04-08 | Y |
