OUR LADY'S HAVEN

Nursing Home Inspector

71 CENTER STREET
FAIRHAVEN, MA 02719
Bristol County
Phone: 508-999-4561
Provider Number: 225485
Last Inspection: 12/21/2016

About the Nursing Home

Number of Beds: 117
Number of Residents: 111
Beds Available: 6
Percent Occupancy: 95%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: Non profit - Church related
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

24

Facility
22

County
16

MA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

24

2016
10

2015
13

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

12/21/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 1/13/2017
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 1/13/2017
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Pattern : Minimal 4 1/13/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 1/13/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 1/13/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 1/13/2017
 
Failed To: Keep all essential equipment working safely. Pattern : Minimal 4 1/13/2017
 

8/31/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 10/9/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 10/9/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 10/9/2015
 

9/10/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. Isolated : Minimal 3 10/8/2014
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Pattern : Minimal 4 10/8/2014
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 10/8/2014
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 10/8/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

8/7/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 9/15/2017
 

5/2/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 5/27/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MA State Avg
Number of Residents 111 104.26 96.79
Registered Nurses 0.60 0.68 0.89
Licensed Practical / Vocational Nurses 0.78 0.83 0.84
Certified Nursing Assistants 2.88 2.31 2.30
Total Staff Hours 4.26 3.82 4.03

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MA State Avg%
of high risk long-stay residents with pressure ulcers 4 4 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 92 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98 94 95
of long-stay residents experiencing one or more falls with major injury 2 3 3
of long-stay residents who have depressive symptoms 0 2 2
of long-stay residents who lose too much weight 4 5 5
of long-stay residents who received an antianxiety or hypnotic medication 27 22 20
of long-stay residents who received an antipsychotic medication 17 15 18
of long-stay residents who self-report moderate to severe pain 3 5 4
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 18 19 18
of long-stay residents whose need for help with daily activities has increased 18 15 14
of long-stay residents with a catheter inserted and left in their bladder 1 1 1
of long-stay residents with a urinary tract infection 5 4 3
of low risk long-stay residents who lose control of their bowels or bladder 23 44 54
of short-stay residents assessed and appropriately given the pneumococcal vaccine 98 81 79
of short-stay residents who had an outpatient emergency department visit 12 13 11
of short-stay residents who made improvements in function 54 62 60
of short-stay residents who newly received an antipsychotic medication 0 1 1
of short-stay residents who self-report moderate to severe pain 14 16 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 93 84 82
of short-stay residents who were rehospitalized after a nursing home admission 19 24 22
of short-stay residents who were successfully discharged to the community 41 51 56
of short-stay residents with pressure ulcers that are new or worsened 4 1 0