ROYAL OF FAIRHAVEN NURSING CENTER

Performance Report

ADMINISTRATION

RESULTS
Standard Survey - 38 of 39 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 38

This nursing facility met 38 out of the 39 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 38. The statewide average facility score was 36.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
11/03/2021 D (F 658)
The services provided or arranged by the facility as outlined by the comprehensive care plan must meet professional standards of quality. (F 658)

NURSING

RESULTS
Standard Survey - 30 of 33 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 30

This nursing facility met 30 out of the 33 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 30. The statewide average facility score was 27.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
11/03/2021 D (F 639 )
A facility must maintain all resident assessments completed within the previous 15 months in the resident?s active record and use the results of the assessments to develop, review and revise the resident?s comprehensive care plan. (F 639 ) and/or; The facility develops and implements comprehensive person-centered care plans for each resident that include measurable objectives and time frames to meet each resident's medical, nursing and mental and psychosocial needs which describe services to be furnished to attain or maintain residents highest practical well-being and assess resident or resident representative goals for desired outcomes. (F 656 )
Deficiency #2
11/03/2021 D (F 675)
The facility ensures that each resident receives and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being. (F 675) and/or; The facility ensures that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents? choices (F 684) and/or; The facility ensures that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (F 697) and/or; The facility ensures that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents? goals and preferences. (F 698) and/or; Resident who displays or are diagnosed with dementia, receive the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. (F 744)
Deficiency #3
11/03/2021 D (F 690 )
The facility ensures that residents continent of bladder and bowel on admission receive services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. The facility ensures residents incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible, specifically not catheterizing residents incontinent of urine who enter the facility without an indwelling catheter and assessing residents who enter with an indwelling catheter for removal of the catheter as soon as possible. (F 690 )

RESIDENT RIGHTS

RESULTS
Standard Survey - 25 of 27 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 24

This nursing facility met 25 out of the 27 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 24. The statewide average facility score was 24.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
03/03/2025 E (F 550 )
The facility treats each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident?s individuality; provide equal access to quality care regardless of diagnosis, severity of condition, or payment source; and ensures that residents can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. (F 550 )
Deficiency #2
03/03/2025 E (F 679 )
The facility provides, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. (F 679 )

KITCHEN/FOOD SERVICES

RESULTS
Standard Survey - 9 of 12 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 9

This nursing facility met 9 out of the 12 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 9. The statewide average facility score was 11.

The following requirement(s) were not met

The regulation(s) survey date and scope and severity rating(s) are listed below.

Deficiency #1
03/03/2025 D (F 804 )
The facility provides each resident food prepared by methods that conserve nutritive value, flavor, and appearance and is palatable, attractive and at a safe and appetizing temperature. (F 804 )
Deficiency #2
03/03/2025 E (F 812 )
The facility procures food from sources approved or considered satisfactory by federal state or local authorities and stores, prepares, distributes and serves food in accordance with professional standards for food service safety. (F 812 ) and/or; The facility has a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. (F 813 )

ENVIRONMENT

RESULTS
Standard Survey - 21 of 21 Met Complaint Investigation Deficiencies - 0 Score after Adjustment for Scope and Severity : 21

This nursing facility met 21 out of the 21 requirements reviewed in this category in its last 3 standard surveys. The number of deficiencies not met as a result of complaint investigations was: 0 . The facility's score after adjustment for scope and severity is 21. The statewide average facility score was 18.