Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Our Ladys Haven Of Fairhaven Inc during CMS and state inspections, most recent first.
Resident Council grievances were not timely addressed, resolved, or documented. Facility policy required complaints and grievances to be followed up through Resident Council and resolved within 72 hours, but minutes showed repeated concerns about overnight lights being turned on, early podiatry/lab visits, housekeeping disrupting sleep, and other issues over several months. The Administrator and AD reported only verbal communication with department heads and no paper trail, no grievance forms for ongoing concerns, and residents said they were not given grievance forms or meaningful follow-up.
Grievance Forms Not Accessible and Complaints Not Resolved: Residents said they did not know where grievance forms were located and staff confirmed the forms were kept behind the nurses’ stations or in a file cabinet, making anonymous filing unavailable on the units. Two residents repeatedly complained about another resident’s excessively loud TV, but no grievance was documented in the grievance book and the SW acknowledged she did not complete a grievance form or resolve the ongoing concern.
Food service staff failed to follow sanitation and food safety practices during meal prep and tray line service. A dietary employee reused a thermometer probe between foods without cleaning it, handled food with contaminated gloves after touching other kitchen items, and served a reheated omelet without checking its temp. A dietary staff member with a beard worked in the kitchen without a beard covering, and multiple opened food and thickened beverage items in unit refrigerators were found undated or improperly dated.
Infection Control and PPE Failures: Staff did not consistently follow isolation PPE requirements for a resident with COVID-19, including a housekeeper who entered without eye protection and did not remove the N95 after exiting, and a CNA who assisted another COVID-positive resident without the eye protection required by the posted sign. The facility also had multiple positive Legionella water samples and low hot water temperatures, but no evidence of action taken in response to the out-of-compliance results.
A resident’s medical record was incomplete because physician documentation was missing for several encounters noted in nursing progress notes. The DON confirmed the resident had been seen by the physician for COVID, a 60-day visit, a coated tongue, and psych recommendation review, but the facility had not received the physician’s notes for those visits.
A nurse in the facility made four medication administration errors out of 30 opportunities, resulting in a 13.33% error rate, impacting two residents. One resident did not receive Repaglinide and Metformin as per the physician's orders, while another resident's Carbidopa-Levodopa and Furosemide were administered outside the prescribed time window. The DON confirmed the expectation for timely medication administration.
The facility failed to meet professional standards of care for two residents. A nurse left a resident's room before confirming medication intake, despite the resident not being documented as able to self-administer. Another resident's pain assessments were inadequate, with vague reasons for administering oxycodone and a lack of documented pain severity assessments. The facility's policy required a numerical pain scale, which was not consistently used.
A facility failed to remove side rails from a resident's bed despite the Health Care Proxy's (HCP) declination of consent. The resident, admitted for a respite stay with dementia, had side rails left from a previous occupant. Observations confirmed the presence of side rails, and the Unit Manager admitted no assessment was conducted, acknowledging the HCP's declined consent.
The facility failed to complete timely AIMS assessments for two residents receiving antipsychotic medications. Both residents, with diagnoses including dementia and bipolar disorder, were on scheduled antipsychotic regimens. Their care plans required AIMS assessments every six months, but the assessments were delayed, missing the scheduled June 2024 assessments. The DON confirmed the assessments should have been conducted in June, not August.
A resident with diabetes experienced a hypoglycemic event and was administered two doses of glucagon, which were not documented on the MAR as required by the facility's policy. Interviews with nursing staff confirmed the oversight, highlighting a failure to maintain complete and accurate medical records.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents, one with an indwelling urinary catheter and another with an unhealed pressure ulcer. Staff did not use gowns and gloves during high-contact care activities, despite EBP signs being posted and gowns available. This indicates a lack of adherence to infection control protocols as expected by the facility's policy and CMS guidance.
Resident Council Grievances Not Timely Addressed or Documented
Penalty
Summary
The facility failed to ensure grievances and complaints brought forward through Resident Council were addressed and resolved in a timely manner, and it failed to document a facility response to the group. Facility policies stated that resident complaints and grievances were to be followed up through Resident Council meetings and individual requests, that department heads were to be notified of complaints, and that grievances were to be responded to within 72 hours and resolved. However, review of Resident Council minutes from April 2025 through September 2025 showed repeated concerns that continued across multiple meetings without documented resolution or follow-up. The minutes reflected ongoing complaints about overnight staff turning on overhead lights during rounds and startling residents, podiatry and lab staff coming in very early and not waking residents before providing care, housekeeping entering at 6:00 A.M. and disrupting residents’ sleep, dirty linen and commodes not being handled promptly, and kitchen cleanliness concerns. Some issues were noted as better or dealt with at later meetings, but several concerns remained ongoing for months. The record also showed that no grievance forms were created for the ongoing individual concerns or for the resident council concerns as a group. During interviews, the Administrator stated there was no paper trail showing department heads were aware of resident council concerns and believed the Activity Director communicated verbally or possibly by email. The Activity Director stated she informed the Administrator and then verbally told department heads, but she had no emails or paper trail documenting notification, no documented plan or resolution to share with residents, and no way of knowing whether department heads were working to resolve the concerns. During a resident group meeting, residents reported that the same issues remained unresolved, that they did not know where grievance forms were located, that staff had not offered grievance forms or assistance, and that complaints were repeatedly met with responses such as being told someone would look into it, but no follow-up or resolution occurred. The Administrator later stated the resident council was not working as intended and the facility could not provide documentation of follow-up or attempts to resolve the concerns brought forward in the meetings.
Grievance Forms Not Accessible and Resident Complaints Not Properly Processed
Penalty
Summary
The facility failed to ensure residents had access to grievance forms that could be used anonymously and failed to implement its grievance process so grievances were addressed, responded to promptly, resolved, and documented on the grievance forms. The facility policy stated grievances were to be responded to within 72 hours and resolved, with actions and results documented on the grievance report. During interviews and unit tours, residents and staff reported that grievance forms were not available to residents on the nursing units and were kept behind the nurses’ stations or in a file cabinet, requiring residents to ask staff for a form or for staff to complete one for them. The Administrator also stated she was unsure how a resident could formulate a grievance anonymously if the resident could not independently get to the lobby where forms were available. During a group meeting, five of eight residents said they did not know where grievance forms were located and had never been offered a form when voicing concerns to staff. On tours of the AB and 2 Medical units and the 1st floor nursing unit, the surveyor did not observe grievance forms or grievance information available for residents or responsible parties. CNA staff, a nurse, and a unit manager all stated the forms were kept behind the nurses’ stations and were not available without asking staff. The Social Worker acknowledged that residents did have the right to complete a grievance anonymously, but said the forms on the nursing units were not accessible to residents and could not be completed anonymously unless a resident could independently get to the lobby. The facility also failed to follow its grievance process for an ongoing complaint about an excessively loud television on the AB unit. Two residents reported that they had repeatedly complained about another resident’s loud TV in the evening and at night and had received no response or resolution. One resident said they were told they did not have a right to complain about it, and another said they were being denied peace and sleep. Review of the grievance book from January 2025 to the present did not show a grievance had been completed for this issue. The Social Worker said she was aware of the ongoing complaints but had not completed a grievance form and had only been trying to keep the peace. The Administrator stated the Social Worker should have completed a grievance and said the grievance process was not being followed as intended.
Food Handling, Reheating, Hair Restraint, and Dating Failures
Penalty
Summary
The facility failed to follow sanitation and food handling practices during food preparation and service in the main kitchen. During observation, a dietary staff member used a thermometer to check multiple food items without wiping or sanitizing the probe between items, and the thermometer had been submerged in food before being rinsed under running sink water and reused. The Food Service Director stated the thermometer should have been cleaned after each food item to prevent cross contamination. During lunch tray line service, the same dietary staff member handled food with gloved hands, left the tray line, touched other kitchen items including a utensil hanger turnstile and a microwave oven door handle, and then returned to plating food without changing gloves or performing hand hygiene. The staff member also retrieved a pre-made omelet, placed it in the microwave for 30 seconds, removed it, and served it without checking the temperature after reheating. The Food Service Director stated the staff member should have changed gloves and performed hand hygiene after touching other items and should have followed reheating safety protocols by temping the omelet after microwaving. The facility also failed to ensure proper hair restraints and dating of food items in unit kitchenettes. In the main kitchen, a dietary staff member with a full beard worked during meal service without wearing a beard covering, despite the facility policy requiring beard restraints. In three unit kitchenettes, surveyors found opened and undated or improperly dated items including Boost Breeze, thickened orange juice, thickened liquids, Lactaid milk, prunes, Gatorade, and a store-bought coffee, as well as a wrapped food item with a resident's name but no date. The Food Service Director and Administrator stated opened items should be labeled and dated when opened so staff know when to discard them.
Infection Control and PPE Failures
Penalty
Summary
The facility failed to follow infection prevention and control practices for residents on transmission-based precautions. For Resident #54, who tested positive for COVID-19, a surveyor observed a housekeeper enter the room wearing an N95 mask, gown, and gloves, but without eye protection. When the housekeeper exited the room, she removed her gown and gloves and sanitized her hands, but did not remove the N95 mask. The facility’s Infection Prevention Nurse stated staff entering a COVID-19 isolation room should wear full PPE, including an N95 mask, gown, gloves, and eye protection, and should remove the N95 mask and don a new one after exiting the room. The facility also failed to implement remediation measures in response to positive Legionella test results in the water system. Review of the facility’s Legionella testing showed multiple positive samples from residential room handwashing sinks, including results of 2.6 MPN, 2.2 MPN, 4.7 MPN, and 50.7 MPN. The facility’s own interpretation of Legionella culture results indicated that results between 10 and 100 CFU/ml required immediate disinfection within 24 hours and retesting in three to seven days. The facility’s hot water temperature logs also showed multiple room temperatures below the facility’s stated range of 108 to 110 degrees F, including readings of 101, 104, 103, 102, and 106 degrees F, with one date not recorded. The facility did not provide evidence of action taken in response to the out-of-compliance temperatures or the actionable test results. The facility also failed to ensure staff wore the PPE required by the isolation signage posted outside Resident #74’s room. Resident #74 tested positive for COVID-19 and had symptoms consistent with fever, and the nurse practitioner directed quarantine per facility protocol. A surveyor observed a CNA assisting the resident with breakfast while not wearing eye protection, despite the posted sign requiring a gown, N95 respirator, eye protection, and gloves. A nurse was present outside the room preparing medications and entered the room with full PPE, but did not redirect the CNA for not wearing the required eye protection. Staff interviews confirmed the expectation was to follow the PPE requirements posted on the isolation sign.
Incomplete Physician Documentation in Resident Record
Penalty
Summary
The facility failed to maintain complete medical records for one resident out of a sample of 18 residents because the resident’s chart did not include physician documentation for encounters that nursing progress notes said occurred. Nursing notes documented that the resident was seen by the physician on 10/8/24 for positive COVID, on 10/15/24 for a 60-day visit, on 11/19/24 for a coated tongue, and on 2/11/25 for psych recommendation review. Review of the medical record did not find the physician’s documentation for those visits. During interview, the DON stated the nursing notes showed the physician had visited the resident on those dates, but the facility had not received the physician’s documentation, and acknowledged that a complete medical record would include the physician’s documentation of those encounters.
Medication Administration Errors Exceeding Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as evidenced by one nurse making four errors out of 30 opportunities, resulting in a 13.33% error rate. These errors affected two residents. For one resident, Repaglinide and Metformin, both oral antihyperglycemic medications, were not administered as per the physician's orders. The Repaglinide was not given within the one-hour window of the scheduled time, and the Metformin was not administered before breakfast as required. The nurse involved stated that the resident preferred to take medications together, which contributed to the deviation from the prescribed schedule. For another resident, Carbidopa-Levodopa, used for treating Parkinson's disease symptoms, and Furosemide, a diuretic, were not administered within the one-hour window of their scheduled times. The electronic Medication Administration Record indicated that the morning doses of these medications were charted late, although the nurse entered comments indicating they were administered on time. The Director of Nursing confirmed that the expectation is for medications to be administered within a one-hour window before or after the scheduled time.
Deficiencies in Medication Administration and Pain Assessment
Penalty
Summary
The facility failed to ensure professional standards of care were met for two residents during medication administration. For one resident, the nurse administered multiple medications but left the room before confirming that the resident had taken all the medications. The resident was not documented as being able to self-administer medications, and the Director of Nursing confirmed that it was expected for the nurse to stay with the resident until all medications were taken. For another resident, the facility failed to perform adequate pain assessments to determine the appropriate dosage of oxycodone to administer, as per the physician's orders. The resident had frequent pain and was receiving pain medication on an as-needed basis. However, the medical records lacked documentation of pain severity assessments when administering oxycodone, and reasons for administering the medication were often vague, such as 'per Resident's request' or 'generalized pain.' Interviews with the Unit Manager and Director of Nursing revealed that the facility's policy was to use a numerical pain scale to assess pain levels, but this was not consistently done. The Director of Nursing acknowledged that the orders did not specify a numerical scale, but nursing staff were expected to use one to determine the appropriate medication dosage.
Failure to Remove Side Rails Despite Declined Consent
Penalty
Summary
The facility failed to adhere to the declination of consent from the Health Care Proxy (HCP) regarding the use of side rails for a resident admitted for a respite stay with a diagnosis of dementia. Upon admission, the resident's HCP explicitly declined the use of side rails, as documented in the medical record. However, during observations on two separate occasions, the surveyor noted that the resident's bed was equipped with side rails on both the upper left and right sides, despite the resident not being present in the bed at those times. In an interview, Unit Manager #1 acknowledged that the side rails were remnants from the previous occupant of the bed and confirmed that no assessment for the use of side rails had been conducted for the current resident. The Unit Manager also confirmed that the HCP had declined consent for the use of side rails, indicating a failure to remove them upon the resident's admission.
Failure to Timely Complete AIMS Assessments for Residents on Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that the drug regimens for two residents were free from unnecessary psychotropic medications. Specifically, the facility did not complete the Abnormal Involuntary Movement Scale (AIMS) assessments in a timely manner for these residents, who were receiving antipsychotic medications. Resident #4, admitted in March 2018, had diagnoses including dementia, paranoid personality disorder, bipolar disorder, personality disorder, and generalized anxiety disorder. The resident was on a regimen of aripiprazole and risperidone, with care plans indicating AIMS assessments every six months. However, the assessments were completed on 12/18/23 and 8/5/24, missing the scheduled assessment in June 2024. Similarly, Resident #26, admitted in June 2021 with dementia and bipolar disorder, was also receiving antipsychotic medication, specifically risperidone. The care plan for this resident also required AIMS assessments every six months. The assessments for Resident #26 were completed on the same dates as Resident #4, indicating a similar delay in the June 2024 assessment. During an interview, the Director of Nursing confirmed that the AIMS assessments should have been conducted in June 2024, not August 2024, highlighting the facility's failure to adhere to the scheduled assessment timeline.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was admitted with diagnoses including diabetes mellitus and peripheral vascular disease. The resident, who was cognitively intact, experienced a hypoglycemic event where they became diaphoretic and unresponsive. In response, facility staff administered two doses of glucagon, an anti-hypoglycemic agent, as per the physician's orders. However, the administration of these doses was not documented on the resident's Medication Administration Record (MAR), which is a deviation from the facility's policy requiring documentation of all medication administrations. Interviews with various nursing staff, including the nurse who administered the glucagon, revealed that the medication administration was noted in a progress note but not recorded on the MAR. The Unit Manager and Director of Nurses confirmed that the administration should have been documented on the MAR, as per standard practice. This oversight indicates a failure to adhere to the facility's medication administration policy, which mandates that all administered medications, including as-needed medications, be documented with the date and time of administration.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of implementation of Enhanced Barrier Precautions (EBP) for two residents. Resident #20, who has an indwelling urinary catheter, was observed being assisted by a CNA for morning hygiene and dressing without the use of gown and gloves, despite an EBP sign being posted at the door. The CNA indicated a misunderstanding of the necessity for precautions, stating that no special precautions were needed for the resident, contrary to the facility's policy and CMS guidance. Similarly, Resident #32, who has an unhealed pressure ulcer, was observed receiving wound care from a Unit Manager who donned gloves but failed to wear a gown, despite the presence of an EBP sign and available gowns. The Unit Manager acknowledged the oversight, recognizing that EBP was required due to the resident's open wound. The Director of Nursing confirmed that it was expected for staff to follow EBP when indicated, highlighting a gap in adherence to infection control protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 307 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fairhaven
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Royal Of Fairhaven Nursing Center | 0.8 mi | ★★★★★ | 0 | 0 |
| Brandon Woods Of New Bedford | 1.5 mi | ★★★★★ | 1 | 0 |
| Alden Court Nursing Care & Rehabilitation Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Sacred Heart Nursing Home | 1.9 mi | ★★★★★ | 3 | 0 |
| Vantage Health & Rehab Of New Bedford | 2.1 mi | ★★★★★ | 25 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Our Ladys Haven Of Fairhaven Inc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.