Cycle 1
Health 2025-11-14 · Fire 2025-11-14
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fairhaven, MA
Our Ladys Haven Of Fairhaven Inc
4-star overall rating with 4-star inspections with 5 recent health deficiencies
71 Center Street, Fairhaven, MA
(508) 999-4561
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
117
Certified beds
Average residents
76
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Diocesan Health Facilities
Operator or chain grouping
Approved since
1990-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 4 overall / 3 health / 5 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.78
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.58
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.26 · national 2.35
Total nurse hours
3.77
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
3.44
Weekend nurse staffing · state 3.45 · national 3.43
Weekend RN hours
0.66
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
4.19
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 40% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,902
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.33
Composite VBP score used to determine payment impact.
Payment multiplier
0.9838
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.91% · Performance 21.74% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Performance 7.92% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.21
Baseline 33.33% · Performance 46.47% · Measure score 4.21 · Achievement 4.21 · Improvement 0
Adjusted total nurse staffing
5.92
Baseline 4.04 hours · Performance 4.76 hours · Measure score 5.92 · Achievement 5.92 · Improvement 3.66
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.99% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 15.28% · Lower 95% interval 8.44% |
| Discharge to community | 52.81% |
50.57%
2.2 pts better
|
No Different than the National Rate · Eligible stays 41 · Observed rate 46.34% · Lower 95% interval 38.68% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 47 · Denominator 47 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 47 |
| Discharge self-care score | 34.29% |
53.69%
19.4 pts worse
|
Numerator 12 · Denominator 35 |
| Discharge mobility score | 57.14% |
50.94%
6.2 pts better
|
Numerator 20 · Denominator 35 |
| Pressure ulcers or injuries, new or worsened | 4.26% |
2.29%
2 pts worse
|
Numerator 2 · Denominator 47 · Adjusted rate 3.21% |
| Healthcare-associated infections requiring hospitalization | 7.92% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 10% · Lower 95% interval 4.49% |
| Staff COVID-19 vaccination coverage | 11.88% |
8.2%
3.7 pts better
|
Numerator 12 · Denominator 101 |
| Staff flu vaccination coverage | 28.8% |
42%
13.2 pts worse
|
Numerator 36 · Denominator 125 |
| Discharge function score | 51.43% |
56.45%
5 pts worse
|
Numerator 18 · Denominator 35 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.64% |
25.2%
11.6 pts worse
|
Numerator 3 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.9
0.6 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 1.6 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.5
0.4 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.3% |
92.2%
2.1 pts better
|
93.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.0% · Q2 92.6% · Q3 93.2% · Q4 100.0% · 4Q avg 94.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.5% |
94.8%
0.3 pts worse
|
95.5%
1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.5%
0.7 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.9% · Q3 1.4% · Q4 4.1% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
12.0%
12 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 7.1% |
5.2%
1.9 pts worse
|
5.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 7.1% · Q3 1.8% · Q4 10.3% · 4Q avg 7.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.2% |
19.2%
1 pts worse
|
19.6%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.5% · Q2 17.2% · Q3 19.7% · Q4 22.4% · 4Q avg 20.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.4% |
22.5%
0.9 pts worse
|
16.7%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 23.6% · Q3 19.3% · Q4 21.7% · 4Q avg 23.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.6% |
17.7%
3.9 pts worse
|
16.3%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 24.5% · Q3 13.9% · Q4 27.4% · 4Q avg 21.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.7% |
17.6%
3.1 pts worse
|
14.9%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 18.4% · Q3 21.2% · Q4 25.9% · 4Q avg 20.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
1.0%
0.8 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 2.3% · Q4 3.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
2.0%
0.6 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 4.5% · Q3 4.3% · Q4 0.0% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.7% |
21.7%
About the same
|
19.8%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.2% · Q2 18.7% · Q3 24.9% · Q4 28.1% · 4Q avg 21.7% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
4.6%
1.8 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.5% · Q3 5.1% · Q4 2.6% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 79.1% |
77.1%
2 pts better
|
81.7%
2.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 75.0% · Q2 79.5% · Q3 81.2% · Q4 81.5% · 4Q avg 79.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
11.8%
4.2 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 6.8% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.2% |
77.7%
6.5 pts better
|
79.7%
4.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.7% |
25.8%
1.9 pts worse
|
23.9%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.7% · Observed 25.0% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-29 · Fire 2024-10-29
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-11-15 · Fire 2023-11-15
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-14
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-12-03
E · Potential for more than minimal harm
2025-11-14
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-12-03
E · Potential for more than minimal harm
2025-11-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-03
E · Potential for more than minimal harm
2025-11-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-03
B · Minimal harm
2025-11-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-12-03
E · Potential for more than minimal harm
2024-10-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-29
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-29
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-29
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-29
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-22
D · Potential for more than minimal harm
2024-10-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-22
F · Potential for more than minimal harm
2023-11-15
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-15
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-15
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-08-08
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-09-01
Penalties and ownership
What sits behind the stars
Ownership
Da Cunha, Edgar
Corporate Officer · Individual
Diocesan Health Facilities
Operational/Managerial Control · Organization
Henry, Diana
Corporate Director · Individual
Kiley, Kevin
Corporate Director · Individual
Long, Joanne
Corporate Director · Individual
Mathias, Gregory
Corporate Director · Individual
Mello, Curtis
Contracted Managing Employee · Individual
Mitchell, Laura
Operational/Managerial Control · Individual
Nelson, David
Corporate Director · Individual
Oliveira, John
Corporate Director · Individual
Pignato, David
Corporate Director · Individual
Roque, Joanne
Operational/Managerial Control · Individual
Simmons, Caitlin
W-2 Managing Employee · Individual
Sullivan, John
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Royal Of Fairhaven Nursing Center
Fairhaven, MA
3-star overall rating with 3-star inspections with $8,648 in total fines with 4 recent health deficiencies
#2
Brandon Woods of New Bedford
New Bedford, MA
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $464,490 in total fines with 46 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
Alden Court Nursing Care & Rehabilitation Center
Fairhaven, MA
4-star overall rating with 4-star inspections with $12,386 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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