Provider Name: VICTORIA HAVEN NURSING FACILITY
Address: 137 NICHOLS STREET, NORWOOD, MA 02062
Phone: (781) 762-0858
County: Norfolk (130)
Ownership Type: For profit - Corporation
Certified Beds: 31
Average Residents Per Day: 23.6 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: 137 NICHOLS ST INC
First Approved Date: March 1, 1994
Affiliated Entity: REHABILITATION ASSOCIATES (445)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 5 ()
Health Inspection Rating: 4 ()
QM Rating: 2 ()
Long Stay QM Rating: 1 ()
Short Stay QM Rating: 4 ()
Staffing Rating: 5 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 3.20113, LPN Staff Hours Per Day: 0.8105, RN Staff Hours Per Day: 0.9748, Licensed Staff Hours Per Day: 1.7853
Total Nurse Staff Hours Per Day, per resident: 4.98651
Weekend Nurse Staff Hours: 4.73333, Weekend RN Staff Hours: 0.8047
PT Staff Hours Per Day, per resident: 0.0617
Nurse Staff Turnover: 35.7, Nurse Turnover Note:
RN Turnover: , RN Turnover Note: 6
Admin Left Number: 1, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.2179, Case Mix LPN Hours Per Day: 0.6697, Case Mix RN Hours Per Day: 0.3374
Adjusted Nurse Aide Hours Per Day, per resident: 2.94033, Adjusted LPN Hours Per Day: 0.8930, Adjusted RN Hours Per Day: 1.0885
Total Adjusted Nurse Hours Per Day, per resident: 4.87343
Adjusted Weekend Nurse Hours Per Day, per resident: 4.62599
Health Survey Dates and Scores: Cycle 1: 2022-10-21 (Score: 56), Cycle 2: 2019-10-03 (Score: 12), Cycle 3: 2018-11-08 (Score: 20)
Total Weighted Health Score: 35.333
Reported Incidents: 0, Substantiated Complaints: 0
Infection Control Citations:
Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 3250.00, Payment Denials Number: 0, Total Penalties Number: 1
Location and GPS: 137 NICHOLS STREET,NORWOOD,MA,02062 (42.1929, -71.208)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-18
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-18
Type: Health, Deficiency: Ensure services provided by the nursing facility meet professional standards of quality.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-18
Type: Health, Deficiency: Provide medically-related social services to help each resident achieve the highest possible quality of life.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-18
Type: Health, Deficiency: 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.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-18
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-18
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-18
Type: Health, Deficiency: Report COVID19 data to residents and families.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-18
Type: Health, Deficiency: Perform COVID19 testing on residents and staff.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-11-18
Type: Health, Deficiency: Give the resident's representative the ability to exercise the resident's rights.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-10-11
Type: Health, Deficiency: Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-10-11
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-10-11
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-11-16
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-11-16
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications: