VICTORIA HAVEN NURSING FACILITY

Nursing Home Inspector

137 NICHOLS STREET
NORWOOD, MA 02062
Norfolk County
Phone: 781-762-0858
Provider Number: 225608
Last Inspection: 08/09/2017

About the Nursing Home

Number of Beds: 31
Number of Residents: 23
Beds Available: 8
Percent Occupancy: 74%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
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

 

7

Facility
20

County
16

MA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

7

2017
21

2016
18

2015

Medicare Ratings

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

 

Details by Inspection Date

8/9/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Widespread : Potential 4 9/1/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 9/1/2017
 

8/4/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 8/5/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 8/5/2016
 
Failed To: Assure that each resident’s assessment is updated at least once every 3 months. Isolated : Minimal 3 9/16/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 9/16/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 8/26/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 8/5/2016
 

6/3/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 6/24/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 6/24/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 6/24/2015
 
Failed To: Provide proper discharge planning and communication, of the resident's health status and summary of the resident's nursing home stay. Isolated : Minimal 3 6/24/2015
 
Failed To: Have enough backup water supply for essential areas of the nursing home. Widespread : Minimal 5 6/24/2015
 

Complaint Investigation Deficiencies

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

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MA State Avg
Number of Residents 23 95.41 96.79
Registered Nurses 1.59 1.00 0.89
Licensed Practical / Vocational Nurses 0.43 0.70 0.84
Certified Nursing Assistants 3.72 2.41 2.30
Total Staff Hours 5.74 4.11 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 86 90 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 96 95 95
of long-stay residents experiencing one or more falls with major injury 4 4 3
of long-stay residents who have depressive symptoms 3 2 2
of long-stay residents who lose too much weight 6 5 5
of long-stay residents who received an antianxiety or hypnotic medication 10 17 20
of long-stay residents who received an antipsychotic medication 14 17 18
of long-stay residents who self-report moderate to severe pain 0 3 4
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 26 19 18
of long-stay residents whose need for help with daily activities has increased 9 16 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 7 3 3
of low risk long-stay residents who lose control of their bowels or bladder 43 53 54
of short-stay residents assessed and appropriately given the pneumococcal vaccine 73 74 79
of short-stay residents who newly received an antipsychotic medication 10 11 11
of short-stay residents who self-report moderate to severe pain 0 60 60
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 88 1 1
of short-stay residents with pressure ulcers that are new or worsened 0 13 14