VICTORIA HAVEN NURSING FACILITY

NORWOOD, MA · 31 beds · For profit - Corporation

10 Trust Score
Grade: F CRITICAL Risk → Stable

Red Flags

  • 1-star staffing rating
  • 2 citation(s) where residents suffered actual harm

Green Flags

No positive signals identified yet.

Quick Facts

★☆☆☆☆
CMS Overall
★★☆☆☆
Health Inspection
10
1.1x state avg
Deficiencies
$40,641
Fines (3-yr)
★☆☆☆☆
Staffing

Violation Timeline

February 17, 2025

10 deficiencyies
F0640 No Harm Scope/Severity: B

Resident Assessment and Care Planning Deficiencies

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Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

F0655 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

F0658 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Ensure services provided by the nursing facility meet professional standards of quality.

F0677 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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Provide care and assistance to perform activities of daily living for any resident who is unable.

F0756 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

F0758 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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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.

F0761 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

F0880 Potential Harm Scope/Severity: E

Infection Control Deficiencies

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Provide and implement an infection prevention and control program.

F0883 Potential Harm Scope/Severity: E

Infection Control Deficiencies

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Develop and implement policies and procedures for flu and pneumonia vaccinations.

F0887 Potential Harm Scope/Severity: E

Infection Control Deficiencies

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Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

February 28, 2024

10 deficiencyies
F0580 Actual Harm Scope/Severity: G

Resident Rights Deficiencies

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Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

F0623 No Harm Scope/Severity: B

Resident Rights Deficiencies

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Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

F0625 No Harm Scope/Severity: B

Resident Rights Deficiencies

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Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

F0656 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

F0658 Potential Harm Scope/Severity: E

Resident Assessment and Care Planning Deficiencies

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Ensure services provided by the nursing facility meet professional standards of quality.

F0684 Actual Harm Scope/Severity: G

Quality of Life and Care Deficiencies

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Provide appropriate treatment and care according to orders, resident’s preferences and goals.

F0759 Potential Harm Scope/Severity: D

Pharmacy Service Deficiencies

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Ensure medication error rates are not 5 percent or greater.

F0761 Potential Harm Scope/Severity: E

Pharmacy Service Deficiencies

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Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

F0813 Potential Harm Scope/Severity: D

Nutrition and Dietary Deficiencies

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Have a policy regarding use and storage of foods brought to residents by family and other visitors.

F0842 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

See full violation history →

Staffing

0.52
RN hrs/res/day
1.07
LPN hrs/res/day
3.07
CNA hrs/res/day
4.42
Weekend hrs/res/day
36%
Total nurse turnover
N/A
RN turnover

A nurse checks on each resident roughly every 5.2 hours on average.

Fines & Penalties

  • Fine Feb 28, 2024
    $40,641
Total $40,641

Ownership

For profit - Corporation Chain: REHABILITATION ASSOCIATES
  • THISSE, MARION

    5% OR GREATER DIRECT OWNERSHIP INTEREST

    Since since 03/14/2024

    100% Individual
  • REHABILITATION ASSOCIATES INC

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 02/01/1985

    Organization
  • THISSE, GILBERT

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 01/06/2025

    Individual
  • THISSE, PETER

    CORPORATE OFFICER

    Since since 01/03/1990

    Individual

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