Victoria Haven Nursing Facility
137 NICHOLS STREET, NORWOOD, MA 02062 · CCN 225608
Ratings
- Overall
- ★☆☆☆☆ 1
- Health inspection
- ★★☆☆☆ 2
- Quality measures
- ★★★★☆ 4
- Staffing
- ★☆☆☆☆ 1
Facility
- Ownership type
- For profit - Corporation
- Certified beds
- 31
- Avg residents/day
- 26.7
- Phone
- 7817620858
Inspection history vs Massachusetts & national averages
Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.
| Cycle | Inspection date | This facility | Massachusetts avg | National avg | vs state |
|---|---|---|---|---|---|
| 1 | 2025-02-18 | 10 | 8.9 | 9.5 | +1.1 worse |
| 2 | 2024-02-29 | 12 | 10.0 | 9.8 | +2.0 worse |
| 3 | 2022-10-21 | 9 | 12.7 | 9.3 | -3.7 better |
Cycle 1 deficiencies by category
| Category | Deficiencies |
|---|---|
| Quality of life and care | 1 |
| Resident assessment and care planning | 3 |
| Pharmacy service | 3 |
| Infection control | 3 |
Staffing (hours per resident per day)
| Metric | This facility | Turnover |
|---|---|---|
| Total nurse staffing (reported) | 4.29 | 36.0% |
| RN staffing (reported) | 0.48 | — |
| Total nurse staffing (adjusted) | 4.66 | — |
Fines & penalties
- Total fines
- $40,641
- Number of fines
- 1
- Number of penalties
- 1
- Payment denials
- 0
Chain
- Chain
- REHABILITATION ASSOCIATES
- Facilities in chain
- 6
- Chain avg overall
- 3.20 / 5
Inspection citations (31)2 actual harm
- BF0640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.2025-02-18 · Health · corrected 2025-03-26
Potential for minimal harm
- DF0655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted2025-02-18 · Health · corrected 2025-03-26
Potential for more than minimal harm
- DF0658Ensure services provided by the nursing facility meet professional standards of quality.2025-02-18 · Health · corrected 2025-03-26
Potential for more than minimal harm
- DF0677Provide care and assistance to perform activities of daily living for any resident who is unable.2025-02-18 · Health · corrected 2025-03-26
Potential for more than minimal harm
- DF0756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.2025-02-18 · Health · corrected 2025-03-26
Potential for more than minimal harm
- DF0758Implement 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.2025-02-18 · Health · corrected 2025-03-26
Potential for more than minimal harm
- DF0761Ensure 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.2025-02-18 · Health · corrected 2025-03-26
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2025-02-18 · Health · corrected 2025-03-26
Potential for more than minimal harm
- EF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2025-02-18 · Health · corrected 2025-03-26
Potential for more than minimal harm
- EF0887Educate 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.2025-02-18 · Health · corrected 2025-03-26
Potential for more than minimal harm
- GF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2024-02-29 · Health · corrected 2024-04-02
Actual harm
- BF0623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.2024-02-29 · Health · corrected 2024-04-02
Potential for minimal harm
- BF0625Notify 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.2024-02-29 · Health · corrected 2024-04-02
Potential for minimal harm
- DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2024-02-29 · Health · corrected 2024-04-02
Potential for more than minimal harm
- EF0658Ensure services provided by the nursing facility meet professional standards of quality.2024-02-29 · Health · corrected 2024-04-02
Potential for more than minimal harm
- GF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2024-02-29 · Health · corrected 2024-04-02
Actual harm
- DF0759Ensure medication error rates are not 5 percent or greater.2024-02-29 · Health · corrected 2024-04-02
Potential for more than minimal harm
- EF0761Ensure 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.2024-02-29 · Health · corrected 2024-04-08
Potential for more than minimal harm
- DF0813Have a policy regarding use and storage of foods brought to residents by family and other visitors.2024-02-29 · Health · corrected 2024-04-02
Potential for more than minimal harm
- DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-02-29 · Health · corrected 2024-04-02
Potential for more than minimal harm
- EF0883Develop and implement policies and procedures for flu and pneumonia vaccinations.2024-02-29 · Health · corrected 2024-04-02
Potential for more than minimal harm
- EF0887Educate 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.2024-02-29 · Health · corrected 2024-04-02
Potential for more than minimal harm
- DF0553Allow resident to participate in the development and implementation of his or her person-centered plan of care.2022-10-21 · Health · corrected 2022-11-18
Potential for more than minimal harm
- DF0578Honor 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.2022-10-21 · Health · corrected 2022-11-18
Potential for more than minimal harm
- DF0658Ensure services provided by the nursing facility meet professional standards of quality.2022-10-21 · Health · corrected 2022-11-18
Potential for more than minimal harm
- EF0745Provide medically-related social services to help each resident achieve the highest possible quality of life.2022-10-21 · Health · corrected 2022-11-18
Potential for more than minimal harm
- EF0758Implement 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.2022-10-21 · Health · corrected 2022-11-18
Potential for more than minimal harm
- DF0808Ensure 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.2022-10-21 · Health · corrected 2022-11-18
Potential for more than minimal harm
- EF0880Provide and implement an infection prevention and control program.2022-10-21 · Health · corrected 2022-11-18
Potential for more than minimal harm
- EF0885Report COVID19 data to residents and families.2022-10-21 · Health · corrected 2022-11-18
Potential for more than minimal harm
- EF0886Perform COVID19 testing on residents and staff.2022-10-21 · Health · corrected 2022-11-18
Potential for more than minimal harm
Ownership
| Owner | Type | Role | Percent | Since |
|---|---|---|---|---|
| THISSE, MARION | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | 2024-03-14 |
| REHABILITATION ASSOCIATES INC | Organization | OPERATIONAL/MANAGERIAL CONTROL | — | 1985-02-01 |
| THISSE, GILBERT | Individual | OPERATIONAL/MANAGERIAL CONTROL | — | 2025-01-06 |
| THISSE, PETER | Individual | CORPORATE OFFICER | — | 1990-01-03 |
Other facilities in NORWOOD
| Name | Overall | Beds |
|---|---|---|
| ELLIS NURSING HOME (THE) | ★★★★☆ | 191 |
| CHARLWELL HOUSE HEALTH AND REHABILITATION | ★☆☆☆☆ | 124 |
| NORWOOD HEALTHCARE | ★☆☆☆☆ | 170 |
Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.