Victoria Haven Nursing Facility

CCN 225608 · 137 NICHOLS ST INC · For profit - Corporation · REHABILITATION ASSOCIATES chain · 31 certified beds · Norfolk · MA


Victoria Haven Nursing Facility is a 31-bed nursing home in NORWOOD, Massachusetts. CMS has certified it for Medicare and Medicaid since 1994-03-01. It averages 25.7 residents a day.

What harm was found in the violations cited at Victoria Haven Nursing Facility?

CMS lists 39 health-inspection deficiencies for Victoria Haven Nursing Facility, all of them in the three years to 2026-08-01: the highest scope-and-severity letter on record is G; the most recent health inspection was 2026-01-21.

Survey dateTagDeficiencySeverity
2026-01-21F0727, F0730, F0867, F0880Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. / Observe each nurse aide's job performance and give regular training. / Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. / Provide and implement an infection prevention and control program.F
2026-01-21F0658, F0684, F0756, F0759, F0761, F0805, F0812Ensure services provided by the nursing facility meet professional standards of quality. / Provide appropriate treatment and care according to orders, resident’s preferences and goals. / Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. / Ensure medication error rates are not 5 percent or greater. / 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. / Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. / Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E
2026-01-21F0580, F0772, F0777, F0840, F0887, F0947Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. / Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. / Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. / 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. / Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.D
2025-02-18F0880, F0883, F0887Provide and implement an infection prevention and control program. / Develop and implement policies and procedures for flu and pneumonia vaccinations. / 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.E
2025-02-18F0655, F0658, F0677, F0756, F0758, F0761Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted / Ensure services provided by the nursing facility meet professional standards of quality. / Provide care and assistance to perform activities of daily living for any resident who is unable. / Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. / 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. / 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.D
2025-02-18F0640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.B
2024-02-29F0580, F0684Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. / Provide appropriate treatment and care according to orders, resident’s preferences and goals.G
2024-02-29F0658, F0761, F0883, F0887Ensure services provided by the nursing facility meet professional standards of quality. / 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. / Develop and implement policies and procedures for flu and pneumonia vaccinations. / 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.E
2024-02-29F0656, F0759, F0813, F0842Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. / Ensure medication error rates are not 5 percent or greater. / Have a policy regarding use and storage of foods brought to residents by family and other visitors. / Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.D
2024-02-29F0623, F0625Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. / 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.B

Why was Victoria Haven Nursing Facility fined?

DateTypeAmount
2024-02-29Fine$40,641

How is Victoria Haven Nursing Facility staffed?

MeasureThis facilityMA average
Total nurse staffing hours per resident per day4.582143.86193
Total nursing staff turnover (%)21.738.2
Average number of residents per day25.798.5

Who owns Victoria Haven Nursing Facility, and what chain is it in?

Victoria Haven Nursing Facility is registered with CMS as For profit - Corporation, operates under the legal business name 137 NICHOLS ST INC and belongs to the REHABILITATION ASSOCIATES chain.

RoleOwnerAssociation date
5% OR GREATER DIRECT OWNERSHIP INTERESTTHISSE, MARIONsince 03/14/2024
CORPORATE OFFICERTHISSE, PETERsince 01/03/1990
OPERATIONAL/MANAGERIAL CONTROLREHABILITATION ASSOCIATES INC, THISSE, GILBERTsince 01/06/2025

Were you or a family member harmed at Victoria Haven Nursing Facility?