Victoria Haven Nursing Facility
137 Nichols Street, Norwood, MA 02062 · Norfolk County · 31 certified beds · avg 26 residents/day · certified since Mar 1, 1994
Part of chain: REHABILITATION ASSOCIATES (6 facilities, chain avg rating 3.8★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Feb 29, 2024 · F-0580
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 2, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 29, 2024 · F-0684
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Apr 2, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (39)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jan 21, 2026 | F · Potential for harm, facility-wide | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Jan 21, 2026 | F · Potential for harm, facility-wide | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Jan 21, 2026 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Jan 21, 2026 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jan 21, 2026 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jan 21, 2026 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jan 21, 2026 | E · Potential for harm, repeated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Jan 21, 2026 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jan 21, 2026 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jan 21, 2026 | E · Potential for harm, repeated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Jan 21, 2026 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jan 21, 2026 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Jan 21, 2026 | D · Potential for harm, one-off | The facility did not have an agreement with an approved laboratory to provide lab services, even though it doesn't offer lab services on site. |
| Jan 21, 2026 | D · Potential for harm, one-off | The facility did not provide or obtain x-rays and other imaging tests when ordered, or did not promptly tell the ordering doctor the results. |
| Jan 21, 2026 | D · Potential for harm, one-off | The facility did not bring in qualified outside professionals to provide a required service when it didn't have a qualified professional on staff. |
| Jan 21, 2026 | D · Potential for harm, one-off | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Jan 21, 2026 | D · Potential for harm, one-off | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. |
| Feb 18, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 18, 2025 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Feb 18, 2025 | E · Potential for harm, repeated | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Feb 18, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 18, 2025 | B · Minimal risk, repeated | The facility did not enter each resident's assessment information into the required format and send it to the state within 7 days of completing the assessment, as the rules require. |
| Feb 29, 2024 | ▲ G · Actual harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Feb 29, 2024 | ▲ G · Actual harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Feb 29, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Feb 29, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 29, 2024 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Feb 29, 2024 | E · Potential for harm, repeated | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. |
| Feb 29, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Feb 29, 2024 | B · Minimal risk, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Feb 29, 2024 | B · Minimal risk, repeated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (10 → 17).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 12 | 2 | G ▲ |
| 2025 | 10 | 0 | E |
| 2026 | 17 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $40,641.
| Date | Type | Amount / length |
|---|---|---|
| Feb 29, 2024 | Fine | $40,641 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Massachusetts avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 5.10 | 3.89 | 3.95 | top 8% in Massachusetts; top 12% in the U.S. |
| Registered Nurse hours | 0.78 | 0.65 | 0.69 | top 20% in Massachusetts; top 29% in the U.S. |
| Weekend total nurse staffing | 4.66 | 3.51 | 3.50 | top 9% in Massachusetts; top 10% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.54 | 0.46 | 0.48 | top 24% in Massachusetts; top 28% in the U.S. |
| Total nursing staff turnover (%) | 21.7 | 38.2 | 45.8 | top 6% in Massachusetts; top 4% in the U.S. |
| RN turnover (%) | 0.0 | 42.6 | 42.9 | — |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.58, RN 0.70, weekend 4.19. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Thisse, Marion | Individual | 5% or Greater Direct Ownership Interest | 100% | 03/14/2024 |
| Rehabilitation Associates INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 02/01/1985 |
| Thisse, Gilbert | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/06/2025 |
| Thisse, Peter | Individual | Corporate Officer | NOT APPLICABLE | 01/03/1990 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How many hours a day is a registered nurse physically in the building, including weekends?"
- "How often do you evaluate your nurse aides and what ongoing training do they receive?"
- "How does your quality committee work, and can you give an example of a problem it recently identified and fixed?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Does a pharmacist review every resident's medications and chart monthly, and how are their concerns acted on?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Norwood Healthcare | 0.6 mi | Norwood, MA | ★☆☆☆☆ | 1/5 | SFF |
| Charlwell House Health and Rehabilitation | 0.8 mi | Norwood, MA | ★☆☆☆☆ | 2/5 | |
| Ellis Nursing Home (the) | 1.5 mi | Norwood, MA | ★★★★★ | 4/5 | |
| Premier Healthcare at Harrington House | 2.1 mi | Walpole, MA | ★★☆☆☆ | 2/5 | |
| Foremost at Sharon LLC | 3.6 mi | Sharon, MA | ★★☆☆☆ | 2/5 | |
| Hellenic Nursing & Rehabilitation Center | 3.6 mi | Canton, MA | ★★★☆☆ | 4/5 | |
| Thomas Upham House | 5.1 mi | Medfield, MA | ★★★★★ | 4/5 | |
| Newbridge on the Charles Skilled Nursing Facility | 5.1 mi | Dedham, MA | ★★★★★ | 5/5 | |
| Brush Hill Care Center | 5.2 mi | Milton, MA | ★★☆☆☆ | 2/5 | |
| Care Village at West Roxbury | 5.7 mi | West Roxbury, MA | ★★★☆☆ | 3/5 | |
| Briarwood Rehabilitation & Healthcare Center | 5.9 mi | Needham, MA | ★★★★☆ | 4/5 | |
| German Center for Extended Care | 6.1 mi | Boston, MA | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 225608.