Victoria Haven Nursing Facility
137 Nichols Street, Norwood, MA 02062
Victoria Haven Nursing Facility is a nursing home in Norwood, Massachusetts. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 2 of 5CMS overall star rating
- 1 of 5CMS health inspection star rating
- 5 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (781) 762-0858
- Last standard health inspection
- January 21, 2026 (9 months ago)
- Certified beds
- 31
- Residents per day, on average
- 24
- Ownership type
- For profit - Corporation
- Legal business name
- 137 Nichols St INC
- Chain
- Rehabilitation Associates
- Takes part in
- Medicare and Medicaid
More health citations than the Massachusetts average (39 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of July 29, 2026
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5.
CMS update of May 27, 2026
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS health inspection star rating changed from 2 of 5 to 1 of 5.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 3 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 4 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
17 citations
Health inspection on January 21, 2026
CMS lists this as a standard inspection.
Citation F0727. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have 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.
CMS lists it as corrected on March 2, 2026.
Citation F0730. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Observe each nurse aide's job performance and give regular training.
CMS lists it as corrected on March 2, 2026.
Citation F0867. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS lists it as corrected on February 27, 2026.
Citation F0880. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on February 27, 2026.
CMS has cited this home for F0880 2 times since 2025.
Citation F0658. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on February 2, 2026.
CMS has cited this home for F0658 3 times since 2024.
Citation F0684. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on February 2, 2026.
CMS has cited this home for F0684 2 times since 2024.
Citation F0756. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on February 3, 2026.
CMS has cited this home for F0756 2 times since 2025.
Citation F0759. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on February 6, 2026.
CMS has cited this home for F0759 2 times since 2024.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on February 20, 2026.
CMS has cited this home for F0761 3 times since 2024.
Citation F0805. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
CMS lists it as corrected on February 14, 2026.
Citation F0812. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on February 14, 2026.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on February 2, 2026.
CMS has cited this home for F0580 2 times since 2024.
Citation F0772. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
CMS lists it as corrected on February 4, 2026.
Citation F0777. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
CMS lists it as corrected on February 14, 2026.
Citation F0840. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 19, 2026.
Citation F0887. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on February 13, 2026.
CMS has cited this home for F0887 3 times since 2024.
Citation F0947. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
CMS lists it as corrected on March 2, 2026.
10 citations
Fire safety inspection on January 21, 2026
CMS lists this as a standard inspection.
Citation K0161. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on March 14, 2026.
CMS has cited this home for K0161 3 times since 2024.
Citation K0241. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have correct number of accessible exits for each story.
CMS lists it as corrected on March 14, 2026.
CMS has cited this home for K0241 3 times since 2024.
Citation K0311. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have an enclosure around a vertical opening shaft.
CMS lists it as corrected on March 14, 2026.
CMS has cited this home for K0311 3 times since 2024.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on April 6, 2026.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 6, 2026.
Citation K0912. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have power receptacles that are properly grounded.
CMS lists it as corrected on April 6, 2026.
Citation K0918. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on April 8, 2026.
CMS has cited this home for K0918 2 times since 2024.
Citation K0211. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on March 14, 2026.
CMS has cited this home for K0211 3 times since 2024.
Citation K0225. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on March 14, 2026.
CMS has cited this home for K0225 3 times since 2024.
Citation K0232. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
CMS lists it as corrected on March 14, 2026.
CMS has cited this home for K0232 3 times since 2024.
CMS update of November 20, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 3 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 5 of 5 to 1 of 5.
Health citation
CMS removed citation F0623 from the health inspection on February 29, 2024.
Health citation
CMS removed citation F0625 from the health inspection on February 29, 2024.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of February 26, 2025
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Ownership
CMS ownership records list new owners for this home.
10 citations
Health inspection on February 18, 2025
CMS lists this as a standard inspection.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on March 26, 2025.
Citation F0883. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on March 26, 2025.
CMS has cited this home for F0883 2 times since 2024.
Citation F0887. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on March 26, 2025.
Citation F0655. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS lists it as corrected on March 26, 2025.
Citation F0658. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on March 26, 2025.
Citation F0677. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS lists it as corrected on March 26, 2025.
Citation F0756. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on March 26, 2025.
Citation F0758. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 26, 2025.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on March 26, 2025.
Citation F0640. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
CMS lists it as corrected on March 26, 2025.
11 citations
Fire safety inspection on February 18, 2025
CMS lists this as a standard inspection.
Citation E0018. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish procedures for tracking staff and patients during an emergency.
CMS lists it as corrected on April 1, 2025.
Citation E0022. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures for sheltering.
CMS lists it as corrected on April 1, 2025.
Citation E0023. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish policies and procedures for medical documentation.
CMS lists it as corrected on April 1, 2025.
Citation E0026. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Establish roles under a Waiver declared by secretary.
CMS lists it as corrected on April 1, 2025.
Citation K0161. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on April 10, 2025.
Citation K0241. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have correct number of accessible exits for each story.
CMS lists it as corrected on April 10, 2025.
Citation K0311. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have an enclosure around a vertical opening shaft.
CMS lists it as corrected on April 10, 2025.
Citation K0711. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide a written emergency evacuation plan.
CMS lists it as corrected on April 1, 2025.
Citation K0211. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on April 10, 2025.
Citation K0225. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on April 10, 2025.
Citation K0232. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
CMS lists it as corrected on April 10, 2025.
CMS update of October 30, 2024
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of May 29, 2024
Star rating
The CMS overall star rating changed from 5 of 5 to 3 of 5.
Star rating
The CMS health inspection star rating changed from 4 of 5 to 2 of 5.
CMS update of April 25, 2024
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
12 citations
Health inspection on February 29, 2024
CMS lists this as a standard inspection.
Severity G is the second-highest of CMS's four levels. It means a resident was harmed.
69 of 341 Massachusetts homes (20%) got a citation at the actual harm level in 2024.
Citation F0580. Severity G: actual harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on April 2, 2024.
Citation F0684. Severity G: actual harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on April 2, 2024.
Citation F0658. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure services provided by the nursing facility meet professional standards of quality.
CMS lists it as corrected on April 2, 2024.
Citation F0761. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 8, 2024.
Citation F0883. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on April 2, 2024.
Citation F0887. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 2, 2024.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on April 2, 2024.
Citation F0759. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure medication error rates are not 5 percent or greater.
CMS lists it as corrected on April 2, 2024.
Citation F0813. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
CMS lists it as corrected on April 2, 2024.
Citation F0842. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on April 2, 2024.
Citation F0623. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on April 2, 2024.
Citation F0625. Severity B: potential for minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on April 2, 2024.
12 citations
Fire safety inspection on February 29, 2024
CMS lists this as a standard inspection.
Citation K0161. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Use approved construction type or materials.
CMS lists it as corrected on March 12, 2024.
Citation K0241. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have correct number of accessible exits for each story.
CMS lists it as corrected on March 12, 2024.
Citation K0311. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have an enclosure around a vertical opening shaft.
CMS lists it as corrected on March 12, 2024.
Citation E0004. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on March 25, 2024.
Citation E0030. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
List the names and contact information of those in the facility.
CMS lists it as corrected on March 25, 2024.
Citation K0291. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on April 15, 2024.
Citation K0911. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on April 15, 2024.
Citation K0918. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on April 15, 2024.
Citation K0211. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on March 12, 2024.
Citation K0225. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
CMS lists it as corrected on March 12, 2024.
Citation K0232. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
CMS lists it as corrected on March 12, 2024.
Citation K0712. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on April 1, 2024.
Fine
February 29, 2024 (2 years ago)
CMS fine of $40,641 on February 29, 2024.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- THISSE, MARION5% or greater direct ownership interest · 100% · since 03/14/2024
- REHABILITATION ASSOCIATES INCOperational/managerial control · not applicable · since 02/01/1985
- THISSE, GILBERTOperational/managerial control · not applicable · since 01/06/2025
Questions
When was Victoria Haven Nursing Facility last inspected?
CMS lists January 21, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Victoria Haven Nursing Facility have?
CMS lists 39 health citations since February 29, 2024. CMS also calls these deficiencies.
Has Victoria Haven Nursing Facility been fined?
CMS lists 1 fine in the past three years, $40,641 in total.
What is the CMS star rating of Victoria Haven Nursing Facility?
Its CMS overall star rating is 2 of 5.
Is Victoria Haven Nursing Facility a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.