Victoria Haven Nursing Facility

Nursing Home · Norwood, MA

CMS overall rating 2/5 For profit - Corporation

CMS certification number225608

Contact & location

137 Nichols Street
Norwood, MA 02062
Norfolk County
Phone
(781) 762-0858
ZIP code
02062 – all care providers

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Facility details

Certified beds
31
Residents per day
25.7 (83% occupied)
Ownership
For profit - Corporation
Legal name
137 Nichols ST INC
Chain
Rehabilitation Associates (6 facilities, avg 3.8★)
Medicare certified since
March 1, 1994
Participates in
Medicare and Medicaid
Council
Resident council

CMS star ratings

Overall★★★★★ 2/5
State avg 3.0
Health inspections★★★★★ 1/5
State avg 3.0
Staffing★★★★★ 5/5
State avg 3.1
Quality measures★★★★★ 5/5
State avg 3.3
Long-stay quality★★★★★ 5/5
Short-stay quality★★★★★ 5/5

Staffing

Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.

Total nurse staffing
4.58 (state 3.86 · U.S. 3.86)
Registered nurses (RN)
0.70 (state 0.65 · U.S. 0.69)
Licensed practical nurses
0.96 (state 0.95 · U.S. 0.86)
Nurse aides
2.93 (state 2.26 · U.S. 2.32)
Weekend total
4.19 (state 3.48 · U.S. 3.42)
Nursing staff turnover
21.7 (state 38.2 · U.S. 45.8)%
RN turnover
—
Administrators who left
0 in the last year

Inspections

Last standard inspection
January 21, 2026
Health deficiencies (last cycle)
17.0 (state 7.2 · U.S. 9.3)
From complaints
0
Citations on record (3 years)
39 health · 33 fire safety · includes actual harm
DateCitationSeverityStatus
2026-01-21 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.
F0727 · Nursing and Physician Services Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2026-03-02
2026-01-21 Observe each nurse aide's job performance and give regular training.
F0730 · Nursing and Physician Services Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2026-03-02
2026-01-21 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F0867 · Administration Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2026-02-27
2026-01-21 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 F
No actual harm, potential for more than minimal harm		 Corrected 2026-02-27
2026-01-21 Ensure services provided by the nursing facility meet professional standards of quality.
F0658 · Resident Assessment and Care Planning Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-02-02
2026-01-21 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-02-02
2026-01-21 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F0756 · Pharmacy Service Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-02-03
2026-01-21 Ensure medication error rates are not 5 percent or greater.
F0759 · Pharmacy Service Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-02-06
2026-01-21 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.
F0761 · Pharmacy Service Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-02-20
2026-01-21 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F0805 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-02-14
2026-01-21 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F0812 · Nutrition and Dietary Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2026-02-14
2026-01-21 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F0580 · Resident Rights Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-02-02
2026-01-21 Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
F0772 · Administration Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-02-04
2026-01-21 Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
F0777 · Administration Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-02-14
2026-01-21 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.
F0840 · Administration Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-02-19
2026-01-21 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.
F0887 · Infection Control Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-02-13
2026-01-21 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
F0947 · Nursing and Physician Services Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2026-03-02
2025-02-18 Provide and implement an infection prevention and control program.
F0880 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-03-26
2025-02-18 Develop and implement policies and procedures for flu and pneumonia vaccinations.
F0883 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-03-26
2025-02-18 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.
F0887 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2025-03-26
2025-02-18 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
F0655 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-26
2025-02-18 Ensure services provided by the nursing facility meet professional standards of quality.
F0658 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-26
2025-02-18 Provide care and assistance to perform activities of daily living for any resident who is unable.
F0677 · Quality of Life and Care Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-26
2025-02-18 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
F0756 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-26
2025-02-18 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.
F0758 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-26
2025-02-18 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.
F0761 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2025-03-26
2025-02-18 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
F0640 · Resident Assessment and Care Planning Deficiencies		 B
No actual harm, potential for minimal harm		 Corrected 2025-03-26
2024-02-29 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F0580 · Resident Rights Deficiencies		 G
Actual harm		 Corrected 2024-04-02
2024-02-29 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F0684 · Quality of Life and Care Deficiencies		 G
Actual harm		 Corrected 2024-04-02
2024-02-29 Ensure services provided by the nursing facility meet professional standards of quality.
F0658 · Resident Assessment and Care Planning Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-04-02
2024-02-29 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.
F0761 · Pharmacy Service Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-04-08
2024-02-29 Develop and implement policies and procedures for flu and pneumonia vaccinations.
F0883 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-04-02
2024-02-29 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.
F0887 · Infection Control Deficiencies		 E
No actual harm, potential for more than minimal harm		 Corrected 2024-04-02
2024-02-29 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F0656 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-04-02
2024-02-29 Ensure medication error rates are not 5 percent or greater.
F0759 · Pharmacy Service Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-04-02
2024-02-29 Have a policy regarding use and storage of foods brought to residents by family and other visitors.
F0813 · Nutrition and Dietary Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-04-02
2024-02-29 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F0842 · Resident Assessment and Care Planning Deficiencies		 D
No actual harm, potential for more than minimal harm		 Corrected 2024-04-02
2024-02-29 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F0623 · Resident Rights Deficiencies		 B
No actual harm, potential for minimal harm		 Corrected 2024-04-02
2024-02-29 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.
F0625 · Resident Rights Deficiencies		 B
No actual harm, potential for minimal harm		 Corrected 2024-04-02

Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results

Fines & penalties

1 penalty in the last three years, including $40,641 in fines.

DateTypeAmount
2024-02-29Fine$40,641

Ownership & management

NameRoleSince
Thisse, Marion (individual)5%+ Direct Ownership Interest · 100%
Thisse, Peter (individual)Corporate Officer · NOT APPLICABLE
Rehabilitation Associates INC (organization)Operational/managerial Control · NOT APPLICABLE
Thisse, Gilbert (individual)Operational/managerial Control · NOT APPLICABLE

Frequently asked questions

What is the rating of Victoria Haven Nursing Facility?

Victoria Haven Nursing Facility has a 2-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 3.0-star average in Massachusetts.

How many beds does Victoria Haven Nursing Facility have?

It has 31 certified beds and cares for about 26 residents per day.

Has Victoria Haven Nursing Facility been fined?

Yes. CMS lists 1 penalty totaling $40,641 in the last three years.

Who owns Victoria Haven Nursing Facility?

It is part of Rehabilitation Associates and is classified as for profit - corporation. See the ownership table above for all owners and managers reported to CMS.

What is the phone number of Victoria Haven Nursing Facility?

(781) 762-0858. The facility is located at 137 Nichols Street, Norwood, MA 02062.

Other nursing homes in Norwood

Compare all nursing homes in Norwood, MA →

Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.