D+
54/100Victoria Haven Nursing Facility Inspection Report, Violations & Safety Grade (NORWOOD, Massachusetts)
137 NICHOLS STREET, NORWOOD, Massachusetts 02062
Phone: 7817620858
CMS Overall:2/5
Overview & Bed Count
Certified Beds
31
Avg Residents/Day
24
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Norfolk
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall2/5
Health1/5
Staffing5/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | Massachusetts Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.72 | 0.66 | +0.07 |
| Total Nurse Hours per Resident per Day | 4.89 | 3.94 | +0.96 |
| CMS Staffing Rating | 5/5 | 3.1/5 | - |
| Nursing Staff Turnover | 25.0% | 37.6% | - |
Health Citation History
39 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-01-21 | Nursing and Physician Services Deficiencies | 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. | F – Moderate Harm Potential |
| 2026-01-21 | Nursing and Physician Services Deficiencies | Observe each nurse aide's job performance and give regular training. | F – Moderate Harm Potential |
| 2026-01-21 | Administration Deficiencies | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | F – Moderate Harm Potential |
| 2026-01-21 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2026-01-21 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | E – Moderate Harm Potential |
| 2026-01-21 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E – Moderate Harm Potential |
| 2026-01-21 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | E – Moderate Harm Potential |
| 2026-01-21 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | E – Moderate Harm Potential |
| 2026-01-21 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2026-01-21 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | E – Moderate Harm Potential |
| 2026-01-21 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E – Moderate Harm Potential |
| 2026-01-21 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2026-01-21 | Administration Deficiencies | Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | D – Moderate Harm Potential |
| 2026-01-21 | Administration Deficiencies | Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | D – Moderate Harm Potential |
| 2026-01-21 | Administration Deficiencies | 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. | D – Moderate Harm Potential |
| 2026-01-21 | Infection Control Deficiencies | 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. | D – Moderate Harm Potential |
| 2026-01-21 | Nursing and Physician Services Deficiencies | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | D – Moderate Harm Potential |
| 2025-02-18 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2025-02-18 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | E – Moderate Harm Potential |
| 2025-02-18 | Infection Control Deficiencies | 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 – Moderate Harm Potential |
| 2025-02-18 | Resident Assessment and Care Planning Deficiencies | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D – Moderate Harm Potential |
| 2025-02-18 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2025-02-18 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2025-02-18 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2025-02-18 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2025-02-18 | Pharmacy Service Deficiencies | 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 – Moderate Harm Potential |
| 2025-02-18 | Resident Assessment and Care Planning Deficiencies | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | B – Minimal Harm Potential |
| 2024-02-29 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | G – Actual Harm |
| 2024-02-29 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G – Actual Harm |
| 2024-02-29 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | E – Moderate Harm Potential |
| 2024-02-29 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-02-29 | Infection Control Deficiencies | Develop and implement policies and procedures for flu and pneumonia vaccinations. | E – Moderate Harm Potential |
| 2024-02-29 | Infection Control Deficiencies | 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 – Moderate Harm Potential |
| 2024-02-29 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2024-02-29 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2024-02-29 | Nutrition and Dietary Deficiencies | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | D – Moderate Harm Potential |
| 2024-02-29 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2024-02-29 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | B – Minimal Harm Potential |
| 2024-02-29 | Resident Rights Deficiencies | 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 – Minimal Harm Potential |
Fire Safety Citation History
33 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-01-21 | Construction Deficiencies | Use approved construction type or materials. | F – Moderate Harm Potential |
| 2026-01-21 | Egress Deficiencies | Have correct number of accessible exits for each story. | F – Moderate Harm Potential |
| 2026-01-21 | Smoke Deficiencies | Have an enclosure around a vertical opening shaft. | F – Moderate Harm Potential |
| 2026-01-21 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | F – Moderate Harm Potential |
| 2026-01-21 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2026-01-21 | Gas, Vacuum, and Electrical Systems Deficiencies | Have power receptacles that are properly grounded. | E – Moderate Harm Potential |
| 2026-01-21 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | E – Moderate Harm Potential |
| 2026-01-21 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | C – Minimal Harm Potential |
| 2026-01-21 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | C – Minimal Harm Potential |
| 2026-01-21 | Egress Deficiencies | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | C – Minimal Harm Potential |
| 2025-02-18 | Emergency Preparedness Deficiencies | Establish procedures for tracking staff and patients during an emergency. | F – Moderate Harm Potential |
| 2025-02-18 | Emergency Preparedness Deficiencies | Establish policies and procedures for sheltering. | F – Moderate Harm Potential |
| 2025-02-18 | Emergency Preparedness Deficiencies | Establish policies and procedures for medical documentation. | F – Moderate Harm Potential |
| 2025-02-18 | Emergency Preparedness Deficiencies | Establish roles under a Waiver declared by secretary. | F – Moderate Harm Potential |
| 2025-02-18 | Construction Deficiencies | Use approved construction type or materials. | F – Moderate Harm Potential |
| 2025-02-18 | Egress Deficiencies | Have correct number of accessible exits for each story. | F – Moderate Harm Potential |
| 2025-02-18 | Smoke Deficiencies | Have an enclosure around a vertical opening shaft. | F – Moderate Harm Potential |
| 2025-02-18 | Miscellaneous Deficiencies | Provide a written emergency evacuation plan. | E – Moderate Harm Potential |
| 2025-02-18 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | C – Minimal Harm Potential |
| 2025-02-18 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | C – Minimal Harm Potential |
| 2025-02-18 | Egress Deficiencies | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | C – Minimal Harm Potential |
| 2024-02-29 | Construction Deficiencies | Use approved construction type or materials. | F – Moderate Harm Potential |
| 2024-02-29 | Egress Deficiencies | Have correct number of accessible exits for each story. | F – Moderate Harm Potential |
| 2024-02-29 | Smoke Deficiencies | Have an enclosure around a vertical opening shaft. | F – Moderate Harm Potential |
| 2024-02-29 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | D – Moderate Harm Potential |
| 2024-02-29 | Emergency Preparedness Deficiencies | List the names and contact information of those in the facility. | D – Moderate Harm Potential |
| 2024-02-29 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | D – Moderate Harm Potential |
| 2024-02-29 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the installation and maintenance of electrical systems. | D – Moderate Harm Potential |
| 2024-02-29 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | D – Moderate Harm Potential |
| 2024-02-29 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | C – Minimal Harm Potential |
| 2024-02-29 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | C – Minimal Harm Potential |
| 2024-02-29 | Egress Deficiencies | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | C – Minimal Harm Potential |
| 2024-02-29 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | C – Minimal Harm Potential |
Total Penalties & Fines
$40,641
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2024-02-29 | Fine | $40,641 | - |
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the NORWOOD area at no cost.
Find Safe, Vetted Facilities Near NORWOOD
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.