01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2026-01-21 | 17 | 2026-01-21 | 10 |
| Cycle 2 | 2025-02-18 | 10 | 2025-02-18 | 11 |
| Cycle 3 | 2024-02-29 | 12 | 2024-02-29 | 12 |
CMS CCN 2256082026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Victoria Haven Nursing Facility
137 Nichols Street · Norwood, MA 02062 · Norfolk County
Certified beds31CMS provider file
Recent citation rows72current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
72 rows in the current release
2 rows carry G–L scope/severity codes; 0 carry J–L. 16 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-01-21 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-022026-01-21 · HEALTHF0658Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Correction field: Deficient, Provider has date of correction · 2026-02-022026-01-21 · HEALTHF0684Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2026-02-022026-01-21 · HEALTHF0727Severity F · widespread; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-03-022026-01-21 · HEALTHF0730Severity F · widespread; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Correction field: Deficient, Provider has date of correction · 2026-03-022026-01-21 · HEALTHF0756Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-032026-01-21 · HEALTHF0759Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2026-02-062026-01-21 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-202026-01-21 · HEALTHF0772Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Correction field: Deficient, Provider has date of correction · 2026-02-042026-01-21 · HEALTHF0777Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Correction field: Deficient, Provider has date of correction · 2026-02-142026-01-21 · HEALTHF0805Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Correction field: Deficient, Provider has date of correction · 2026-02-142026-01-21 · HEALTHF0812Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2026-02-142026-01-21 · HEALTHF0840Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-192026-01-21 · HEALTHF0867Severity F · widespread; potential for more than minimal harm
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Correction field: Deficient, Provider has date of correction · 2026-02-272026-01-21 · HEALTHF0880Severity F · widespread; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-02-272026-01-21 · HEALTHF0887Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-02-132026-01-21 · HEALTHF0947Severity D · isolated; potential for more than minimal harm
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.
Correction field: Deficient, Provider has date of correction · 2026-03-022026-01-21 · FIREK0161Severity F · widespread; potential for more than minimal harm
Construction Deficiencies
Use approved construction type or materials.
Correction field: Deficient, Provider has date of correction · 2026-03-142026-01-21 · FIREK0211Severity C · widespread; potential for minimal harm
Egress Deficiencies
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Correction field: Deficient, Provider has date of correction · 2026-03-142026-01-21 · FIREK0225Severity C · widespread; potential for minimal harm
Egress Deficiencies
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Correction field: Deficient, Provider has date of correction · 2026-03-142026-01-21 · FIREK0232Severity C · widespread; potential for minimal harm
Egress Deficiencies
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Correction field: Deficient, Provider has date of correction · 2026-03-142026-01-21 · FIREK0241Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Have correct number of accessible exits for each story.
Correction field: Deficient, Provider has date of correction · 2026-03-142026-01-21 · FIREK0311Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have an enclosure around a vertical opening shaft.
Correction field: Deficient, Provider has date of correction · 2026-03-142026-01-21 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2026-04-0603 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-02-29 | Fine | $40,641 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- THISSE, MARIONIndividual · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 03/14/2024
- THISSE, PETERIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/03/1990
- REHABILITATION ASSOCIATES INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/1985
- THISSE, GILBERTIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 01/06/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours4.58per resident day
RN hours0.70per resident day
Weekend nurse hours4.19per resident day
Staff turnover21.7%CMS reported field