SNF

Victoria Haven Nursing Facility

CCN: 225608 · NORWOOD, MA 02062 · Norfolk County

Overview

Address
137 NICHOLS STREET, NORWOOD, MA 02062
Phone
7817620858
Certified beds
31
Avg daily residents
27 (86% of beds filled)
Ownership
For-profit corporation
Provider type
Medicare and Medicaid
Medicare/Medicaid since
1994-03-01
Setting
Urban
1 /5
★★★★★
CMS Overall Rating

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
★★★★★ 1/5
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
★★★★★ 2/5
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
Footnote 24.
★★★★★ 1/5
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
★★★★★ 4/5
Quality Measures breakdown
Long-Stay Quality Measures ★★★★★ 3/5
Short-Stay Quality Measures ★★★★★ 5/5

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
 4.29 3.56 4.66 ≥ 3.48
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
 0.48 0.62 0.52 ≥ 0.55 Below floor
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
 0.99 0.79 1.07 —
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
 2.83 2.15 3.07 —
Licensed (RN + LPN)
Combined licensed nurse coverage.
 1.47 — — —
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
 0.07 — — —

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
4.08
hrs / resident / day
RN (weekend)
0.43
hrs / resident / day
Total nurse (adjusted, weekend)
4.42
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
36.0%
annual
RN turnover
Staffing penalized (missing PBJ submission).
Administrators departed
0
last 12 months

Resident acuity

Nursing Case-Mix Index
1.26
higher acuity than avg
Case-Mix Index Ratio
0.91
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2025-02-18 10 10 0 48 1 48
Cycle 2/3 (prior) 2024-02-29 12 12 0 88 2 132
Total weighted health score
69.0
lower is better

Deficiencies (31)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

3 A/B/C No actual harm — minor
26 D/E/F Actual harm — potential for minor
2 G/H/I Actual harm
Tag Description Scope/Severity Survey date Corrected
0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. B 2025-02-18 2025-03-26
0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted D 2025-02-18 2025-03-26
0658 Ensure services provided by the nursing facility meet professional standards of quality. D 2025-02-18 2025-03-26
0677 Provide care and assistance to perform activities of daily living for any resident who is unable. D 2025-02-18 2025-03-26
0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. D 2025-02-18 2025-03-26
0758 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 2025-02-18 2025-03-26
0761 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 2025-02-18 2025-03-26
0880 Provide and implement an infection prevention and control program. E 2025-02-18 2025-03-26
0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. E 2025-02-18 2025-03-26
0887 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 2025-02-18 2025-03-26
0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. G 2024-02-29 2024-04-02
0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. B 2024-02-29 2024-04-02
0625 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 2024-02-29 2024-04-02
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D 2024-02-29 2024-04-02
0658 Ensure services provided by the nursing facility meet professional standards of quality. E 2024-02-29 2024-04-02
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. G 2024-02-29 2024-04-02
0759 Ensure medication error rates are not 5 percent or greater. D 2024-02-29 2024-04-02
0761 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 2024-02-29 2024-04-08
0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. D 2024-02-29 2024-04-02
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. D 2024-02-29 2024-04-02
0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. E 2024-02-29 2024-04-02
0887 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 2024-02-29 2024-04-02
0553 Allow resident to participate in the development and implementation of his or her person-centered plan of care. D 2022-10-21 2022-11-18
0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. D 2022-10-21 2022-11-18
0658 Ensure services provided by the nursing facility meet professional standards of quality. D 2022-10-21 2022-11-18
0745 Provide medically-related social services to help each resident achieve the highest possible quality of life. E 2022-10-21 2022-11-18
0758 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. E 2022-10-21 2022-11-18
0808 Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. D 2022-10-21 2022-11-18
0880 Provide and implement an infection prevention and control program. E 2022-10-21 2022-11-18
0885 Report COVID19 data to residents and families. E 2022-10-21 2022-11-18
0886 Perform COVID19 testing on residents and staff. E 2022-10-21 2022-11-18

Penalties (1)

Fines issued
1
last 3 years
Total fines
$40,641
Date Type Fine amount
2024-02-29 Fine $40,641

Source: CMS Nursing Home Penalties.

Financial Health (FY 2023)

Payer mix (share of resident days)

Medicare 21.9% Medicaid 53.6% Other 24.5%

Operating performance

Operating Margin
-10.6%
Total Margin
-10.1%
Occupancy Rate
73.3%
Cost per Resident Day
$32

Revenue & costs

Net Patient Revenue
$3.2M
Total Costs
$262K
Net Income
-$320K

Balance sheet

Total Assets
$427K
Total Liabilities
$1.0M
Fund Balance
-$582K
Current Ratio
0.78

Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.

Ownership & Corporate Structure

Chain: REHABILITATION ASSOCIATES

Chain ID
445
Facilities in chain
6
Legal business name
137 NICHOLS ST INC
Chain-average star ratings (for peer context)
Overall
3.2
Health
3.0
Staffing
4.0
QM
3.0

Owner / manager organizations (1)

Organization Role Association
REHABILITATION ASSOCIATES INC OPERATIONAL/MANAGERIAL CONTROL since 02/01/1985

Owner / manager individuals (3)

Name Role Association
THISSE, MARION 5% OR GREATER DIRECT OWNERSHIP INTEREST since 03/14/2024
THISSE, GILBERT OPERATIONAL/MANAGERIAL CONTROL since 01/06/2025
THISSE, PETER CORPORATE OFFICER since 01/03/1990

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
No
Hospital-based
No
Resident / family council
Resident
Sprinkler systems
Yes
Abuse citation flag
No
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

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Show 113 rows
Source Metric Value Raw key
Cost Report Cost per Resident Day ($) $32 metrics.cost_per_resident_day
Cost Report Current Ratio 0.78 metrics.current_ratio
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Medicaid Day Share (%) 53.6% metrics.medicaid_day_share
Cost Report Medicare Day Share (%) 21.9% metrics.medicare_day_share
Cost Report Net Income ($) $-319,606 metrics.net_income
Cost Report Net Patient Revenue ($) $3,161,093 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 73.3% metrics.occupancy_rate
Cost Report Operating Margin (%) -10.6% metrics.operating_margin
Cost Report Total Assets ($) $427,452 metrics.total_assets
Cost Report Total Costs ($) $261,858 metrics.total_costs
Cost Report Total Fund Balances ($) $-582,298 metrics.fund_balance
Cost Report Total Liabilities ($) $1,009,750 metrics.total_liabilities
Cost Report Total Margin (%) -10.1% metrics.total_margin
Provider Information Abuse Icon N Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 1.07446 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 3.06718 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 0.51860 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 4.66025 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 4.42308 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote — Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 26.7 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote — Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 0.78958 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 2.14590 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 0.62236 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 3.55785 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 3.13587 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 3.0 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 3.2 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 3.0 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 4.0 Chain Average Staffing Rating
Provider Information Chain ID 445 Chain ID
Provider Information Chain Name REHABILITATION ASSOCIATES Chain Name
Provider Information City/Town NORWOOD City/Town
Provider Information CMS Certification Number (CCN) 225608 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community N Continuing Care Retirement Community
Provider Information County/Parish Norfolk County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 1994-03-01 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote — Geocoding Footnote
Provider Information Health Inspection Rating 2 Health Inspection Rating
Provider Information Health Inspection Rating Footnote — Health Inspection Rating Footnote
Provider Information Latitude 42.1929 Latitude
Provider Information Legal Business Name 137 NICHOLS ST INC Legal Business Name
Provider Information Location 137 NICHOLS STREET,NORWOOD,MA,02062 Location
Provider Information Long-Stay QM Rating 3 Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote — Long-Stay QM Rating Footnote
Provider Information Longitude -71.208 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago N Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home 0 Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 31 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections — Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 6 Number of Facilities in Chain
Provider Information Number of Fines 1 Number of Fines
Provider Information Number of Payment Denials 0 Number of Payment Denials
Provider Information Nursing Case-Mix Index 1.26039 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 0.91488 Nursing Case-Mix Index Ratio
Provider Information Overall Rating 1 Overall Rating
Provider Information Overall Rating Footnote — Overall Rating Footnote
Provider Information Ownership Type For profit - Corporation Ownership Type
Provider Information Physical Therapist Staffing Footnote — Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 137 NICHOLS STREET Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name Victoria Haven Nursing Facility Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 130 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating 4 QM Rating
Provider Information QM Rating Footnote — QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 48 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 0 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 10 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2025-02-18 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 48 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 10 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 12 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2024-02-29 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 88 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 44 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 0 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 2 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 132 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 12 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 0.43244 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover — Registered Nurse turnover
Provider Information Registered Nurse turnover footnote 27 Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 1.46801 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 0.99012 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 2.82641 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.07291 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 0.47789 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote — Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 4.29442 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating 5 Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote — Short-Stay QM Rating Footnote
Provider Information Special Focus Status — Special Focus Status
Provider Information Staffing Rating 1 Staffing Rating
Provider Information Staffing Rating Footnote 24 Staffing Rating Footnote
Provider Information State MA State
Provider Information Telephone Number 7817620858 Telephone Number
Provider Information Total Amount of Fines in Dollars 40641.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 4.07587 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 1 Total Number of Penalties
Provider Information Total nursing staff turnover 36.0 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote — Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 69.000 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council Resident With a Resident and Family Council
Provider Information ZIP Code 02062 ZIP Code