Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Victoria Haven Nursing Facility

NORWOOD, MA · 31 certified beds · Last Life Safety survey January 21, 2026

CMS Certification Number 225608 · first certified March 1994

Ownership

Operated by REHABILITATION ASSOCIATES · For profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

33
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
7
Tags cited more than once
Across separate surveys
6
Inspection & testing records
Of the citations on file

Position within MA

33 citations — more than 98% of the 341 certified nursing homes in MA. Compared within MA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 10 citations; the earlier surveys in the window averaged 11.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens January 2027 — about 4 months from now. This facility’s last Life Safety survey was January 2026. Facilities in MA are typically surveyed 12–15 months after the last one (median 13), measured over 556 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

6 of the 33 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 33 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in MA, and nationally. Surveyors differ markedly between states, so the MA figure is the meaningful one.

This facility33MA median11National median11
Citations on file over three years, compared
MeasureCitations
This facility33
Median facility in MA11
Median facility nationally11

Survey history

Citations at each Life Safety survey
122024-02112025-02102026-01
Citations at each Life Safety survey
Survey dateCitations
February 29, 202412
February 18, 202511
January 21, 202610

Most-cited tags

Most-cited tags at this facility
K-03113K-02413K-02113K-02323K-02253K-01613K-09182K-03531
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0311Have an enclosure around a vertical opening shaft.32026-01-21
K-0241Have correct number of accessible exits for each story.32026-01-21
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.32026-01-21
K-0232Have corridors or aisles that are unobstructed and are at least 8 feet in width.32026-01-21
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.32026-01-21
K-0161Use approved construction type or materials.32026-01-21
K-0918Have generator or other power source capable of supplying service within 10 seconds.22026-01-21
K-0353Inspect, test, and maintain automatic sprinkler systems.12026-01-21

What the citations cover

Citations by CMS category
  • Egress Deficiencies 13
  • Emergency Preparedness Deficiencies 6
  • Smoke Deficiencies 5
  • Gas, Vacuum, and Electrical Systems Deficiencies 4
  • Other 5
Citations by CMS category
CategoryCitations
Egress Deficiencies13
Emergency Preparedness Deficiencies6
Smoke Deficiencies5
Gas, Vacuum, and Electrical Systems Deficiencies4
Construction Deficiencies3
Miscellaneous Deficiencies2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

January 21, 2026 — 10 citations

Citations issued on January 21, 2026
TagWhat the surveyor checksStatus
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (March 14, 2026)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (March 14, 2026)
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.Deficient, Provider has date of correction (March 14, 2026)
K-0232Have corridors or aisles that are unobstructed and are at least 8 feet in width.Deficient, Provider has date of correction (March 14, 2026)
K-0241Have correct number of accessible exits for each story.Deficient, Provider has date of correction (March 14, 2026)
K-0311Have an enclosure around a vertical opening shaft.Deficient, Provider has date of correction (March 14, 2026)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (April 6, 2026)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (April 6, 2026)
K-0912Have power receptacles that are properly grounded.Deficient, Provider has date of correction (April 6, 2026)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (April 8, 2026)

February 18, 2025 — 11 citations

Citations issued on February 18, 2025
TagWhat the surveyor checksStatus
E-0018Establish procedures for tracking staff and patients during an emergency.Deficient, Provider has date of correction (April 1, 2025)
E-0022Establish policies and procedures for sheltering.Deficient, Provider has date of correction (April 1, 2025)
E-0023Establish policies and procedures for medical documentation.Deficient, Provider has date of correction (April 1, 2025)
E-0026Establish roles under a Waiver declared by secretary.Deficient, Provider has date of correction (April 1, 2025)
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (April 10, 2025)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (April 10, 2025)
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.Deficient, Provider has date of correction (April 10, 2025)
K-0232Have corridors or aisles that are unobstructed and are at least 8 feet in width.Deficient, Provider has date of correction (April 10, 2025)
K-0241Have correct number of accessible exits for each story.Deficient, Provider has date of correction (April 10, 2025)
K-0311Have an enclosure around a vertical opening shaft.Deficient, Provider has date of correction (April 10, 2025)
K-0711Provide a written emergency evacuation plan.Deficient, Provider has date of correction (April 1, 2025)

February 29, 2024 — 12 citations

Citations issued on February 29, 2024
TagWhat the surveyor checksStatus
E-0004Develop and maintain an Emergency Preparedness Program (EP).Deficient, Provider has date of correction (March 25, 2024)
E-0030List the names and contact information of those in the facility.Deficient, Provider has date of correction (March 25, 2024)
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (March 12, 2024)
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (March 12, 2024)
K-0225Have stairways and smokeproof enclosures used as exits that meet safety requirements.Deficient, Provider has date of correction (March 12, 2024)
K-0232Have corridors or aisles that are unobstructed and are at least 8 feet in width.Deficient, Provider has date of correction (March 12, 2024)
K-0241Have correct number of accessible exits for each story.Deficient, Provider has date of correction (March 12, 2024)
K-0291Install emergency lighting that can last at least 1 1/2 hours.Deficient, Provider has date of correction (April 15, 2024)
K-0311Have an enclosure around a vertical opening shaft.Deficient, Provider has date of correction (March 12, 2024)
K-0712Have simulated fire drills held at unexpected times.Deficient, Provider has date of correction (April 1, 2024)
K-0911Meet requirements for the installation and maintenance of electrical systems.Deficient, Provider has date of correction (April 15, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (April 15, 2024)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.