The Vardell Report.Victoria Haven Nursing Facility

Across 3 inspections from February 2024 to January 2026, state surveyors documented 39 findings at Victoria Haven Nursing Facility; 39 have a recorded correction; CMS lists 1 enforcement action in the window.

Inspections

3

2024–2026, standard

Findings

39

Deficiencies cited by state inspectors

Corrected

39

Of 39 findings, with a recorded correction date

Penalties

1

1 fine; payment not published

Every inspection in the record window, newest first. A finding is a deficiency an inspector cited. CMS publishes what a complaint investigation cited, not what the complaint alleged.

1. Jan 212026

   Standard health inspection

   17 findings

   • F727Have 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.Level FNo actual harm, potential for moreCorrected Mar 2, 2026
   • F730Observe each nurse aide's job performance and give regular training.Level FNo actual harm, potential for moreCorrected Mar 2, 2026
   • F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.Level FNo actual harm, potential for moreCorrected Feb 27, 2026
   • F880Provide and implement an infection prevention and control program.Level FNo actual harm, potential for moreCorrected Feb 27, 2026
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Feb 2, 2026
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level ENo actual harm, potential for moreCorrected Feb 2, 2026
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level ENo actual harm, potential for moreCorrected Feb 3, 2026
   • F759Ensure medication error rates are not 5 percent or greater.Level ENo actual harm, potential for moreCorrected Feb 6, 2026
   • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Feb 20, 2026
   • F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Level ENo actual harm, potential for moreCorrected Feb 14, 2026
   • F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Level ENo actual harm, potential for moreCorrected Feb 14, 2026
   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level DNo actual harm, potential for moreCorrected Feb 2, 2026
   • F772Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.Level DNo actual harm, potential for moreCorrected Feb 4, 2026
   • F777Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.Level DNo actual harm, potential for moreCorrected Feb 14, 2026
   • F840Employ 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.Level DNo actual harm, potential for moreCorrected Feb 19, 2026
   • F887Educate 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.Level DNo actual harm, potential for moreCorrected Feb 13, 2026
   • F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Level DNo actual harm, potential for moreCorrected Mar 2, 2026

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

2. Feb 182025

   Standard health inspection

   10 findings

   • F880Provide and implement an infection prevention and control program.Level ENo actual harm, potential for moreCorrected Mar 26, 2025
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level ENo actual harm, potential for moreCorrected Mar 26, 2025
   • F887Educate 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.Level ENo actual harm, potential for moreCorrected Mar 26, 2025
   • F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedLevel DNo actual harm, potential for moreCorrected Mar 26, 2025
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level DNo actual harm, potential for moreCorrected Mar 26, 2025
   • F677Provide care and assistance to perform activities of daily living for any resident who is unable.Level DNo actual harm, potential for moreCorrected Mar 26, 2025
   • F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Level DNo actual harm, potential for moreCorrected Mar 26, 2025
   • F758Implement 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.Level DNo actual harm, potential for moreCorrected Mar 26, 2025
   • F761Ensure 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.Level DNo actual harm, potential for moreCorrected Mar 26, 2025
   • F640Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.Level BPotential for minimal harmCorrected Mar 26, 2025

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

3. Feb 292024

   Standard health inspection

   12 findings

   • F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Level GActual harmCorrected Apr 2, 2024
   • F684Provide appropriate treatment and care according to orders, resident’s preferences and goals.Level GActual harmCorrected Apr 2, 2024
   • F658Ensure services provided by the nursing facility meet professional standards of quality.Level ENo actual harm, potential for moreCorrected Apr 2, 2024
   • F761Ensure 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.Level ENo actual harm, potential for moreCorrected Apr 8, 2024
   • F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Level ENo actual harm, potential for moreCorrected Apr 2, 2024
   • F887Educate 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.Level ENo actual harm, potential for moreCorrected Apr 2, 2024
   • F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F759Ensure medication error rates are not 5 percent or greater.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Level DNo actual harm, potential for moreCorrected Apr 2, 2024
   • F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Level BPotential for minimal harmCorrected Apr 2, 2024
   • F625Notify 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.Level BPotential for minimal harmCorrected Apr 2, 2024

   Enforcement Action

   Civil money penalty, $40,641 imposed February 29, 2024. CMS publishes the fine, not whether it has been paid. CMS does not tie a penalty to a survey; listed with the standard health inspection of February 29, 2024, the nearest before the penalty date.

   Source: Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

Severity levels follow the CMS scope and severity grid. A–C: potential for minimal harm. D–F: no actual harm, potential for more than minimal harm. G–I: actual harm. J–L: immediate jeopardy.

A repeated citation can merit attention, but context and corrective action must be reviewed before drawing a conclusion.

1. 1

   Professional Standards, Cited in Three Inspections

   Inspectors cited F658 in February 2024, February 2025 and January 2026. This citation covers whether the home’s services meet professional standards of quality. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242526F658 across all 3 inspections, oldest to newest
2. 2

   Medication Labeling and Storage, Cited in Three Inspections

   Inspectors cited F761 in February 2024, February 2025 and January 2026. This citation covers how drugs are labeled and kept locked, including controlled drugs. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242526F761 across all 3 inspections, oldest to newest
3. 3

   Citation F887, Cited in Three Inspections

   Inspectors cited F887 in February 2024, February 2025 and January 2026. The agency describes it this way: 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. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242526F887 across all 3 inspections, oldest to newest
4. 4

   Telling Families About Changes, Cited in Two Inspections

   Inspectors cited F580 in February 2024 and January 2026. This citation covers whether the resident, their doctor and a family member are told promptly about an injury, a decline or another significant change. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242526F580 across all 3 inspections, oldest to newest
5. 5

   Quality of Care, Cited in Two Inspections

   Inspectors cited F684 in February 2024 and January 2026. This citation covers whether residents receive the treatment their orders, preferences and goals call for. The most serious of these was recorded at level G (actual harm). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242526F684 across all 3 inspections, oldest to newest
6. 6

   Citation F756, Cited in Two Inspections

   Inspectors cited F756 in February 2025 and January 2026. The agency describes it this way: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242526F756 across all 3 inspections, oldest to newest
7. 7

   Medication Error Rate, Cited in Two Inspections

   Inspectors cited F759 in February 2024 and January 2026. This citation covers whether medication errors stayed under 5 percent when inspectors watched medications being given. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242526F759 across all 3 inspections, oldest to newest
8. 8

   Infection Control, Cited in Two Inspections

   Inspectors cited F880 in February 2025 and January 2026. This citation covers hand hygiene, isolation practice and the home’s infection-prevention program. None rose above level F (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242526F880 across all 3 inspections, oldest to newest
9. 9

   Citation F883, Cited in Two Inspections

   Inspectors cited F883 in February 2024 and February 2025. The agency describes it this way: Develop and implement policies and procedures for flu and pneumonia vaccinations. None rose above level E (no actual harm, potential for more). Each citation has a recorded correction, and a repeat after correction is worth a direct question.

   242526F883 across all 3 inspections, oldest to newest

Bring these to the tour. Each one comes from something in the record; the reason is under the question.

1. 01

   How do you check that nurses and aides follow professional standards, and what happens when they do not?

   Professional Standards: cited in three inspections, most seriously at level E.

2. 02

   How are medications stored and secured, and who checks the medication carts?

   Medication Labeling and Storage: cited in three inspections, most seriously at level E.

3. 03

   What changed after F887 was cited, and how do you check it now?

   Citation F887: cited in three inspections, most seriously at level E.

4. 04

   How quickly will we hear about a fall, an injury or a change in condition, and from whom?

   Telling Families About Changes: cited in two inspections, most seriously at level G.

5. 05

   How do nurses make sure a doctor’s orders are carried out, and how are families told when something is missed?

   Quality of Care: cited in two inspections, most seriously at level G.

6. 06

   What changed after F756 was cited, and how do you check it now?

   Citation F756: cited in two inspections, most seriously at level E.

7. 07

   How are medication passes checked, and what happens when an error is found?

   Medication Error Rate: cited in two inspections, most seriously at level E.

8. 08

   Who leads infection control here, and how often are hand-hygiene and isolation practices audited?

   Infection Control: cited in two inspections, most seriously at level F.

9. 09

   What changed after F883 was cited, and how do you check it now?

   Citation F883: cited in two inspections, most seriously at level E.

10. 10

    How many nurses and aides are on each shift, including nights and weekends, for the unit we are considering?

    No staffing citation appears in this window. Staffing levels are published separately by CMS and are worth asking about directly.

11. 11

    What led to the 2024 fine, and has it been paid?

    A $40,641 civil money penalty was imposed February 29, 2024. CMS publishes the fine, not whether it has been paid.

Inspection results and penalties are published by the Centers for Medicare & Medicaid Services from surveys conducted by the Massachusetts state survey agency.

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Massachusetts state survey agency

  Inspection Feb 29, 2024 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Massachusetts state survey agency

  Inspection Feb 18, 2025 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Health inspection results, as published by CMS (Health Deficiencies and Inspection Dates, Provider Data Catalog)

  Massachusetts state survey agency

  Inspection Jan 21, 2026 · Published Oct 1, 2026 · Retrieved Nov 1, 2026

• Penalties, Provider Data Catalog

  Centers for Medicare & Medicaid Services

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗
• Provider Information, Provider Data Catalog

  Centers for Medicare & Medicaid Services · 225608

  Published Oct 1, 2026 · Retrieved Nov 1, 2026

  View Dataset ↗

Historical coverage varies by agency and location. Missing records do not mean that no complaint or violation occurred.

Data architecture: Cierto supplies the source-backed machine-readable bundle. Life by Vardell independently creates the narrative, design, and consumer report.