Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Norwalk Care Center during CMS and state inspections, most recent first.
Environmental maintenance and hand hygiene supplies were not maintained. Surveyors observed widespread damage and poor upkeep in resident rooms and bathrooms, including torn wallpaper, damaged walls, broken blinds, missing tile, dirty floors, insects, and stained curtains. A resident who was working toward using the toilet instead of a commode reported that the bathroom toilet would not flush and the sink leaked into a bucket, and surveyors confirmed both problems remained unresolved during the survey. Several resident bathrooms also lacked hand soap, and staff acknowledged that some dispensers were not working and soap was not available in those bathrooms.
Two residents with dementia and impaired cognition engaged in a sexual encounter when staff failed to maintain required supervision during an overnight shift. Due to improper break scheduling, only one staff member was present and unable to monitor the unit, allowing the incident to occur. A subsequent psychiatric evaluation determined that one resident lacked capacity to consent.
The facility failed to document the clinical criteria for placing residents in a secured unit, which is meant for those with specific needs related to dementia and wandering. Observations and interviews revealed a lack of clear criteria and incomplete assessments for residents placed on the unit. Some residents, including those with intact cognition, expressed feeling imprisoned and unable to make independent choices about leaving the unit.
The facility failed to ensure that care plans for residents on a secured unit accurately reflected their placement and criteria for such placement. Observations and reviews revealed that care plans did not identify the residents' residence on a secured unit, nor did they specify the criteria for placement or confirm that it was the least restrictive setting. This deficiency was noted for residents with various diagnoses, including dementia and schizoaffective disorder.
The facility's kitchen was found to be unsanitary, with sticky floors, dusty vent covers, and buildup on equipment. Interviews revealed unclear cleaning responsibilities and a lack of documentation for cleaning schedules, despite policy requirements for regular cleaning.
The facility failed to review its infection control policies annually, complete monthly and quarterly infection surveillance reports, and report positive Legionella water test results to the State Agency. The Infection Preventionist Nurse, new to the role, was unable to locate necessary documentation, and the facility's consultant incorrectly advised that reporting was unnecessary.
Two residents in the facility did not receive the pneumococcal and influenza vaccines as required. One resident, admitted with anemia and end-stage renal disease, did not receive the pneumococcal vaccine, and another resident with COPD and hypertension did not receive both the pneumococcal and influenza vaccines despite giving consent. The facility's policies required these vaccinations, but there was no documentation of their administration.
The facility failed to administer and document COVID-19 vaccinations for two residents upon admission. One resident, with impaired cognition and multiple diagnoses, consented to the vaccine but did not receive it, and the facility could not provide documentation of refusal. Another resident, also with impaired cognition, was not offered the vaccine, and the facility lacked documentation of an offer or refusal. The facility's policy required offering the vaccine within 14 days of admission and updating records accordingly.
The facility failed to maintain kitchen equipment, with a non-functional dishwasher and two ovens, and a leaking sink. Disposable items were used for meals due to the broken dishwasher, which had been out of order for months. The Maintenance Director was unaware of some issues and the facility had not paid a deposit for a new dishwasher despite obtaining a quote.
A facility failed to refer a resident with a new diagnosis of major depressive disorder for a level II PASARR assessment. The resident, who required assistance with daily activities and was at risk for psychotropic drug complications, had a new diagnosis documented by a social worker. However, the responsible social worker was not informed, and the referral was not made, highlighting a breakdown in communication and procedure.
A resident readmitted with a surgical wound from a hip replacement did not have a physician's order for wound care documented. The facility failed to follow the surgeon's instructions, resulting in the dressing falling off prematurely and no record of physician notification. The wound later showed signs of infection, prompting a delayed physician's order.
The facility failed to ensure accurate controlled medication counts and proper documentation for one of the medication carts reviewed. Discrepancies were found in the medication counts for three residents, with the actual number of tablets not matching the control drug receipt and disposition records. Interviews with an RN and the DNS highlighted the responsibility of nurses to ensure expired medications are not stored and that controlled medications are secured and documented correctly. The facility's policies require controlled substances to be stored in a double-locked container and accurately recorded, which was not adhered to in this case.
A facility failed to store medications appropriately, as observed in a medication cart review. Expired medications were found, and a bottle of Lantus lacked an open date and discard date. The narcotic box was not locked, although the cart was secured. Interviews with staff revealed that it was everyone's responsibility to ensure expired medications were not stored and that controlled medications should be secured behind two locks. The facility's guidelines require controlled substances to be stored in a double door, double locked container.
The facility failed to document and assess a secured unit, as observed during a survey. The East 1 Unit required a code for entry and exit, but the facility's assessment did not acknowledge its existence or include criteria for resident placement. The assessment was outdated, signed by current staff without their participation, and a new assessment still failed to identify the secured unit. Interviews revealed a lack of awareness and participation in the assessment process by the DNS, Administrator, and medical staff.
Environmental Maintenance and Hand Hygiene Supplies Not Maintained
Penalty
Summary
The facility failed to maintain resident rooms and bathrooms in good repair and in a homelike condition. Survey observations on the 4 East wing identified damaged, torn, stained, marred, and peeling wallpaper; chipped, stained, and marred bathroom walls; cracks between walls and floors; bent, missing, and damaged window blinds; broken, missing, peeling, and dirty cove base; broken or missing toilet bowl covers; stained and debris-covered floor corners and crevices; damaged or missing floor tile; winged flying black insects in bedrooms, bathrooms, and hallways; damaged, chipped, marred, rusty, and peeling door frames; and stained privacy curtains. Facility staff acknowledged awareness of some of these environmental issues and stated that maintenance and housekeeping were responsible for repairs and upkeep. Resident #89 was admitted in August 2025 with diagnoses including orthopedic aftercare and difficulty walking. The care plan identified muscle weakness, difficulty walking, bladder incontinence, and the need for supervision or touching assistance with transfers to a bedside commode, along with an unobstructed path to the bathroom. The resident also had a goal of returning to the community and was working with rehabilitation services to begin using the toilet instead of the commode. The resident reported that the bathroom toilet had not been flushing for over a week and that the bathroom sink had been leaking into a bucket on the floor. The resident stated the concerns had been reported to the Maintenance Director, but the toilet and sink were still broken, so the resident continued using the bedside commode. Survey observations confirmed that the toilet in Resident #89's bathroom did not flush and that the sink drain pipe was leaking into basins on the floor. An RN observed that the toilet was not functioning and that the sink pipe still leaked after an apparent attempted repair. The Regional Clinical Director later observed the same conditions and stated the toilet and sink should have already been repaired after the issue was brought to the facility's attention. The Maintenance/Housekeeping Director stated he had inspected the toilet and sink and determined the toilet needed internal mechanical parts and the sink needed a new drainage pipe, but the repairs had not been completed at the time of survey because he had not gotten the parts. In addition, an anonymous resident reported that a shared bathroom used by multiple residents had been without hand soap for over 2 months. Survey observations confirmed that several resident bathrooms lacked hand soap, and staff acknowledged that some soap dispensers were not functional and that individual hand soap should have been placed in the bathrooms.
Failure to Provide Adequate Supervision Resulting in Sexual Abuse
Penalty
Summary
The facility failed to provide adequate supervision to prevent sexual abuse between two residents, both of whom had dementia and impaired cognitive function. One resident, with a history of vascular dementia, psychotic and mood disturbances, and aphasia, was identified as having sexual expression behaviors and was care planned to discuss feelings and receive psychology consults as needed. The other resident, with anxiety, depression, and dementia, was care planned as being at risk for abuse and sexual risk due to congregate living, with interventions to seek staff assistance and avoid contact with aggressors. On the night of the incident, staff scheduling and supervision were not properly managed. During the overnight shift, two staff members went on break at the same time, leaving only one staff member on the unit, who was seated in a location without visibility of the resident hallway. This lapse in supervision allowed one resident to enter another resident's room, where a sexual encounter occurred. The incident was discovered when the remaining staff member began rounds and found the two residents together, with clothing and briefs displaced, indicating sexual activity. Subsequent interviews and documentation revealed that both residents initially stated the encounter was consensual. However, a psychiatrist later determined that the resident who was the victim of the incident lacked the capacity to consent to sexual activity. The facility's policy required that two staff be present on the unit at all times, and the Director of Nursing confirmed that this protocol was not followed, contributing to the failure to prevent the incident.
Failure to Document Criteria for Secured Unit Placement
Penalty
Summary
The facility failed to ensure proper documentation and assessment for the placement of residents in a secured unit, which is intended for individuals with specific needs related to dementia and wandering. Observations and interviews revealed that the secured unit required a code for entry and exit, and was equipped with wanderguard alarm sensors. However, the facility did not have clear criteria for placement on this unit, as evidenced by interviews with the Director of Nursing Services, the Administrator, and the Corporate Social Worker, who were unable to specify the criteria for placement. For several residents, including those with diagnoses such as dementia, schizoaffective disorder, and muscular dystrophy, the clinical records lacked documentation by the physician of the clinical criteria met for placement on the secured unit. Additionally, the records did not demonstrate that the secured unit was the least restrictive setting for these residents. For instance, one resident with severely impaired cognition and behavioral disturbances was placed on the unit without the required signatures from nursing, psychiatric providers, or the attending physician on the assessment form. Another resident, who was cognitively intact and did not exhibit wandering behaviors, expressed feeling imprisoned on the unit and was not allowed to make independent choices about leaving the unit. The facility's policy for the secured unit indicated that the interdisciplinary team, along with the resident or their representative, should identify those who need placement on the unit based on diagnoses, cognitive status, functional status, and behavioral health needs. However, the policy was not followed, as evidenced by the lack of physician documentation and interdisciplinary team assessments that were incomplete or missing required signatures. Interviews with staff, including LPNs and social workers, further highlighted the lack of a structured process for assessing and documenting the appropriateness of placement on the secured unit.
Care Plan Deficiencies for Residents on Secured Unit
Penalty
Summary
The facility failed to ensure that the care plans for five residents residing on a secured unit accurately reflected their placement and the criteria for such placement. Observations and reviews of clinical records revealed that the care plans did not identify the residents' residence on a secured unit, nor did they specify the criteria for their placement or confirm that the secured unit was the least restrictive setting. This deficiency was noted for residents with various diagnoses, including dementia, schizoaffective disorder, and muscular dystrophy, among others. For Resident #1, the care plan did not reflect the resident's placement on a secured unit despite the resident having severe cognitive impairment and behavioral disturbances. The care plan lacked details on the criteria for the resident's placement on the secured unit and did not confirm that it was the least restrictive environment. Similarly, Resident #9's care plan failed to document the resident's placement on a secured unit, and there was no mention of a physician's review for such placement, despite the resident expressing feelings of being in a prison-like environment. Residents #21, #33, and #82 also had care plans that did not reflect their secured unit placement. Resident #21, who had moderately impaired cognition, was noted to have difficulty with decision-making but was otherwise alert and oriented. Resident #33, who was cognitively intact, had no documented physician's order for placement on a secured unit. Resident #82, with severely impaired cognition, had no abnormal behaviors observed, yet the care plan did not document the secured unit placement. Interviews with the Director of Nursing Services and the Medical Director confirmed that care plans should reflect special circumstances, including secured unit placement, but this was not evident in the reviewed care plans.
Kitchen Sanitation Deficiency
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, as observed during a tour with the Corporate Food Service Director. The kitchen floor was sticky with scattered food debris and water was present under the 3-bay sink near the cooking area. Additionally, a ceiling vent cover and the ceiling in the 3-bay sink area had a moderate amount of black dusty buildup, and multiple vent covers near the coffee station were similarly affected. The side and front of the stove oven had a buildup of brownish/grey matter, and the ice machine had metal pieces inside that were covered with brown stains resembling rust. The ice cream freezer's plastic covering inside was cracked with a black stain noted inside the plastic cover. The prep counter was cluttered with scattered food debris, white stains, papers, and pens. Interviews with the kitchen staff revealed a lack of clarity regarding cleaning responsibilities and schedules. Dietary Aide #1 stated that the kitchen staff is responsible for cleanliness, with the floor cleaned after each meal and equipment cleaned after each use, but was unsure about who was responsible for cleaning the ceiling and vents. The Corporate Food Service Director was also uncertain about the cleaning schedule and could not provide documentation of a cleaning log during the survey. The facility's policy indicated that vents and ceilings should be cleaned monthly, the oven weekly and as needed, and floors and counters after each use and as needed. However, there was no evidence that these cleaning schedules were being followed, contributing to the unsanitary conditions observed during the survey.
Infection Control Program Deficiencies and Unreported Legionella
Penalty
Summary
The facility failed to ensure that its infection prevention and control program policies and procedures were reviewed annually. The Infection Control Program Policies and Procedure manual was last reviewed and approved in July 2023, but there was no documentation of a review for 2024. The newly hired Infection Preventionist Nurse, who started in July 2024, was unable to locate the signature page for the 2024 review. The Director of Nursing Services also confirmed the lack of documentation for the 2024 review. The facility did not complete monthly infection surveillance reports and analysis of infection trends from April 2022 through September 2024. The Infection Preventionist Nurse, responsible for these reports, had only started in July 2024 and was unable to provide documentation of the reports. The facility's policy requires monthly surveillance forms to be maintained and a monthly report compiled to identify areas of high infection incidence. Additionally, quarterly infection statistical reports were not completed for several specified periods, and the Infection Preventionist Nurse was unable to locate these reports. The facility also failed to report positive Legionella water sampling test results to the State Agency. Several water samples collected between March 2023 and March 2024 tested positive for Legionella, but the facility did not report these results. The Director of Maintenance and the Administrator were unaware of the requirement to notify the State Agency, and the facility's consultant had incorrectly informed them that reporting was not necessary. The facility's policy requires reporting any positive Legionella testing results to the Connecticut Department of Public Health.
Failure to Administer Vaccines to Residents
Penalty
Summary
The facility failed to administer the pneumococcal and influenza vaccines to two residents as required by their policies. Resident #26, who was admitted in September 2023 with diagnoses including anemia, end-stage renal disease, and major depressive disorder, did not receive the pneumococcal vaccine upon admission. The facility's electronic medical record system indicated that Resident #26 required the pneumococcal vaccine, but there was no documentation of its administration. The Infection Preventionist (IP) nurse, who started in July 2024, noted that the admitting supervisor was responsible for obtaining vaccination consent and status, but this was not completed for Resident #26. Resident #87, admitted in November 2022 with chronic obstructive pulmonary disease, hypertension, and a pulmonary nodule, also did not receive the pneumococcal vaccine despite giving consent on November 7, 2022. The electronic medical record system showed that Resident #87 required the vaccine, but there was no record of its administration. The IP nurse indicated that the infection control nurse should have followed up on the vaccine consent documentation and obtained a physician's order to administer the vaccine, but this was not done. Additionally, Resident #87 consented to receive the influenza vaccine on November 7, 2022, but there was no documentation of its administration in the clinical records. The facility's policy required that all residents receive the influenza vaccine annually unless contraindicated or refused, and that new admissions during the influenza season be offered the vaccine. The IP nurse was in the process of reviewing the resident's vaccination information, but the deficiency in administering the vaccines was evident.
Failure to Administer and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccine was administered as requested by two residents upon admission and did not offer or assess for COVID-19 immunizations upon admission. Resident #26, admitted in September 2023 with diagnoses including anemia, end-stage renal disease, and major depressive disorder, had moderately impaired cognition. Despite giving consent for the COVID-19 vaccine on 9/20/23, the clinical records did not show that the vaccine was administered. The electronic medical record indicated a refusal, but the facility could not provide a consent form showing the resident's refusal. The Infection Preventionist Nurse (RN #1) confirmed the resident had declined the vaccine on 6/7/24 but could not locate the consent form. The facility's policy required that new residents be offered the vaccine within 14 days of admission, and the care plan and immunization tab should be updated accordingly. Resident #52, admitted in October 2022 with chronic kidney disease, type 2 diabetes mellitus, and legal blindness, also had moderately impaired cognition. The immunization records did not show that the COVID-19 vaccine was offered or assessed for past immunization. The facility failed to provide documentation that the resident was offered the vaccine or had declined it. RN #1 stated that the supervisor at the time of admission was responsible for assessing and obtaining vaccination consent and status, and the infection control nurse would follow up on the documentation. The facility's policy required that new residents be offered the vaccine within 14 days of admission, and the care plan and immunization tab should be updated to reflect the vaccine administration.
Kitchen Equipment Maintenance Deficiency
Penalty
Summary
The facility failed to maintain kitchen equipment in a safe and functional manner, as observed during a survey. On the morning of October 7, 2024, it was noted that the facility was using disposable plates and cups for serving breakfast to all residents due to a non-functional dishwasher. A tour of the kitchen revealed that the dishwasher had been broken for months and could not be repaired, necessitating a replacement. Additionally, two out of four ovens were not operational, and there was a continuous water leak from the 3-bay sink near the oven area. Dietary Aide #1 confirmed the prolonged dysfunction of the dishwasher and the use of disposable items for meals, indicating that both the Maintenance Director and the Administrator were aware of these issues. The Maintenance Director, who had recently started his position, acknowledged the non-functional dishwasher and mentioned that a new one was supposedly being ordered, although he was unaware of the order's status or installation timeline. He was also unaware of the non-functional ovens and the sink leak until the survey. Further interviews revealed that the facility had obtained a price quote for a new dishwasher on October 2, 2024, but had not yet paid the deposit required to process the order. This lack of action and communication among the facility's staff contributed to the ongoing equipment deficiencies in the kitchen.
Failure to Refer Resident for Level II PASARR Assessment
Penalty
Summary
The facility failed to ensure that a resident with a qualifying diagnosis was referred to the state-designated authority for a level II PASARR assessment. Resident #62, who had diagnoses including major depressive disorder, unspecified psychosis, and generalized anxiety disorder, was identified as cognitively intact and required various levels of assistance for daily activities. The care plan noted the risk of complications from psychotropic drug use, with interventions to monitor behavior and medication side effects. However, a new diagnosis of major depressive disorder was documented, which should have triggered a referral for a level II assessment. Interviews revealed a breakdown in communication and procedure. Social Worker #2 documented the new diagnosis but failed to notify Social Worker #1, who was responsible for submitting the referral. Social Worker #1 was unaware of the new diagnosis and thus did not make the necessary referral. The Regional MDS Coordinator noted that the Social Worker attends weekly meetings with psychiatric providers to be informed of new diagnoses requiring referrals, but this process was not followed in this instance, leading to the deficiency.
Failure to Obtain Physician's Order for Surgical Wound Care
Penalty
Summary
The facility failed to obtain a physician's order for the treatment of a surgical wound for a resident who was readmitted with a right femur fracture, polyneuropathy, and type 2 diabetes mellitus. Upon readmission, the resident had undergone a partial hip replacement and had specific instructions to keep the surgical dressing in place for seven days. However, the facility did not document a treatment order for the surgical wound from the time of readmission until several days later. The nursing staff did not follow the surgeon's instructions for the surgical wound care, as evidenced by the lack of documentation in the treatment administration record (TAR) and the absence of a physician's order for the wound care. The dressing fell off prematurely, and although it was replaced, there was no record of the type of dressing used or whether the physician was notified. This oversight continued until the wound showed signs of infection, at which point a physician's order was finally obtained. Interviews with the facility's wound nurse and the Director of Nursing Services (DNS) revealed that the responsibility for ensuring proper wound care orders were in place was not fulfilled. The facility's policy required that dressing changes and wound cleaning be conducted according to the surgeon's orders, which was not adhered to in this case. The lack of communication and documentation led to a delay in appropriate wound care management for the resident.
Controlled Medication Count and Documentation Discrepancies
Penalty
Summary
The facility failed to ensure the accuracy of controlled medication counts and proper documentation on the control disposition record for one of the three medication administration carts reviewed. Specifically, discrepancies were found in the controlled medication counts for three residents. A blister pack of Alprazolam 0.5mg for one resident contained 11 tablets, while the record indicated 12. Another resident's Tramadol 50mg blister pack had 3 tablets, but the record stated 4. Additionally, a blister pack of Alprazolam 0.25mg for a third resident contained 1 tablet, whereas the record showed 2. These discrepancies indicate a failure to maintain accurate records and accountability for controlled substances. Interviews with RN #4 and the Director of Nursing Services (DNS) revealed that it was the responsibility of all nurses to ensure expired medications were not stored in the cart and that controlled medications should be secured behind two locks. RN #4 acknowledged that she should have signed the control drug receipt and disposition record when administering medication. The facility's Medication Administration Guidelines and Control Substances policy require that controlled substances be stored in a double-locked container and that the administration of these medications be accurately recorded. The failure to adhere to these guidelines and policies resulted in the identified discrepancies in medication counts and documentation.
Medication Storage Deficiency
Penalty
Summary
The facility failed to store medications appropriately as observed during a review of the 2 East medication administration cart. Two bottles of Oyster Shell Calcium with Vitamin D were found with an expiration date of 9/2024, indicating they were expired. Additionally, a bottle of Lantus 100 units/ml was found without an open date, approximately one-quarter full, in a plastic sandwich bag with the last name of a resident written in black marker that was worn away and barely visible. There was no open date or discard date written on the bottle. Furthermore, the narcotic box located in the medication administration cart was not locked, although the cart itself was secured and located behind the nurses' station. Interviews with RN #4 and the Director of Nursing Services (DNS) revealed that it was the responsibility of all nurses to ensure expired medications were not stored in the medication cart and that controlled medications should be secured behind two locks. RN #4 acknowledged that insulin should be labeled with the opened date and discard date, and that she should have signed the control drug receipt and disposition record when administering the medication. The facility's Medication Administration Guidelines and Control Substances policy require that controlled substances be stored in a double door, double locked container, and that accountability and security must be maintained at all times.
Failure to Document and Assess Secured Unit
Penalty
Summary
The facility failed to properly document and assess the presence of a secured unit within its premises, as observed during a survey. The East 1 Unit was identified as a secured unit requiring a code for entry and exit, with additional security features such as wanderguard alarm sensors on fire exits. However, the facility's assessment did not acknowledge the existence of this secured unit, nor did it include criteria for resident placement or the physical and environmental characteristics of the unit. The assessment was outdated, containing signatures from former staff and information from the previous year, and was signed by the current administrator and DNS without their participation in its completion. Interviews with the DNS and Administrator revealed that they were unaware of the details of the facility assessment they signed, and the secured unit was not included in the assessment. The Corporate Administrator later provided a new assessment, which still failed to identify the secured unit. The facility policy for the secured unit outlined criteria for placement and quarterly assessments, but the facility could not provide policies or procedures for ongoing assessments or physician input. Interviews with medical staff indicated a lack of participation in the facility assessment process, highlighting a disconnect between the facility's documentation and its operational practices.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Norwalk
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Notre Dame Health And Rehabilitation Center | 1.4 mi | ★★★★★ | 1 | 0 |
| Autumn Lake Healthcare At Norwalk | 2 mi | ★★★★★ | 25 | 0 |
| Waveny Care Center | 3.9 mi | ★★★★★ | 12 | 0 |
| Stamford Care Center | 6.1 mi | ★★★★★ | 18 | 0 |
| Wilton Meadows Health Care Center | 6.3 mi | ★★★★★ | 1 | 0 |
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