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 Norwich Sub-acute And Nursing during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a known history of falls was left unsupervised on the edge of the bed by a nurse aide, who turned away to respond to a roommate's calls for help. Despite care plans and physician orders requiring staff assistance for transfers, the resident fell and sustained a head laceration requiring stitches. Staff interviews and facility documentation confirmed that the resident was a known fall risk and should not have been left alone.
A resident who required two-person assistance for stand pivot transfers was transferred by a single NA, contrary to physician orders and the care plan. During the transfer, the resident's knee gave out, leading to a fall and a mildly displaced distal fibula fracture. Staff interviews confirmed the NA did not verify the required assistance level prior to the transfer.
A resident with multiple medical conditions and a high risk for falls was left unsupervised outside the facility after a staff member changed the main entrance door to automatic mode, allowing the resident to exit without assistance. The resident fell from a wheelchair while attempting to pick up an object, resulting in a head laceration and facial abrasion. The area outside the entrance was found to be unsafe for wheelchair use, and staff were unaware the resident was outside unattended.
The facility did not ensure that a resident was protected from being separated from others, their room, or being confined to their room, as required by regulations. The report does not provide further details about the circumstances or the resident's condition.
A deficiency was cited when a resident's care plan did not address all assessed needs and failed to include measurable timetables and specific actions, as observed in the care planning documentation.
A resident with multiple chronic conditions sustained a forehead laceration from a fall and was to receive daily wound care per physician's orders. Observations found the dressing unchanged and with drainage, despite the TAR indicating the treatment was completed. An LPN admitted to signing off the treatment before actually providing care, as the resident was asleep at the time, and the facility could not provide a relevant policy when requested.
Failure to Provide Adequate Supervision for High Fall Risk Resident
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, Alzheimer's disease, dementia, and generalized muscle weakness, who was identified as a high fall risk, was left unsupervised while sitting on the edge of the bed. The resident's care plan and physician orders required staff assistance for transfers due to confusion, deconditioning, and poor balance. Despite these directives and a history of previous falls when attempting to stand without help, the resident was left sitting at the edge of the bed while the nurse aide (NA) turned away to address the roommate's repeated calls for assistance. During this time, the NA had her back to the resident and was not in a position to intervene when the resident leaned forward and fell, striking their head on the floor. The fall resulted in a laceration above the left eyebrow that required seven stitches, as well as additional bruising and pain. Staff interviews confirmed that the resident was known to be impulsive and at risk for falls, and that the NA should not have left the resident unsupervised on the edge of the bed. Facility documentation and staff interviews further indicated that the NA could have used the call light to request additional assistance rather than leaving the resident's side. The facility's fall prevention policy directed staff to reduce resident fall risk factors, but this was not followed in this instance, directly leading to the resident's fall and injury.
Failure to Follow Transfer Orders Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of deep vein thrombosis and anxiety, who required assistance of two staff members for stand pivot transfers and ambulation only with therapy, was transferred by a single nurse aide (NA). Physician orders, the resident's care plan, and the NA care card all specified that two staff were required for transfers. Despite these clear directives, the NA attempted to transfer the resident alone from bed to chair using a rolling walker. During the transfer, the resident's knee gave out, resulting in the resident twisting their leg and being lowered to the floor by the NA. The resident was subsequently unable to move their right ankle or knee due to pain and was transferred to the hospital, where imaging confirmed an acute mildly displaced fracture of the distal fibula. The incident report and facility investigation confirmed that the resident required two-person assistance at the time of the fall, and that the NA did not follow the established plan of care or verify the transfer status prior to attempting the transfer alone. Interviews with facility staff and the resident confirmed that the NA believed only one person was needed for the transfer and did not check the care card or physician orders. The Director of Rehabilitation and the DON both acknowledged that the NA failed to follow the prescribed plan of care, which directly resulted in the resident's injury.
Failure to Supervise High-Risk Resident Outside Facility Resulting in Fall
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including CHF, COPD, atrial fibrillation, anxiety disorder, and personality disorder, was left unsupervised outside the facility, resulting in a fall with injury. The resident was assessed as having intact cognition but required substantial assistance for bed mobility and was dependent on staff for transfers. The Morse Fall Scale identified the resident as high risk for falls due to a history of falls, weak gait, and poor safety awareness. The care plan specified interventions such as ensuring appropriate footwear, anticipating needs, and maintaining a safe environment, but did not specifically address supervision outside the facility. On the day of the incident, the resident independently moved in a wheelchair to the main entrance, exited the building, and sat outside unsupervised. The main entrance area was observed to have a steep decline, making it unsafe for wheelchair use. The resident leaned forward to pick up an object from the ground and fell out of the wheelchair, sustaining a laceration to the forehead and an abrasion to the nose. The resident was found on the ground by staff, assessed, and transferred to the hospital for evaluation and treatment of the injuries. The investigation revealed that the main entrance door had been switched from night mode (requiring staff assistance to open) to day mode (automatic opening), allowing residents to exit unsupervised. This change was made by a nursing assistant who was interrupted by the door buzzer while providing care and decided to switch the door mode for convenience. There was no staff present at the receptionist desk at the time, and staff were not aware that the area was unsupervised. Facility policies regarding door locking and criteria for resident supervision outside were not provided.
Failure to Protect Residents from Unwarranted Separation or Confinement
Penalty
Summary
A deficiency was identified regarding the protection of residents from separation from other residents, their rooms, or confinement to their rooms. The report notes that the facility failed to ensure that each resident was protected from being separated or confined, as required by regulations. Specific actions or inactions by staff or facility policies that led to this deficiency are not detailed in the report. No additional information about the residents involved or their medical conditions at the time of the deficiency is provided.
Incomplete Care Plan Lacking Measurable Actions
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover all assessed needs or provide clear, measurable interventions.
Failure to Administer Wound Care per Physician's Orders After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including CHF, COPD, atrial fibrillation, anxiety disorder, and personality disorder, sustained a laceration to the forehead following a fall. The resident's care plan required that the injury be treated according to physician's orders, which specified cleansing the wound with normal saline, applying bacitracin, and covering it with a band aid daily and as needed. Observations on two separate occasions revealed a band aid dated two days prior, with dark drainage noted underneath, indicating the dressing had not been changed as ordered. Review of the Treatment Administration Record (TAR) showed the treatment was signed off as completed, but there was no corresponding documentation in the nurse's notes for that day. Further investigation revealed that the LPN responsible for the treatment signed off the order as completed before actually administering it. The LPN admitted that she did not assess or change the dressing as ordered because the resident was sleeping when she attempted to provide care, and she acknowledged that she should not have signed off the treatment prior to its completion. The Director of Nursing confirmed that licensed nurses are not to sign off orders until they are administered. The facility was unable to provide a policy for physician's orders and treatment administration when requested.
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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.
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Nursing homes near Norwich
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Apple Rehab Uncasville | 4.1 mi | ★★★★★ | 1 | 0 |
| Douglas Manor | 11 mi | ★★★★★ | 7 | 0 |
| Greentree Manor Nursing And Rehabilitation Center | 11.1 mi | ★★★★★ | 7 | 0 |
| Complete Care At Harrington Court | 12 mi | ★★★★★ | 8 | 1 |
| Apple Rehab Colchester | 12 mi | ★★★★★ | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.