Above 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 Notre Dame Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe dementia and a high fall risk, dependent on staff for toileting and transfers, was left alone in the bathroom by a nursing assistant who was called away to assist elsewhere. During this unsupervised period, the resident fell and sustained a displaced femoral neck fracture, requiring hospital transfer. Staff interviews confirmed the resident should not have been left alone, and no facility policy on supervising residents with dementia during toileting was provided.
A resident with chronic respiratory conditions was administered continuous oxygen therapy by licensed staff without a physician's order for eight days. Documentation showed the resident received varying oxygen flow rates, and the required order was only obtained after the DON identified the omission during a record review, in violation of facility policy.
A resident with a history of falls and identified as a moderate fall risk did not have a comprehensive care plan addressing their fall risk upon admission. Despite assessments indicating the need for interventions, the care plan lacked focus on fall prevention, leading to a fall and major injury. The facility's policy to develop a care plan within seven days of the MDS assessment was not followed.
A facility failed to complete quarterly fall risk assessments for a resident with a history of falls, as required by policy. The resident, initially assessed as moderate risk, experienced a fall and was hospitalized. Upon return, they were identified as high risk due to various factors. The DNS confirmed the lack of assessments over nine months.
The facility did not complete annual performance evaluations for nurse aides in 2023. A review in 2024 found no documentation for two aides. The DNS, new to the facility, confirmed the absence of evaluations for 2023 but had completed them for 2024. A policy was implemented in 2024 to ensure future compliance.
A resident with a suprapubic catheter and pressure ulcer was on enhanced barrier precautions, but an RN failed to follow proper infection control protocols during a dressing change. The RN did not wear a gown initially, neglected consistent hand hygiene, and accessed supplies without maintaining precautions. The facility lacked policies on dressing changes and PPE usage.
The facility failed to document that residents or their representatives were educated about pneumococcal immunizations and whether they received the vaccine according to CDC guidelines. Interviews revealed confusion about vaccination responsibilities, and the facility's policy was not followed, leading to a deficiency in vaccination documentation.
The facility failed to document that residents or their representatives were provided with current COVID-19 information or offered subsequent vaccinations. Five residents were identified without evidence of further COVID-19 vaccination offerings or education. Interviews with the DNS and Medical Director revealed a lack of awareness and documentation regarding these vaccinations.
Failure to Supervise Resident with Dementia During Toileting Results in Fall and Injury
Penalty
Summary
A resident with a diagnosis of dementia and a known fall risk, as indicated by a BIMS score of 6 (severely impaired cognition), was dependent on staff for toileting and transfers. The resident's care plan required assistance of one staff member for these activities. On the date of the incident, a nursing assistant (NA) assisted the resident to the bathroom and left the resident sitting on the toilet for privacy, waiting outside the door. The NA was then called to assist another staff member across the hall, leaving the resident alone in the bathroom. During this time, the resident fell and was found on the bathroom floor, complaining of right hip pain and exhibiting a skin tear on the left shin. The fall was unwitnessed, and the resident was unable to provide a reliable account of the incident due to cognitive impairment. Subsequent evaluation revealed the resident had sustained a displaced right femoral neck fracture and was transferred to the hospital for further care. Interviews with facility staff, including the NA involved and the Director of Nursing, confirmed that the resident required assistance for transfers and should not have been left alone in the bathroom. The facility was unable to provide a policy regarding supervision of residents with dementia during toileting for surveyor review. The deficiency resulted from the failure to provide adequate supervision and prevent accident hazards for a resident at high risk for falls.
Oxygen Therapy Administered Without Timely Physician Order
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen was admitted and administered continuous oxygen therapy without a physician's order. Nursing documentation indicated that the resident was receiving oxygen at varying flow rates, including 6 to 7 liters at rest and up to 10 liters with ambulation, starting from the time of admission. The care plan and care card referenced the need for oxygen and specific interventions, but there was no documented physician's order for oxygen administration until eight days after the resident began receiving it. Facility policy required that only licensed staff administer oxygen as prescribed by a physician, and interviews confirmed that a physician's order should have been obtained at the time of admission. The Director of Nursing acknowledged that the order was missing and was only obtained after reviewing the clinical record several days later. This lapse resulted in the resident receiving oxygen therapy without the necessary physician authorization, contrary to facility policy and standard practice.
Failure to Implement Comprehensive Care Plan for Fall Risk Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident with a history of repeated falls and identified as a moderate fall risk upon admission. The resident, who had diagnoses including syncope, Alzheimer's disease, and repeated falls, was assessed to have a moderate risk for falls due to factors such as medication use, inadequate vision, and impaired gait. Despite these assessments, the care plan did not include any focus, goals, or interventions related to the resident's fall risk prior to an incident where the resident fell and sustained a major injury. The resident experienced a fall resulting in a left hip fracture, which led to hospitalization. Upon readmission to the facility, the care plan was updated to include interventions such as a physical therapy consult. Interviews with the Director of Nursing Services and the MDS coordinator revealed a lack of documentation for a comprehensive care plan addressing the resident's fall risk before the incident. The facility's policy requires a comprehensive care plan to be developed within seven days after the completion of the comprehensive MDS assessment, but this was not adhered to in the case of this resident.
Failure to Conduct Quarterly Fall Risk Assessments
Penalty
Summary
The facility failed to complete quarterly fall risk assessments for a resident, as required by their policy. The resident, who was admitted with diagnoses including syncope, Alzheimer's disease, and a history of repeated falls, was initially assessed as being at moderate risk for falls. Despite this, the facility did not conduct the necessary quarterly assessments following the admission assessment, which spanned a period of nine months. During this time, the resident experienced a fall resulting in severe hip pain and was subsequently hospitalized. Upon readmission, a new fall risk assessment identified the resident as being at high risk for falls, due to factors such as medication use, inadequate vision, total incontinence, and decreased muscle coordination. The Director of Nursing Services confirmed the lack of quarterly assessments and acknowledged that the facility's policy requires such assessments to be conducted on admission, quarterly, and after any fall.
Failure to Complete Annual Performance Evaluations for Nurse Aides
Penalty
Summary
The facility failed to ensure that annual performance evaluations were completed for nurse aide staff for the year 2023. During a review conducted on August 26, 2024, it was found that there was no documentation of performance evaluations for two nurse aides for the year 2023. An interview with the Director of Nursing Services (DNS) on August 27, 2023, revealed that she was unable to locate any completed evaluations for the nurse aide staff for 2023. The DNS, who was new to the facility, had completed evaluations for 2024 but confirmed that evaluations for 2023 had not been conducted. The facility had implemented an annual performance evaluation policy in June 2024 to ensure evaluations were completed in the future. The facility's assessment policy indicated that evaluations were necessary to determine the resources needed to competently care for residents, including staff training, education, and competencies.
Infection Control Deficiency During Dressing Change
Penalty
Summary
The facility failed to implement appropriate infection control techniques during a dressing change for a resident on enhanced barrier precautions. The resident, who was admitted with diagnoses including Parkinson's disease, bladder cancer, and dementia, required a suprapubic catheter and was on enhanced barrier precautions. However, the care plan did not include interventions related to potential skin integrity issues or enhanced barrier precautions. A pressure ulcer was identified on the resident's sacrum, and a treatment plan was established. During an observation, an RN was seen performing a dressing change without adhering to the required infection control protocols. The RN did not wear a gown initially and failed to perform hand hygiene consistently throughout the procedure. The RN also used the resident's bedside table for the dressing change setup and accessed supplies from outside the room without maintaining proper precautions. The RN admitted to being aware of the enhanced barrier precautions but was focused on the dressing supplies and did not remember to don a gown. The facility was unable to provide policies related to dressing changes, PPE usage, and hand hygiene when requested. The facility's policy on Enhanced Barrier Precautions required the use of gown and gloves during high-contact resident care activities, such as wound care, to prevent the transfer of multidrug-resistant organisms. The RN's actions during the dressing change did not align with these policies, leading to the deficiency.
Failure to Document Pneumococcal Vaccination Education and Administration
Penalty
Summary
The facility failed to provide documentation that residents or their representatives were educated about the benefits and potential side effects of the pneumococcal immunization. This deficiency was identified for five residents who were reviewed for vaccinations. The facility's records did not show whether these residents received the pneumococcal immunization according to CDC guidelines or if they did not receive it due to medical contraindication or refusal. The residents involved had various medical conditions, including mild cognitive impairment, anxiety disorder, dementia, and diabetes, and were all older than the age specified in the report. Interviews with the Director of Nursing Services (DNS) and the Administrator revealed a lack of clarity and communication regarding the responsibility for managing pneumococcal vaccinations. The DNS was under the impression that the Infection Control Nurse was handling the vaccinations per CDC guidelines, but there was no documentation to support this. The Administrator acknowledged that vaccinations were discussed in Medical/Staff meetings, but there was no evidence that pneumococcal vaccinations were included in these discussions. The facility's policy stated that residents should be offered pneumococcal immunizations unless medically contraindicated or previously immunized, with documentation required in the medical record. However, the policy was not dated, and there was no evidence that the policy was being followed. The Medical Director also indicated a misunderstanding regarding the exemption of residents from subsequent vaccinations, further contributing to the deficiency. The facility failed to provide evidence of previously administered vaccinations or education provided to residents or their representatives.
Deficiency in COVID-19 Vaccination Documentation and Education
Penalty
Summary
The facility failed to provide documentation that residents or their representatives were given current COVID-19 information regarding additional doses, including education on risks or potential side effects, or offered subsequent COVID-19 vaccinations. This deficiency was identified for five residents who were reviewed for COVID-19 immunizations. For each of these residents, there was no evidence of subsequent COVID-19 vaccinations being offered, declined, administered, or if education was provided to the residents or their representatives. Resident #3, with mild cognitive impairment and anxiety disorder, received a COVID-19 vaccine on 6/22/22, but no further vaccinations or education were documented. Resident #14, with type 2 diabetes and a history of myocardial infarction, received three COVID-19 vaccines, the last on 12/22/23, with no further documentation of offerings or education. Resident #27, diagnosed with dementia and muscle weakness, received a second dose on 12/22/23, with no further documentation. Resident #30, with osteoarthritis and anxiety disorder, received a second dose on 4/7/21, with no further documentation. Resident #209, with dementia and anxiety disorder, had no immunization information documented. Interviews with the DNS and Medical Director revealed a lack of awareness and documentation regarding the offering of subsequent COVID-19 vaccinations.
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Illustrative
What surveyors actually found near you
We read the 425 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
A prioritized, do-first checklist
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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) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Norwalk | 0.6 mi | ★★★★★ | 25 | 0 |
| Norwalk Care Center | 1.4 mi | ★★★★★ | 4 | 0 |
| Waveny Care Center | 4.2 mi | ★★★★★ | 12 | 0 |
| Wilton Meadows Health Care Center | 5 mi | ★★★★★ | 1 | 0 |
| Southport Center For Nursing & Rehabilitation Llc | 6.6 mi | ★★★★★ | 0 | 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.