Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Rehabilitation & Nursing Center during CMS and state inspections, most recent first.
A deficiency was cited when the facility did not provide a safe, clean, comfortable, and homelike environment, nor did it ensure that treatment and supports for daily living were delivered safely to residents.
The facility failed to maintain an effective discharge planning process for two residents. One resident with cardiac arrest, a coagulation defect, and AFib was progressing with PT and wanted to return home, but there was no documented ongoing re-evaluation of discharge goals while the resident remained in the facility for daily heel wound care. Another resident with a femur fracture and orthopedic aftercare wanted to leave AMA and return to an apartment, but the record showed no active discharge plan, no documented ongoing reassessment of discharge goals, and no completed discharge planning documentation despite the resident’s impaired cognition, dependence for mobility, and stated need for home services.
Missing Anticoagulant Care Plan: A resident with atrial fibrillation, a coagulation defect, and an order for Eliquis had a care plan addressing a pacemaker but not anticoagulant therapy or bleeding precautions. Staff interviews confirmed nursing was administering and monitoring the blood thinner, but the care plan did not document it.
A resident with dementia, CKD, and HF had a significant weight loss, missed ordered weekly weights, and a decline in self-feeding ability. RD review confirmed a 9.2% monthly weight loss, but the MD was not notified, and OT evaluation for the feeding decline was not completed until the resident was observed needing added assistance at meals.
A resident with OSA, acute respiratory failure with hypoxia, and HF was observed using a CPAP at the bedside, but the chart lacked a physician order and the care plan did not include CPAP use. The resident said they used the CPAP nightly, staff had not helped clean it, and they had to ask for distilled water. An LPN and RN unit manager stated CPAP use required a physician order and documentation on the care plan and TAR.
Food was not served at palatable, safe temperatures for a resident’s meal tray and for a bowl of soup. A resident’s chicken, potatoes, and beets were served at low temperatures and were described as lacking flavor or tasting cold, and a dietary aide served soup after microwaving it to only 130 degrees Fahrenheit. The FSD stated hot food should be served at 165 to 180 degrees Fahrenheit.
A resident with a history of heart disease updated their Medical Orders for Life-Sustaining Treatment to a Do Not Resuscitate (DNR) status, but the facility failed to update the medical record, leading to the initiation of CPR against the resident's wishes. The oversight occurred due to a lack of communication and verification among staff, resulting in the continuation of Full Code orders despite the resident's updated directive.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Maintain Ongoing Discharge Planning for Two Residents
Penalty
Summary
The facility did not develop and implement an effective discharge planning process that focused on residents’ discharge goals for two residents. For one resident, who had diagnoses including cardiac arrest, a coagulation defect, and atrial fibrillation, the record showed intact cognition, partial/moderate assistance needed for hygiene and oral care, and a discharge goal of returning to the community. Social services documented that the resident wanted to return to an apartment where they lived alone, and therapy notes showed progress with gait training, mobility, balance, and ambulation with a rolling walker. However, there was no documented evidence of an ongoing assessment or re-evaluation of the resident’s discharge goals, even though the resident and therapy staff stated the resident was ready for discharge and the resident was upset about not being able to leave because of a facility-acquired heel wound requiring daily dressing changes. For the second resident, who had diagnoses including a left femur fracture and orthopedic aftercare, the record documented moderately impaired cognition, dependence for transfers and mobility, and no active discharge planning on the MDS. The care plan and social services evaluation documented the resident’s wish to return to an apartment where they lived alone, and the resident later stated they wanted to leave against medical advice. The resident refused rehabilitation, expressed that they were being held hostage, and said they would hurt themselves if they could not leave. Social services informed the health care proxy, who would not support the resident leaving, and the resident was transported to the hospital after independently contacting authorities reporting chest pain. The record also showed that the resident’s daughter refused to pick the resident up from the hospital, stating the resident had no one in the home to care for them, while the resident said neighbors would help. The facility documented that the resident was unsafe to go home and would require full-time skilled nursing care to discharge safely, but there was no documented evidence of an ongoing assessment or re-evaluation of the resident’s discharge goals. Social services stated there was no documentation of conversations with the resident regarding discharge planning and safety and that no discharge plan had been completed after the resident wanted to leave against medical advice.
Missing Anticoagulant Care Plan
Penalty
Summary
The facility did not develop and implement a comprehensive person-centered care plan for Resident #1 that included services to maintain the resident’s highest practicable physical well-being. Resident #1 had diagnoses including cardiac arrest, a coagulation defect, and atrial fibrillation, and the 7/1/2025 MDS documented intact cognition and use of an anticoagulant. A physician order dated 6/27/2025 directed Eliquis 5 mg twice daily for atrial fibrillation, and the resident’s comprehensive care plan initiated the same day addressed the pacemaker and monitoring for malfunction and a pulse lower than the programmed rate. The care plan did not include the resident’s anticoagulant therapy or monitoring for bleeding precautions. During interviews, a CNA stated they were unsure whether anticoagulant therapy should be in the care plan but wanted to know so they could monitor for bleeding when shaving the resident. An LPN stated care plans were completed by RN unit managers and department heads, and an RN unit manager stated the resident was receiving and being monitored for Eliquis by nursing staff, was unaware it was not in the care plan, and confirmed there was no documentation regarding anticoagulant therapy.
Failure to Monitor Weight Loss and Feeding Decline
Penalty
Summary
The facility did not ensure that Resident #3 maintained acceptable nutritional status. Resident #3 had diagnoses including dementia, chronic kidney disease, and heart failure, and the 6/9/2025 MDS documented severe cognitive impairment, supervision needed for eating, and a mechanically altered diet. The care plan identified a nutritional problem and ADL self-care performance deficit, with interventions including meal set-up, intake monitoring, supplements, and weights per policy. The facility policy required monthly weights by the 7th of each month, weekly weights on Tuesdays completed by Wednesday, and notification of the nurse manager, medical doctor, and care plan team for significant weight variance. The resident’s documented weights showed 224 pounds on 5/8/2025, 222.4 pounds on 6/3/2025, and 202 pounds on 7/1/2025, reflecting a 9.2% loss. There was no documented evidence that the 7/1/2025 weight was verified, and there was no documented evidence that weekly weights were obtained from 4/28/2025 through 8/1/2025 as ordered. The 7/14/2025 RD note documented a 20.4-pound decline and confirmed the 9.2% weight loss as accurate, with meal intake ranging from 25% to 100% and a recommendation to increase the calorie supplement to four times daily. There was no documented evidence that the medical providers were notified of the resident’s weight loss. The resident also had a functional decline in eating ability. The July 2025 CNA documentation showed the resident required limited or extensive assistance with eating at multiple breakfast, lunch, and dinner meals. During observation on 7/30/2025, the resident was unable to manage the meal independently, used hands to move food, and ate from a bowl with a spoon while an LPN remained present and no staff assistance was provided. On 7/31/2025, OT observed the resident and documented that the resident required assistance with self-feeding and needed skilled services to assess adaptations and improve intake; there was no documented evidence of an OT evaluation before that date. Staff interviews indicated the resident’s increased difficulty had been noticed over the prior couple of months, weekly weights were expected but not completed as ordered, and the medical team had not been notified of the significant weight loss.
Missing CPAP Order and Care Plan Documentation
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident who was observed with a CPAP machine at the bedside. The resident had diagnoses including obstructive sleep apnea, acute respiratory failure with hypoxia, and heart failure, and the hospital transfer note documented that the resident used a CPAP machine. However, the medical record did not include a physician order for CPAP use, and the comprehensive care plan initiated and revised after admission did not include CPAP use. The undated resident care instructions also did not include CPAP use. During observation and interview, the resident stated they used the CPAP every night before admission and continued using it every night at the facility because they stopped breathing at night. The resident also stated staff had not assisted with cleaning the machine and that they had to ask staff for distilled water for it. A CNA was observed bringing water to the resident, and the resident asked for distilled water for the machine. An LPN stated CPAP use required a physician order and documentation on the care plan and treatment administration record, and an RN unit manager stated a physician order was required and that the admission nurse was responsible for notifying the physician to obtain an order.
Food Served at Improper Temperatures
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and served at a safe and appetizing temperature for one of two meal trays tested. The facility policy stated residents were to receive a nourishing, palatable, well-balanced diet and that food and nutrition staff would inspect trays to ensure food appeared palatable, attractive, and served at a safe and appetizing temperature. The facility’s microwave policy also stated foods were to be heated to at least 165 degrees Fahrenheit and not served unless the temperature was less than or equal to the recommended temperature. Resident #78’s lunch tray included water, coffee, milk, baked chicken, oven browned potatoes, seasoned beets, canned fruit, and pears with graham cream. During observation, the resident was given a replacement tray, and the original food was found to be inadequately heated: the chicken lacked flavor, was tough to cut, and measured 114 degrees Fahrenheit; the potatoes measured 112 degrees Fahrenheit; and the beets tasted cold and measured 106.5 degrees Fahrenheit. In a separate observation, a dietary aide microwaved cream of chicken soup for one minute and served it after measuring it at 130 degrees Fahrenheit. A resident later stated the food was tasteless and the soup was warm. The dietary aide stated 130 degrees Fahrenheit was not hot enough and that the soup should have been returned to the microwave until it reached 135 degrees Fahrenheit or higher, while the Food Services Director stated hot food should be served at 165 to 180 degrees Fahrenheit.
Failure to Update and Communicate Advance Directive Leads to Incorrect CPR
Penalty
Summary
The facility failed to properly document and communicate a resident's advance directive change from Full Code to Do Not Resuscitate (DNR). The resident, who had a history of myocardial infarction and atherosclerotic heart disease, updated their Medical Orders for Life-Sustaining Treatment to reflect a DNR status. However, the medical record and code status indicators were not updated accordingly, and the facility continued to operate under the Full Code orders. When the resident was found without signs of life, the nursing staff verified the incorrect Full Code status in the electronic medical record and initiated cardiopulmonary resuscitation (CPR), contrary to the resident's wishes. The Medical Orders for Life-Sustaining Treatment, which indicated the resident's desire for a DNR, were not consulted until after CPR had been initiated. This oversight was due to a failure in communication and verification processes among the staff responsible for updating and checking the resident's code status. Interviews with staff revealed that the nurse who witnessed the Medical Orders for Life-Sustaining Treatment did not ensure the physician order was updated in the electronic medical record, assuming it would be done by the admission nurse. This lack of verification and communication led to the implementation of CPR on a resident who had expressed a wish not to be resuscitated, highlighting a critical gap in the facility's procedures for handling advance directives.
Removal Plan
- 100% of staff on duty were educated according to the approved training plan.
- All staff identified for education received education. The staff that did not receive education will complete education upon their return, prior to the start of their shift.
- Interviews were completed to determine compliance with staff training and education including 3 licensed practical nurses, 3 registered nurses and 2 certified nurse aides. Staff confirmed participation and understanding of the education.
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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.
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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) |
|---|---|---|---|---|
| Valley View Manor Nursing Home | 1.1 mi | ★★★★★ | 12 | 0 |
| N Y S Veterans Home | 7.5 mi | ★★★★★ | 0 | 0 |
| Chasehealth Rehab And Residential Care | 11.5 mi | ★★★★★ | 0 | 0 |
| Chestnut Park Rehabilitation And Nursing Center | 23.5 mi | ★★★★★ | 4 | 1 |
| Aurelia Osborn Fox Memorial Hospital | 23.8 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.