Cycle 1
Health 2024-08-27 · Fire 2024-08-27
8 health deficiencies
Top issue: Infection Control (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Norwalk, CT
Notre Dame Health And Rehabilitation Center
4-star overall rating with 4-star inspections with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
76 West Rocks Road, Norwalk, CT
(203) 847-5893
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
52
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.71
Registered nurse staffing · state 0.70 · national 0.68
LPN hours / resident day
1.22
Licensed practical nurse staffing · state 0.84 · national 0.87
Aide hours / resident day
2.48
Nurse aide staffing · state 2.28 · national 2.35
Total nurse hours
4.41
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.54 · national 1.54
Weekend hours
3.93
Weekend nurse staffing · state 3.41 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.46 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
4.60
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
7,373
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9857
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.30% · Performance 21.23% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.88
Baseline 6.36% · Performance 7.57% · Measure score 0.88 · Achievement 0.88 · Improvement 0
Total nurse turnover
6.45
Performance 37.31% · Measure score 6.45 · Achievement 6.45 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.63
Baseline 4.57 hours · Performance 4.40 hours · Measure score 4.63 · Achievement 4.63 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.78% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 90 · Observed rate 6.67% · Lower 95% interval 6.24% |
| Discharge to community | 59.32% |
50.57%
8.8 pts better
|
Better than the National Rate · Eligible stays 92 · Observed rate 53.26% · Lower 95% interval 51.66% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 55 · Denominator 55 |
| Falls with major injury | 1.82% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 55 |
| Discharge self-care score | 73.68% |
53.69%
20 pts better
|
Numerator 28 · Denominator 38 |
| Discharge mobility score | 65.79% |
50.94%
14.9 pts better
|
Numerator 25 · Denominator 38 |
| Pressure ulcers or injuries, new or worsened | 3.64% |
2.29%
1.4 pts worse
|
Numerator 2 · Denominator 55 · Adjusted rate 3.66% |
| Healthcare-associated infections requiring hospitalization | 7.57% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 8.2% · Lower 95% interval 3.95% |
| Staff COVID-19 vaccination coverage | 66.67% |
8.2%
58.5 pts better
|
Numerator 58 · Denominator 87 |
| Staff flu vaccination coverage | 58.62% |
42%
16.6 pts better
|
Numerator 51 · Denominator 87 |
| Discharge function score | 78.95% |
56.45%
22.5 pts better
|
Numerator 30 · Denominator 38 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 8.7% |
25.2%
16.5 pts worse
|
Numerator 2 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
2.1
0.9 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.0 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.5
0.6 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.6 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.6% |
87.5%
3.9 pts worse
|
93.4%
9.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 78.2% · Q2 81.6% · Q3 83.3% · Q4 91.8% · 4Q avg 83.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.3% |
93.5%
6.2 pts worse
|
95.5%
8.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 87.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
3.4%
0.1 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.1% · Q3 2.1% · Q4 4.1% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
17.1%
16.5 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
6.4%
1.2 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 11.9% · Q3 2.6% · Q4 4.5% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.6% |
17.3%
7.7 pts better
|
19.6%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 9.3% · Q3 9.3% · Q4 9.1% · 4Q avg 9.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.4% |
19.4%
4 pts better
|
16.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 19.4% · Q3 13.2% · Q4 5.3% · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.4% |
18.1%
10.7 pts better
|
16.3%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.3% · Q3 7.3% · Q4 13.0% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.2% |
18.4%
2.2 pts better
|
14.9%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 30.8% · Q3 10.8% · Q4 18.4% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.9%
0.4 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.6% · Q3 2.2% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.2% |
1.7%
3.5 pts worse
|
1.7%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 10.4% · Q3 4.7% · Q4 4.1% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.6% |
24.8%
1.2 pts better
|
19.8%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 19.9% · Q3 18.7% · Q4 20.4% · 4Q avg 23.6% |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
4.4%
1.5 pts worse
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 6.4% · Q3 7.9% · Q4 4.7% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 52.2% |
70.5%
18.3 pts worse
|
81.7%
29.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 33.3% · Q3 59.4% · Q4 72.7% · 4Q avg 52.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.3% |
11.1%
2.8 pts better
|
12.0%
3.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.3% · Observed 7.3% · Expected 9.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.1% |
1.5%
5.6 pts worse
|
1.6%
5.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q3 10.0% · Q4 4.5% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 29.6% |
69.7%
40.1 pts worse
|
79.7%
50.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 29.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
25.0%
4.1 pts better
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 18.2% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-05-19 · Fire 2022-05-19
4 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2019-10-03 · Fire 2019-10-03
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-08-27
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-27
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-27
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-27
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-04
F · Potential for more than minimal harm
2022-05-19
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-06-29
D · Potential for more than minimal harm
2022-05-19
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-06-29
D · Potential for more than minimal harm
2022-05-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-06-29
D · Potential for more than minimal harm
2022-05-19
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-06-29
D · Potential for more than minimal harm
2022-05-19
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-29
Inspection history
Recent health citations
G · Actual harm
2025-12-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-23
D · Potential for more than minimal harm
2025-05-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-22
D · Potential for more than minimal harm
2024-08-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-08-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-08-27
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-08-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-08-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-20
D · Potential for more than minimal harm
2024-08-27
F887 · Infection Control Deficiencies
Health
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.
Corrected 2024-10-20
E · Potential for more than minimal harm
2022-05-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-06-30
D · Potential for more than minimal harm
2022-05-19
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-06-30
G · Actual harm
2019-10-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-11-15
D · Potential for more than minimal harm
2019-10-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-11-15
D · Potential for more than minimal harm
2019-10-03
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2019-11-15
Penalties and ownership
What sits behind the stars
Ownership
Devine, John
Corporate Officer · Individual
Golder, Francoise
Corporate Director · Individual
Monast, Marie Lucian
Corporate Officer · Individual
Paul, Dana
Operational/Managerial Control · Individual
Paul, Dana
Corporate Officer · Individual
Simon, Mark
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Autumn Lake Healthcare At Norwalk
Norwalk, CT
3-star overall rating with 3-star inspections with $12,834 in total fines with 20 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
#2
Norwalk Care Center
Norwalk, CT
1-star overall rating with 1-star inspections with abuse icon flag with $198,225 in total fines with 13 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Waveny Care Center
New Canaan, CT
5-star overall rating with 5-star inspections with 5 recent health deficiencies
Jump out