Norwalk Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Norwalk Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF658Dec 31, 2025

  Based on clinical record review, staff interview, Nurse Practitioner (NP) interview and facility policy the facility failed to ensure insulin orders transcribed for staff awareness, failed to verify the order accuracy before signing, failed to administer insulin for diabetes management, Resident #5 (R#5). The facility reported a census of 42.The Minimum Data Set (MDS) quarterly assessment for R#5 dated 10/10/26 for R#5 revealed diagnosis of diabetes was coded as receiving insulin during last 7 days. The Brief Interview for Mental Status (BIMS) score of 15 out of 15 indicated intact cognitive impairment. […]

• No harm, potential for more than minimal, isolatedF689Apr 16, 2025

  Based on clinical record review, observation, and staff interview, the facility failed to ensure staff appropriately and safely transferred a resident for 2 of 5 residents observed during transfers (Resident #5 & #6). The facility reported a census of 40 residents. Findings include: 1. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 had diagnoses of Parkinson's Disease, anxiety disorder, muscle weakness, and a history of falls. The MDS documented the resident had a Brief Interview for Mental Status score of 6, indicating severely impaired cognition. The MDS indicated the resident used a wheelchair, required substantial to maximum assistance for transfers and had dependence on staff for wheeling her in a wheelchair 50 feet and 150 feet. […]

• No harm, potential for more than minimal, isolatedF550Dec 5, 2024

  Based on observations, clinical record review, facility policy review and staff interviews the facility failed to provide a dependent resident a dignified eating experience during a noon meal service for 1 of 3 residents reviewed (Resident #3). The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) of Resident #3, dated 11/27/24, identified a Brief Interview of Mental Status (BIMS) score of 2 which indicated severe cognitive impairment. The MDS coded the resident as dependent for eating. The Care Plan revised 11/13/24, included a Focus area to address [Name redacted] has a self-care deficit as evidenced by requires assistance with ADLs (activities of daily living), impaired balance during transitions requires assistance and/or walking. […]

• No harm, potential for more than minimal, isolatedF578Dec 5, 2024

  Based on clinical record review, facility policy review and staff interviews the facility failed to ensure accurate code status for 1 of 16 resident reviewed for advanced directives (Resident #28). The facility reported a census of 42 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #28 medical diagnoses included Parkinson's disease, peripheral vascular disease and respiratory disease. The Brief Interview for Mental Status exam scored 15 out of 15 which indicated intact cognition. The MDS reflected resident elected hospice care. The Clinical Resident Profile in the electronic health record for Resident #28 indicated Code Status: (Advance Directives) FULL CODE. Special Instructions: [Name redacted] Hospice. […]

• No harm, potential for more than minimal, isolatedF606Dec 5, 2024

  Based on personnel file reviews, staff interviews and facility policy review, the facility failed to assure all employees had a child abuse background check completed prior to working in the facility as a Certified Nursing Assistant (CNA) for 1 of 5 current employees sampled. The facility reported a census of 42 residents. Findings include: A review of the personnel file for Staff I, CNA revealed a hire date of 2/28/24. The file failed to contain an abuse registry check prior to hire date. Review of the background check titled Singe Contact License & Background Check (SING), completed on 2/27/24 at 11:02 AM, revealed Child Abuse results required initiating record check evaluation by contacting the Department of Human Services (DHS). […]