Inspection Reports for Norwalk Nursing and Rehabilitation Center
921 Sunset Drive, IA, 502111425
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 31, 2025, cited a deficiency related to transcription, verification, and administration of insulin orders for diabetes management. Earlier inspections showed a mixed pattern with deficiencies involving resident care, such as safe transfers and infection control, as well as documentation and policy implementation issues. Complaint investigations were mostly unsubstantiated, though some were substantiated, including one involving unsafe wheelchair transfers and another related to staff abuse and disrespectful treatment of residents. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history indicates ongoing challenges with clinical care and policy adherence, with no clear pattern of consistent improvement or worsening over time.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
42 residents
Based on a December 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 1
Dec 31, 2025
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and an investigation of complaint #2578842-C from December 29, 2025 to December 31, 2025. The complaint did not result in deficiencies.
Findings
The facility failed to ensure insulin orders were properly transcribed, verified, and administered for diabetes management for Resident #5. Numerous instances were documented where insulin doses ordered per sliding scale were not given, and the Nurse Practitioner acknowledged errors in transcription and verification of the insulin orders.
Complaint Details
Complaint #2578842-C was investigated during the survey but did not have deficiencies cited.
Severity Breakdown
SS = D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure insulin orders were transcribed for staff awareness, verified for accuracy before signing, and administered as ordered for diabetes management for Resident #5. | SS = D |
Report Facts
Census: 42
Blood sugar readings requiring insulin not administered: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Nurse Practitioner | Interviewed regarding insulin order transcription and administration errors for Resident #5 |
| Staff B | Registered Nurse | Reported transcription issues and plans to correct medication record |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 9, 2025
Visit Reason
A complaint investigation for facility reported incident #2562423-I was conducted on October 09, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Investigation was related to incident #2562423-I; the facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 30, 2025
Visit Reason
The document serves as a Plan of Correction following acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance and will be certified in compliance effective April 24, 2025.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Apr 16, 2025
Visit Reason
Investigation of Complaint #127777-C conducted April 15, 2025 to April 16, 2025 regarding the facility's failure to ensure adequate supervision and safe transfer of residents in wheelchairs.
Findings
The facility failed to ensure staff appropriately and safely transferred two residents in wheelchairs without foot pedals, posing accident hazards. The facility lacked a policy for transporting or pushing residents in wheelchairs.
Complaint Details
Complaint #127777-C was substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to ensure adequate supervision and assistance devices to prevent accidents during resident transfers in wheelchairs without foot pedals. |
Report Facts
Resident census: 40
Dates of complaint investigation: April 15, 2025 to April 16, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Observed pushing residents in wheelchairs without foot pedals |
| Director of Nursing | Reported foot pedals needed to be on wheelchairs during interview | |
| Administrator | Reported facility lacked policy for transporting or pushing residents in wheelchairs |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 25, 2025
Visit Reason
A complaint investigation for Complaints #125309-C and #126109-C was conducted on February 24, 2025 to February 25, 2025.
Findings
The facility was found to be in substantial compliance.
Complaint Details
Complaint investigation for Complaints #125309-C and #126109-C; facility found in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Dec 27, 2024
Visit Reason
The document is a Plan of Correction submitted following a survey to address deficiencies and certify the facility's compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, leading to certification effective December 27, 2025.
Inspection Report
Annual Inspection
Census: 42
Deficiencies: 5
Dec 5, 2024
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints #120580-C, #123117-C, 124238-C, and 124876-C.
Findings
The facility was found deficient in multiple areas including failure to provide a dignified eating experience for a dependent resident, failure to ensure accurate code status for a resident, failure to complete required background checks for staff, failure to update care plans timely, and failure to use proper infection control techniques during incontinence care.
Complaint Details
Complaints #120580-C and 124876-C were substantiated.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide a dependent resident a dignified eating experience during a noon meal service. | SS=D |
| Failed to ensure accurate code status for a resident regarding advance directives. | SS=D |
| Failed to assure all employees had a child abuse background check completed prior to working in the facility. | SS=D |
| Failed to update the care plan to reflect a resident's change in choice of advance directives. | SS=D |
| Failed to utilize infection control techniques during incontinence care for a resident with a history of multiple urinary tract infections. | SS=D |
Report Facts
Census: 42
Deficiencies cited: 5
Correction completion date: Dec 27, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide/Housekeeping Supervisor | Named in dignified eating experience deficiency |
| Staff B | Certified Nurse Aide | Named in dignified eating experience deficiency |
| Staff C | Certified Nurse Aide | Named in dignified eating experience and infection control deficiencies |
| Staff D | Certified Nurse Aide | Named in dignified eating experience and infection control deficiencies |
| Staff E | Activities Director/CNA | Named in dignified eating experience deficiency |
| Staff F | Certified Nurse Aide | Named in dignified eating experience deficiency |
| Staff G | Licensed Practical Nurse | Named in dignified eating experience deficiency |
| Staff H | Registered Nurse | Named in code status deficiency |
| Staff I | Certified Nurse Aide | Named in background check deficiency |
| Director of Nursing | Director of Nursing | Named in code status and dignified eating experience deficiencies |
| Administrator | Administrator | Named in code status deficiency |
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 0
Nov 30, 2023
Visit Reason
An annual recertification survey along with a complaint survey was conducted from November 27, 2023 to November 30, 2023.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities.
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 23, 2023
Visit Reason
The inspection was conducted to investigate incident 110259-I and complaints 110332-C and 109087-C reported by the facility.
Findings
The incident and complaints investigated during the visit were found to be not substantiated.
Complaint Details
Incident 110259-I and complaints 110332-C and 109087-C were investigated and found not substantiated.
Inspection Report
Renewal
Deficiencies: 0
Nov 13, 2022
Visit Reason
The inspection was conducted as a recertification survey and investigation to determine compliance for continued certification of the facility.
Findings
Based on acceptance of the facility's credible allegation of compliance and plan of correction following the recertification survey and investigation ending October 11, 2022, the facility was certified in compliance effective November 13, 2022.
Inspection Report
Annual Inspection
Census: 37
Deficiencies: 5
Oct 11, 2022
Visit Reason
The facility's annual health survey and investigation of a facility-reported incident #105279-I was conducted from October 4 to October 11, 2022.
Findings
The survey found deficiencies related to abuse/neglect policies, accuracy of assessments, comprehensive care planning, ADL care for dependent residents, and mobility management. The facility failed to ensure resident safety and proper implementation of policies and care plans for multiple residents.
Complaint Details
Facility-reported incident #105279-I was substantiated involving abuse allegations against staff toward Resident #29.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to develop and implement abuse/neglect policies including immediate removal of alleged perpetrators and reporting abuse allegations. | SS=D |
| Failure to complete assessments that accurately reflect the resident's status for 2 of 2 residents reviewed. | SS=D |
| Failure to develop and implement comprehensive person-centered care plans for residents. | SS=D |
| Failure to provide adequate ADL care including bathing for dependent residents. | SS=D |
| Failure to ensure residents with limited range of motion receive appropriate treatment and services to prevent decrease in mobility. | SS=D |
Report Facts
Census: 37
Deficiencies cited: 5
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 31, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction related to the facility's certification compliance.
Findings
The facility submitted a credible allegation of compliance and plan of correction, resulting in certification in compliance effective 3/31/22.
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 1
Mar 28, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted from 3/21 to 3/28/22, including an investigation of complaint 101918-C and a facility-reported incident 102978-I.
Findings
The facility was found in compliance with COVID-19 practices. Complaint 101918-C was substantiated without a deficiency, but the facility-reported incident 102978-I resulted in a deficiency related to resident rights and staff behavior toward Resident #1.
Complaint Details
Complaint 101918-C was substantiated without a deficiency. Facility-reported incident 102978-I resulted in a deficiency related to verbal abuse and disrespectful treatment of Resident #1 by staff.
Deficiencies (1)
| Description |
|---|
| Facility staff failed to treat Resident #1 with respect and dignity, including verbal abuse and forcing a shower against the resident's wishes. |
Report Facts
Total Residents: 39
Survey Dates: 3/21/22 to 3/28/22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Named in verbal abuse and disrespectful treatment of Resident #1 |
| Staff B | Certified Nursing Assistant | Witnessed verbal abuse by Staff A and assisted with Resident #1's shower |
| Staff C | Nursing Assistant | Witnessed verbal abuse and assisted with Resident #1's shower |
| Staff D | Nurse | Involved in follow-up and assessment of Resident #1 after incident |
| Staff E | Hospice CNA | Interviewed regarding Resident #1 and incident |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Jun 30, 2021
Visit Reason
The inspection was conducted as an investigation of a mandatory report 97655-M related to an allegation of abuse involving Resident #1.
Findings
The facility failed to immediately separate the alleged abuse perpetrator from the victim and did not meet requirements for abuse/neglect policies and procedures. The investigation detailed an incident where a staff member forcefully grabbed Resident #1 during a transfer, causing bruising. The facility's abuse prevention policy requires immediate reporting and removal of alleged perpetrators, which was not fully followed.
Complaint Details
The complaint investigation was substantiated based on clinical record review, policy review, staff interviews, and documentation of an alleged abuse incident occurring on 3/23/21 involving Resident #1 and Staff B. The ADON and Administrator took actions including suspension of Staff B pending investigation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop and implement abuse/neglect policies including immediate separation of alleged abuse perpetrator from victim. | SS=D |
Report Facts
Resident census: 35
Bruise measurements: 1.8
Bruise measurements: 2.5
Bruise measurements: 3.4
Bruise measurements: 3
Bruise measurements: 1
Bruise measurements: 2
Staff B work hours: 12
Staff B work hours: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Reported the alleged abuse incident and delayed reporting due to personal issues |
| Staff B | Certified Nursing Assistant | Alleged perpetrator who forcefully grabbed Resident #1 during transfer |
| Staff B | Registered Nurse | Assisted with transferring Resident #1 and observed Staff B's behavior |
| Assistant Director of Nursing | ADON | Recorded incident report and managed investigation including suspension of Staff B |
Inspection Report
Annual Inspection
Census: 33
Deficiencies: 5
Mar 17, 2021
Visit Reason
The Iowa Department of Inspections and Appeals conducted a Medicare Recertification and State Licensure survey including investigation of facility reported incidents and complaints.
Findings
The facility was found not in compliance with several requirements including enteral feeding management, competent nursing staff scheduling, infection prevention and control, influenza and pneumococcal immunizations, and abuse, neglect, and exploitation training.
Complaint Details
Facility reported incidents 87634-I and 89789-I and complaints 87464-C and 88019-C were investigated and found not substantiated.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to administer enteral feeding at the appropriate rate for one resident with a feeding tube. | SS=D |
| Failed to ensure staff certified in CPR was scheduled 24 hours per day. | SS=D |
| Failed to utilize infection control techniques for 2 of 3 residents reviewed. | SS=D |
| Failed to administer pneumococcal vaccine for one resident as ordered. | SS=D |
| Failed to ensure 2 of 5 staff completed Dependent Adult Abuse Training within 6 months of hire. | SS=D |
Report Facts
Total residents: 33
Dates with no CPR certified staff scheduled: 15
Residents reviewed for infection control: 3
Residents reviewed for pneumococcal vaccine: 5
Staff reviewed for abuse training: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A Temporary Nurse's Aide | Lacked documentation of completed Dependent Adult Abuse Mandatory Reporter Training | |
| Staff B Temporary Nurse's Aide | Lacked documentation of completed Dependent Adult Abuse Mandatory Reporter Training | |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Confirmed feeding rate error and CPR certification lapses |
| Administrator | Facility Administrator | Confirmed no CPR certified staff on duty for overnight shifts and lack of abuse training for staff |
Inspection Report
Abbreviated Survey
Census: 36
Deficiencies: 0
Jul 28, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 7/28/2020 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 24, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/24/20 to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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