Inspection Reports for
Norwalk Nursing and Rehabilitation Center

Complaint #2578842-C was investigated during the survey but did not have deficiencies cited.

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.

The complaint investigation found that insulin was not administered as ordered on multiple occasions for Resident #5, despite blood sugar readings requiring insulin per the sliding scale. The Nurse Practitioner acknowledged the transcription error and missed verification of the sliding scale order.

The facility failed to ensure insulin orders were accurately transcribed and verified before signing, and failed to administer insulin as ordered for Resident #5, resulting in multiple missed insulin doses despite documented high blood sugar levels. The Nurse Practitioner acknowledged the transcription error and the facility took steps to correct the medication record.

The facility failed to ensure staff appropriately and safely transferred 2 of 5 residents observed during transfers. Staff pushed residents in wheelchairs without foot pedals, causing residents' feet to brush or be near the floor. The facility lacked a policy for transporting or pushing residents in wheelchairs.

Complaint #127777-C was substantiated.

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.

Complaints #120580-C and 124876-C were substantiated.

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.

The facility failed to provide a dependent resident (Resident #3) a dignified eating experience during a noon meal service, as evidenced by multiple staff changes assisting the resident and inconsistent attention during the meal. The resident has severe cognitive impairment and requires assistance with eating, but staff frequently left the resident unattended or distracted during feeding.

The facility was found deficient in providing a dignified eating experience for a dependent resident, maintaining accurate and updated advanced directives, completing required child abuse background checks for employees, updating care plans to reflect changes in resident preferences, and following proper infection control procedures during incontinence care.

Facility-reported incident #105279-I was substantiated involving abuse allegations against staff toward Resident #29.

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 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.

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.

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.

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.

Facility reported incidents 87634-I and 89789-I and complaints 87464-C and 88019-C were investigated and found not substantiated.

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.