New London Sub-acute And Nursing

F-F949.

Based on the deficiencies during the survey, immediate jeopardy and substandard care were identified in the areas of: Freedom from Abuse, Neglect, and Exploitation; Quality of Care; and Training Requirements.

Interview on 3/19/25 at 9:45 AM with the Director of Nursing Services (DNS) and the Administrator identified that the Administrator was aware that an allegation of staff-to-resident abuse was made on 1/3/25, that the State Agency (SA) was not notified of the Reportable Event (RE), and the DNS created a summary on 3/18/25 for the event that happened on 1/3/25 to present to the state agency.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of 98 075158 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075158 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New London Sub-Acute and Nursing 90 Clark Lane Waterford, CT 06385

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0835 Interview on 3/20/25 at 8:36 AM with the DNS and Administrator identified that the Administrator failed to provide adequate oversight of the DNS in ensuring the reporting of an allegation of abuse was submitted to Level of Harm - Minimal harm or the SA and that the facility's policy for reporting was followed, following a conversation on 3/20/25 at 8:36 AM potential for actual harm at which time both the DNS and Administrator were informed of the lack of reporting and lack of starting an investigation for an incident on 1/3/25. The Administrator was responsible for signing the Reportable Events. Residents Affected - Few

Interview on 3/27/25 at 9:46 AM with the Administrator, Regional Registered Nurse (RN) #4, and Regional Registered Nurse (RN) #8 identified that although the Administrator stated he met with the DNS on a weekly basis, he failed to keep a record of those conversations in meeting minutes, his personal notes, or email correspondences. Further, the Administrator was aware the facility had no ethics or compliance policy, nor did the facility discuss issues pertaining to resident abuse in Quality Assurance and Performance Improvement meetings.

The facility failed to utilize resources effectively to attain/maintain the resident's well-being.

Review of the Administrator Job Description identified the responsibility of the Administrator was to plan, organize, develop, direct, control and supervise the overall operations of the facility in accordance with current federal, state, and local laws, regulations, standards and guidelines, and to ensure the highest degree of quality resident life is maintained.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of 98 075158 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075158 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New London Sub-Acute and Nursing 90 Clark Lane Waterford, CT 06385

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50250

Residents Affected - Some Based on observations, clinical record review, review of facility policy, and interviews for 2 of 6 sampled residents (Resident #43 and Resident #46) for Resident #43 reviewed for abuse and Resident #46 reviewed for falls, the documentation failed to correctly reflect actual events. The findings include:

1. Resident #43's diagnoses included dementia, chronic kidney disease, and hypertensive heart disease with heart failure.

The quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] identified Resident #43 was cognitively intact, did not experience episodes of delusions, and required maximal assistance for his/her toileting hygiene and chair to bed and bed to chair transfers.

The Resident Care Plan (RCP) in effect on 1/3/25 identified Resident #43 experienced frequent episodes of incontinence of bladder with an intervention of an assist of 2 with toileting upon request.

The Resident Care Card in effect on 1/3/25 identified Resident #43 was to have 2 staff members present at all times when in his/her room including when performing bathing and toileting tasks.

An interview with Resident #43 on 3/18/25 at 11:51 AM was conducted by the surveyor in the presence of

the DNS. Resident #43 alleged a few weeks prior that while he/she was trying to get into bed from his/her wheelchair, LPN #7 reached over the back of the wheelchair and pushed him/her onto the bed in a non-sexual manner. Resident #43 further identified that he/she was alone in the room with LPN #7 and started yelling for help, at which point LPN #7 grabbed the phone out of his/her hand and threw it across the room. It was noted by Resident #43, that Nurse Aide (NA) #7 entered the room and assisted him/her into bed for the provision of incontinence care. Resident #43 stated she experienced great humiliation over the event and continued to be afraid of LPN #7, noting LPN #7 continued to come into his/her room to provide care

after the alleged incident of abuse. The Director of Nursing Services (DNS) identified he was aware of the allegation of abuse and stated he had completed an investigation and reported the incident to the State Agency (SA).

An interview and review of abuse documentation with the DNS on 3/19/25 at 7:51 AM failed to produce investigation documentation following the 1/3/25 incident. The DNS, in lieu of investigation documentation, provided an undated and unsigned summary of the incident. The DNS stated the summary was created at

the time of his investigation.

An interview with the DNS and Administrator on 3/19/25 at 9:45 AM identified the summary of the alleged abuse event was not created at the time of the investigation but instead created on 3/18/25.

A review of the DNS's undated summary of the 1/3/24 allegation of abuse created on 3/18/25 inaccurately identified Resident #43 was admitted on [DATE REDACTED], was [AGE] years old, had a BIMS of 13, had a diagnosis of dementia with behavioral disturbances, and wanted to be changed for incontinence care during the 1/3/25 incident. Further, the DNS summary stated the DNS assessed Resident #43 for injuries of any kind and there were no new areas or signs of injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of 98 075158 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075158 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New London Sub-Acute and Nursing 90 Clark Lane Waterford, CT 06385

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Contrary to the DNS statement, a review of Resident #43's MDS dated [DATE REDACTED], in effect at the time of the 1/3/25 allegation of abuse, identified that Resident #43 was admitted on [DATE REDACTED], was [AGE] years old, and Level of Harm - Potential for had a BIMS of 15, an inaccurate account of Resident #43's information. A review of Resident #43's facility minimal harm face-sheet dated 3/19/25 identified an admitting diagnosis of dementia without behavioral disturbance. A

review of Resident #43's progress notes from 1/3/25 through 1/10/25 identified there were no progress notes Residents Affected - Some or assessments for Resident #43 documented by the DNS within the electronic medical record for the 1/3/25 allegation of abuse.

An interview on 3/19/25 at 4:26 PM with LPN #7 identified that Resident #43 declined incontinence care the shift previous to his shift with him/her on 1/3/25. LPN #7 further indicated that Resident #43 declined incontinence care during his shift, and he informed the resident he/she had to be changed. LPN #7 stated that Resident #43 was crying and yelling for help during the provided incontinence care, and he removed the phone from his/her hand and told Resident #43 he/she could call for help when he was done. LPN #7 stated

the reason he made the late entry nurses note regarding the incident 2 days after it occurred was he was advised to do so by the DNS to protect himself.

The DNS's summary document indicated that Resident #43 had wanted to be changed. Review of an email dated 3/20/25 at 1:23 PM from LPN #7 to the DNS identified Resident #43 refused incontinence care twice

during his shift on 1/3/25 and he instructed the NA to perform care to which Resident #43 had been opposed.

A review of the Reportable Event Form, submitted on 3/20/25 for the allegation of abuse occurring on 1/3/25, incorrectly identified the event type to be resident to resident abuse without injury, the age of Resident #43 to be [AGE] years old (resident was [AGE] years old), date of admission to be 2/9/24 (date of admission was 10/10/23), and that the resident had no injury, distress, or discomfort.

2. Resident #46 diagnoses included generalized muscle weakness, heart failure, cerebral palsy, contracture of muscle, right upper arm and mild intellectual disabilities.

The quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] identified Resident #46 was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 5), was dependent on staff for toileting and personal hygiene and required maximum assistance for toilet transfers. The MDS identified Resident #46 with an impairment on one side of his/her upper extremity and further identified that he/she ambulated in

a wheelchair.

The Resident Care Plan (RCP) dated 10/21/24 identified Resident #46 was at risk for falls related to impaired mobility. Interventions included, ensuring Resident #46 was wearing appropriate footwear while mobilizing in his/her wheelchair, following facility fall protocol, placing call light within reach and encouraging Resident#46 to use it for assistance as needed.

The Resident Care Card (RCC) for the month of March 2025 identified Resident #46 was at risk of falls and required assistance of 1 staff for personal care, bed mobility, and stand pivot transfers and wheelchair for mobility.

The Reportable Event form dated 11/16/24 at 12:30 PM identified Resident #46 was with Nurse Aide (NA#5)

in the bathroom being toileted, Resident #46 lost his/her grip on the grab bar, slipped to the right and struck his/her head on the wall.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of 98 075158 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075158 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New London Sub-Acute and Nursing 90 Clark Lane Waterford, CT 06385

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 A Post Fall Assessment form completed identified Resident #46 was oriented to person and place. The Post Fall assessment further identified a gait imbalance during transfer as the predisposing physiological factor Level of Harm - Potential for related to the incident. minimal harm RN #3's nurse's note dated 11/16/24 at 5:29 PM identified that Resident #46 was being toileted by NA #5 Residents Affected - Some when she/he became unsteady and leaned over placing the right side of his/her head on the wall. Resident #46 did not complain of pain at the time of the incident and no marks or bruises were observed. Vital signs and neuro vital signs were initiated, and Resident #46's family member and physician were notified.

A DNS late entry nurse's progress note dated 11/18/24 at 7:31 AM dated back to 11/16/24 at 1:02 PM, identified that he was called to Resident #46's room related to a witnessed fall in bathroom. The DNS indicated that according to NA #5 while she was transferring Resident # 46 to the toilet, he/she became weak and leaned against the wall. The DNS identified that Resident #46 was lowered to ground by NA #5 with a gait belt, to sitting then lying position. The note identified that when Resident#46 leaned against the wall initially his/her head hit the wall. Additionally, the note identified that neurological, vital signs, a head to toe assessment, and range of motion were all within normal limits and Resident #46 did not lose consciousness.

The note indicated that Resident #46 denied pain and there was no injury or new skin issue noted, and that two staff members assisted Resident #46 back to the toilet to finish using bathroom as originally intended.

Interview with NA #5 on 3/19/25 at 11:06 AM, identified that she responded to Resident #46's call light, and he/she requested to be assisted to the bathroom urgently. NA #5 indicated that she did not have a gait belt and assisted Resident #46 to the bathroom without using a gait belt. NA #5 stated that when Resident #46 stood up, he/she lost her grip on the pull bar and hit the right side of his/her head on the wall. NA #5 identified that she managed to safely assist Resident #46 to the toilet and stayed with him/her until he/she was done, then transferred him/her back to wheelchair safely without the use of a gait belt. NA #5 further indicated that she wheeled Resident #46 to the nurse's station and reported the incident to RN #3. NA #5 stated that she completed a paper incident report and handed it to RN#5. NA#3 identified that Resident #46 did not fall during transfer in the bathroom but only bumped his/her head on the wall. NA #5 further identified that the DNS did not respond to the incident in Resident #46's bathroom, nor had he interviewed her regarding the bathroom accident with Resident #46.

Interview on 3/19/25 at 2:50 PM with DNS identified that he responded to Resident #46's bathroom incident but could not recall details of the incident. The DNS was unable to explain if he responded to the incident in person as he stated in his progress note regarding the incident or whether his documentation was based on

an interview with NA #5 and RN #3. The DNS indicated that he would seek clarification from RN # 3 and NA#5.

Interview with RN #3 on 3/25/25 at 2:37 PM identified that she assessed Resident #46 after the bathroom accident with NA #5. RN #3 identified that Resident #46 was not lowered to ground by NA #5 with the use of

a gait belt as indicated in the DNS progress note. RN#3 further identified that the DNS was not present when

she assessed Resident #46.

The DNS's documentation failed to describe an accurate representation of Resident #46's incident and actual experience in the bathroom.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of 98 075158 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075158 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New London Sub-Acute and Nursing 90 Clark Lane Waterford, CT 06385

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Review of the facility's Charting and Documentation policy, identified in part, that documentation in the medical record will be objective (not opinionated or speculative), complete and accurate, and be completed Level of Harm - Potential for for treatments or services provided and for events, incidents, or accidents involving the resident. minimal harm 51182 Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of 98 075158 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075158 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New London Sub-Acute and Nursing 90 Clark Lane Waterford, CT 06385

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Potential for 51182 minimal harm Based on staff interviews, facility policy, and documentation reviewed for the facility Quality Assurance Residents Affected - Some Improvement Plan (QAPI), the facility failed to include the Infection Preventionist in the Quality Assessment and Assurance (QAA) meetings. The findings include:

An interview on 3/20/25 at 10:20 AM with Licensed Practical Nurse (LPN) #9 identified she began her oversight of the Infection Prevention program around September/October of 2024.

An interview and QAPI documentation review with the Administrator on 3/24/25 at 11:13 AM identified the facility meets on a monthly basis for QAPI/QAA meetings. A review of the meeting sign-in sheets with the Administrator identified meetings were held in July 2024, August 2024, September 2024, October 2024, November 2024, December 2024, and January 2025. Although the Infection Preventionist did attend the January 2025 meeting she failed to attend the meetings in July through December of 24 (missing 6 of 7 opportunities for attendance).

The Administrator indicated the reason an Infection Preventionist did not attend the QAPI/QAA meetings was due to staffing issues, with the prior Infection Preventionist resigning her position in August 2024, and the facility's current Infection Preventionist not being hired immediately after August 2024. The Administrator noted that although some staff are shared between facilities within the parent organization, the Infection Preventionist position is not shared.

Review of the facility's QAPI policy identified the facility will establish an interdisciplinary QAPI committee.

The committee shall consist of a minimum of the Administrator, Director of Nursing, Medical Director, and three other staff members. The QAPI policy failed to identify that per Federal guidelines, an Infection Preventionist must be included in the QAPI committee.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of 98 075158 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075158 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New London Sub-Acute and Nursing 90 Clark Lane Waterford, CT 06385

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50250 potential for actual harm Based on observations, clinical record review, review of facility policy, and interviews for 1 of 3 sampled Residents Affected - Few residents (Resident #4) reviewed for pressure ulcers, the facility failed to ensure appropriate Personal Protective Equipment (PPE) was worn prior to personal care, for 1 of 5 sampled resident units (for Resident #96, Resident #404, and Resident #407) reviewed for infection control practices, for Resident #96, failed to implement the appropriate precautions for an active Multi-Drug Resistant Organism (MDRO) and failed to perform appropriate hand hygiene during wound care for Resident #404, failed to ensure appropriate PPE was worn upon entering the resident's room and failed to implement appropriate precautions for an active MDRO, and for Resident #407 failed to ensure appropriate hand washing for a resident with an active MDRO. The findings include:

1. Resident #4's diagnoses included dementia, generalized muscle weakness, anxiety, and hypertension.

The quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] identified Resident #4 had severe cognitive impairment (Brief Interview for Mental Status (BIMS) score of 5), and was dependent on staff for toileting hygiene, personal hygiene, transfers and required maximum assistance for bed mobility. The MDS identified that Resident #4 had impairment on both sides of the upper and lower extremities and was always incontinent of urine and bowel.

The Resident Care Plan in effect for the month of March 2025 identified Resident #4 was on Enhanced Barrier Precautions (EBP). Interventions included maintaining EBP per facility policy and observing for signs and symptoms of infection and reporting accordingly.

The care card (NA Resident Assignment) identified EBP was in place and directed staff to wear a gown and gloves when delivering direct care to Resident #4.

Observations on 3/20/25 at 10:30 AM, identified EBP signage on the right side of the wall outside of Resident #4's room directing to wear gloves and a gown for high contact resident care (dressing, bathing, changing linen, device care and wound care) and a precaution cart stocked with gloves and gowns was present on the opposite side of Resident #4's room in the hallway. Further, NA #10 and NA #11 were in Resident #4's room providing incontinent care wearing gloves but without the benefit of gowns.

Interview on 3/20/25 at 11:00 AM, with NA #10 and NA #11 identified that they were not aware that Resident #4 was on EBP precautions. Although NA #10 and NA #11 were aware of the EBP sign posted outside Resident #4's room and the yellow dot indicating EBP next to Resident #4's name, they stated they were unaware that Resident #4 was on EBP and NA #11 indicated this was due to the precaution cart being located across the hall.

Interview with RN #5 on 3/20/25 at 11:10 AM, identified EBP signage on the wall meant staff should wear personal protective equipment (gowns and gloves) with high contact activities such as providing personal care and transfers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of 98 075158 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075158 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New London Sub-Acute and Nursing 90 Clark Lane Waterford, CT 06385

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 The facility's Enhanced Barrier Precautions policy identified, in part, that the use of gowns and gloves for high contact resident care activities is indicated, when contact precautions do not otherwise, apply, in Level of Harm - Minimal harm or residents with wounds and/or indwelling devices regardless of MDRO colonization. potential for actual harm 2. Resident #96's diagnoses included pressure ulcer of sacral region, neuromuscular dysfunction of bladder, Residents Affected - Few and obstructive uropathy.

The quarterly Minimum Data Set (MDS) assessment dated [DATE REDACTED] identified Resident #96 was cognitively intact, dependent on staff for toileting, hygiene and lower body dressing. Additionally, the MDS identified pressure ulcer/injury care was required.

a. The Resident Care Plan dated 2/13/25 identified that Resident #96 was on Enhanced Barrier Precautions (EBP). Interventions included following precautions per the facility policy and monitoring for signs and symptoms of infection.

A physician's order dated 3/17/25 directed staff to obtain a urinalysis with culture and sensitivity.

A physician's order dated 3/18/25 directed to maintain EBP precautions every shift for a history of Methicillin Resistant Staph Aureus (MRSA).

Observations intermittently throughout the day on 3/17/25, 3/18/25, and 3/19/25 identified Resident #96 had

an EBP sign posted outside his/her room.

Review of the clinical record identified that on 3/19/25 APRN #1 had reviewed the

urinalysis culture and sensitivity results from the physician order dated 3/17/25.

Resident #96 was noted to be positive for Extended-Spectrum Beta-Lactamase (ESBL) (an active Multi-Drug Resistant Organism (MDRO) infection) and ordered antibiotic treatment. Further review of the physician orders identified that although a culture sensitivity indicated an active MDRO, the orders failed to indicate the EBP (gloves and gown) had been changed to the appropriate contact precautions, gown and gloves, and in certain instances restriction of movement/precautions for the resident in the facility for an active MDRO infection.

Observation on 3/20/25 at 10:47 AM identified the EBP sign had been removed and replaced with a contact precaution sign.

In an interview with the Laboratory Customer Service Representative on 3/20/25 at 11:18 AM identified the laboratory had called Registered Nurse (RN) #1 on 3/17/25 at 12:17 PM and verbally notified her of Resident #96's positive ESBL result, in addition to the results being faxed to the facility.

Interview with LPN #2 on 3/20/25 at 11:34 AM identified Resident #96 was changed to contact precautions by the Infection Preventionist (IP) on 3/20/25 in the morning due to something in his/her urine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of 98 075158 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075158 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New London Sub-Acute and Nursing 90 Clark Lane Waterford, CT 06385

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Interview with RN #1 on 3/20/25 at 11:41 AM identified it was the facility policy to notify the IP when a resident was identified to have an active MDRO, and if the MDRO was determined by lab work, RN #1 would Level of Harm - Minimal harm or provide the results to the IP and APRN so they could review the results and potentially obtain new physician potential for actual harm orders. RN #1 identified she was knowledgeable of what an MDRO was, denied ever receiving a call from

the lab with the positive ESBL results, but stated she had passed Resident #96's faxed laboratory results to Residents Affected - Few the APRN. She failed to identify if she had reviewed the lab work result prior to providing the information to

the APRN. Additionally, RN #1 identified that it was the responsibility of the Infection Preventionist to initiate

the appropriate precautions.

Interview with the Infection Prevention nurse (IP) on 3/20/25 at 1:11 PM indicated she identified positive laboratory and culture results through the nursing supervisor, who also notified the APRN and charge nurse. If results were positive for an active MDRO, it was the charge nurse's or RN supervisors' responsibility to initiate the appropriate precautions immediately. Additionally, she stated Resident #96 was not changed from EBP to contact precautions for the 3/17/25 positive ESBL result in his/her urine because the MDRO was not identified by any staff until this morning (3/20/25 3 days after the results were obtained) when she reviewed

the results and changed Resident #96 to the appropriate contact precautions.

Interview with APRN #1 on 3/20/25 at 1:57 PM identified she was aware of the laboratory result showing Resident #96 was positive for ESBL, and that is why she changed resident #96's antibiotic to one that was sensitive for ESBL. She stated that she had not initiated an order for contact precautions because that was

the facility's responsibility.

b. The Resident Care Plan dated 12/2/24 identified Resident #96 had a stage 4 pressure ulcer on the sacrum. Interventions included consultation and treatment by a wound nurse, and special mattress in place.

The physician's order dated 3/6/25 directed for the pressure ulcer on the sacrum to be cleansed with hibiclens solution, patted dry, skin prep applied to the peri wound, followed by a silver alginate sheet to the wound bed, then cover with super absorbent dressing every shift.

The physicians order dated 3/18/25 directed to maintain EBP precautions every shift for history of MRSA.

Observation of the pressure ulcer dressing change with Licensed Practical Nurse (LPN) #2 and Nurse Aide (NA) #3 on 3/19/25 at 10:14 AM identified an EBP sign and precaution cart outside Resident #96's room. Both LPN #2 and NA #3 applied gloves and gowns without the benefit of hand hygiene prior. NA #3 assisted

the resident onto his/her left side. LPN #2 prepared a sterile field, then removed her gloves and applied a new pair without the benefit of performing hand hygiene. LPN #2 opened Resident #96's brief, removed the dressing and provided him/her with peri care. She then removed her gloves and applied new gloves without

the benefit of hand hygiene. LPN #2 performed the treatment per the physician's order, removed her gloves, then gown and washed her hands. NA #3 stayed with Resident #96 to assist with morning care.

Interview with LPN #2 on 3/19/25 at 10:25 AM identified it was facility policy to perform hand hygiene between glove changes only when there was an active infection, otherwise it was not necessary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of 98 075158 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075158 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New London Sub-Acute and Nursing 90 Clark Lane Waterford, CT 06385

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Interview with the IP on 3/19/25 at 10:27 AM identified the hand hygiene policy was to perform hand hygiene between glove changes. Level of Harm - Minimal harm or potential for actual harm 3. Resident #404's diagnoses included chronic obstructive pulmonary disease, cough, and esophageal obstruction. Residents Affected - Few

The hospital Plan of Care Summary dated 3/3/25 identified Resident #404 was on contact precautions for MRSA in the wound and lower respiratory tract.

The baseline Resident Care Plan dated 3/6/25 identified Resident #404 had Methicillin-Resistant Staphylococcus Aureus (MRSA), colonization (not an active MRSA infection). Interventions included contact isolation, bagging and transporting used linen according to facility protocol prevent skin exposure or contamination and a provide a private room.

The New Admission Alert dated 3/6/25 identified Resident #404 was MRSA positive (had an active infection).

The admission Minimum Data Set (MDS) assessment dated [DATE REDACTED] identified Resident #404 was cognitively intact and required partial/moderate assistance from staff for toileting, transfers, and personal hygiene. The MDS failed to identify that Resident #404 had an MDRO.

A physician's order dated 3/12/25 directed to ensure MRSA droplet (sputum) precautions; place a sign and cart outside room, and wear gown and gloves every shift as instructed.

Review of nurses notes from 3/7/25 through 3/18/25 intermittently identified both an active and colonized MRSA infection.

Observations on 3/17/25 at 9:17 AM, 3/18/25 at 11:37 AM and 3/18/25 at 11:44 AM identified Enhanced Barrier Precaution (EBP) signage outside Resident #404's room. The sign directed gloves and gown be applied for high contact activities such as dressing, bathing/showering, transferring, providing hygiene, changing linens, assisting with toileting, device care, and wound care.

Observation on 3/18/25 at 11:55 AM identified 2 physical therapy staff members walking into Resident #404's room without the benefit of applying PPE per the EBP sign.

Interview and observation with LPN #2 on 3/18/25 at 11:57 AM identified that Resident #404 had been diagnosed with an active MRSA in the sputum. Observation of the EBP precaution sign with LPN #2 identified the precaution sign posted was not accurate given the active MRSA diagnosis. She stated the sign should have indicated droplet precautions, (to apply a mask, gown and gloves) and that the 2 physical therapy staff members would not have known to wear the correct personal protective equipment due to the incorrect signage. Additionally, the physical therapy staff members were on their way out the door with Resident #404 when LPN #2 stopped them. She informed the physical therapists of Resident #404 diagnosis indicating the Resident #404 required a mask on exiting his/her room.

Subsequent to surveyor inquiry LPN #2 explained the active MRSA infection to the physical therapists, that Resident #404 should not have been on EBP, and he/she should have been on droplet precautions. The physical therapists had Resident #404 remain in his/her room. LPN #2 verbalized that she would be changing the signage to reflect the appropriate droplet precautions for Resident #404.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of 98 075158 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075158 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New London Sub-Acute and Nursing 90 Clark Lane Waterford, CT 06385

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 3. Resident # 407's diagnoses included Vancomycin Resistant Enterococci (VRE), an MDRO in the urine, gastroenteritis, and alcoholic hepatitis. Level of Harm - Minimal harm or potential for actual harm a. Observation of NA #3 on 3/19/25 at 11:25 AM identified him outside of Resident #407's room with a contact precautions sign posted, he applied the gown then one glove without the benefit of hand hygiene Residents Affected - Few prior to applying the PPE.

Interview with NA #3 on 3/19/25 at 11:30 AM identified it was facility policy to foam in and out, stating that although it was not facility policy, he always performs hand hygiene before applying gloves and after taking them off. NA #3 identified he did not perform hand hygiene prior to applying the gown and glove, but he should have, he then removed his gloves and performed hand hygiene by using the alcohol-based hand rub that was located on the wall.

b. Observation of NA #2 on 3/17/25 at 10:11 AM identified her walking down the hallway while wearing gloves, she took off one glove at the nurses' station, picked up a drink and took a sip, then reapplied the same glove without the benefit of hand hygiene.

Interview with NA #2 on 3/17/25 at 10:16 AM identified the facility policy was no gloves in the hallway, but hers were clean. She failed to identify the facility policy on hand hygiene, with glove removal and reapplication, stating she was new and just orienting and could not recall if she received education on infection control.

Review of the new hire orientation packet identified that infection control; hand hygiene training was provided.

Review of the MDRO policy dated 4/16 directed that when a resident tests positive for a MDRO, they will be placed on appropriate precautions as soon as the facility is notified of a positive result.

Review of the Hand Hygiene policy dated 4/2017 directed, in part, the facility considers hand hygiene the primary means to prevent the spread of infections and directed use of alcohol based hand rub before and

after direct care with residents, before handling clean or soiled dressings, after removing gloves, before and

after isolation precaution settings and as a final step after removing and disposing of PPE.

Review of the Non-sterile Dressing policy dated 6/2023 directed in part to wash hands or hand sanitize prior to the procedure and between glove changes.

Review of the Enhanced Barrier Protection policy dated 8/2023 directed in part the use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, in residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for a resident with a MDRO infection or colonization.

Review of the Contact Precautions policy dated 8/2023 directed contact precautions were required for care of specified residents with documented or suspected infections for highly transmittable or epidemiologically significant pathogens.

51102

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 93 of 98 075158 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075158 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New London Sub-Acute and Nursing 90 Clark Lane Waterford, CT 06385

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0943 Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51102

Residents Affected - Some Based on interviews, record review, and policy review, the facility failed to provide all staff with abuse and neglect training and failed to develop staff training for abuse that included federal components for abuse education. The findings included:

1. A review of abuse and neglect training documentation identified education was provided for new hires

during orientation and during in-services that had occurred in May 2024, September 2024 and March 2025.

Review of the sign-in sheets identified 31 employees had not received any abuse and neglect training (19% of the facility employees).

Interview with the Administrator on 3/27/25 at 2:03 PM identified that the facility policy training program for abuse and neglect training directed all staff were in-serviced annually. Additionally, the Staff Development nurse was responsible for ensuring all employees received the mandatory in-service training on neglect and abuse.

Interview and in-service signature record review with the Staff Development Nurse on 3/27/25 at 3:25 PM identified that it was her as well as the Director of Nurses responsibility to provide staff with abuse and neglect education annually according to the facility training program policy. Review of the abuse and neglect training sign-in sheets with the Staff Development nurse identified that 31 staff members, employed prior to 2024, had not received the directed mandatory abuse and neglect training. The Staff Development nurse was unable to explain why the facility failed to implement their policy ensuring all staff received abuse and neglect training on an annual basis.

Interview with the HR Director on 3/27/25 at 4:07 PM identified there were 164 staff members currently employed at the facility, and the 31 employees identified as not having had abuse and neglect training since prior to 2024 were still currently employed with the facility.

The Director of Nurses was not available for an interview.

The facility assessment dated [DATE REDACTED] identified staff is educated on abuse, neglect and exploitation.

The Preventing Resident Abuse training policy dated 4/2016 directed, in part, the facility abuse prevention/intervention program included regularly scheduled in-service programs.

2. A review of the Abuse Training for staff identified that in-services occurred on 9/13/2024, 9/16/2024, 9/19/2024, 9/20/2024, 9/27/2024, and 10/18/2024. The seven components of the requirement include:

Screening

Training

Prevention

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 94 of 98 075158 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075158 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New London Sub-Acute and Nursing 90 Clark Lane Waterford, CT 06385

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0943 Identification

Level of Harm - Minimal harm or Investigation potential for actual harm Protection Residents Affected - Some Reporting/response

Although the training did discuss investigation, protection, and a portion of reporting/response (page 1), it failed to address the screening of residents (current and new admissions) for abuse, identification of physical or psychosocial indicators of abuse (including injuries from an unknown source), mandated reporting, and/or reporting allegations without fear of reprisal. Additionally, the training lacked misappropriation of resident property, resident exploitation, chemical and physical restraints, recognizing signs of burnout, frustration, and stress that may increase the risk for abuse, and dementia management for resident abuse prevention.

Interview with the Staff Development nurse on 3/25/2025 at 10:48 AM identified she did not create the abuse training she provided to staff, and it was given to her when she started her role as Staff Development nurse.

She further indicated the DNS was responsible for the accuracy of the abuse education and ensuring it matched the facility policy. The Staff Development nurse stated she had never seen the facility policy on abuse and believed the training did not match the policy on abuse because someone didn't take the time to read the policy when creating the education.

A follow-up interview with the Staff Development nurse on 3/25/2025 at 12:02 PM identified that she was aware the staff abuse education was not sufficient, and she failed to review and update the information. Further, she indicated she was directed to include the abuse policy to staff during abuse training beginning in November 2024 and failed to start distributing the abuse policy until March of 2025.

An interview with the DNS on 3/25/2025 at 11:03 AM identified that abuse education was created by the Staff Development nurse, and it had been reviewed by him prior to staff distribution. He further identified that the abuse education should be based off the facility policy.

Review of the facility's Preventing Resident Abuse policy identified, in part, that the facility will not condone any form of resident abuse and will continually monitor the facility's policies, procedures, training programs, systems, etc. to assist in preventing resident abuse.

51182

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 95 of 98 075158 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075158 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New London Sub-Acute and Nursing 90 Clark Lane Waterford, CT 06385

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0944 Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program. Level of Harm - Potential for minimal harm 51182

Residents Affected - Some Based on interviews, facility documentation review, and facility policy, during the extended survey, the facility failed to provide staff with mandatory training on the QAPI program or how to communicate concerns, problems or opportunities for improvement. The findings included:

Interview with the Administrator, Regional Registered Nurse (RN) #4, and Regional Registered Nurse (RN) #8 on 3/27/25 at 9:46 AM identified the facility had a Code of Conduct policy, but this Code of Conduct was not communicated to the entire facility staff.

The DNS was unavailable for interview.

Although requested, a policy was not provided.

The Code of Conduct policy failed to include the basic components of utilizing a QAPI program.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 96 of 98 075158 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075158 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New London Sub-Acute and Nursing 90 Clark Lane Waterford, CT 06385

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0946 Provide training in compliance and ethics.

Level of Harm - Minimal harm or 51182 potential for actual harm Based on interviews, facility documentation review, and facility policy, the facility failed to develop a Residents Affected - Some compliance and ethics program and failed to provide staff with compliance and ethics training. The findings included:

Interview with the Administrator, Regional Registered Nurse (RN) #4, and Regional Registered Nurse (RN) #8 on 3/27/25 at 9:46 AM identified the facility did not have a compliance and ethics program and also did not have a compliance and ethics policy. It was further identified that compliance and ethics training is not part of new hire orientation or annual training. RN #4 and RN #8 stated there was a Code of Conduct policy, but this Code of Conduct is not communicated to the entire facility staff.

The DNS was unavailable for interview.

Although requested, a policy on Compliance and Ethics was not provided.

The Code of Conduct policy failed to include the basic components of an ethics and compliance program including but not limited to: identification of a compliance officer or committee; how and who to report ethical concerns to; secure, confidential, and timely reporting of concerns; conducting internal monitoring and auditing for compliance and ethical concerns; response and corrective action to detected offenses; and risk assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 97 of 98 075158 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 075158 B. Wing 03/27/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

New London Sub-Acute and Nursing 90 Clark Lane Waterford, CT 06385

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0949 Provide behavior health training consistent with the requirements and as determined by a facility assessment.

Level of Harm - Potential for **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51102 minimal harm Based on interviews, record reviews, and the facility assessment, the facility failed to provide facility staff with Residents Affected - Many behavioral health education as identified on the annual assessment. The findings included:

A review of the facility assessment dated [DATE REDACTED] identified the facility was able to admit residents that needed care for psychiatric/mood disorders such as psychosis, impaired cognition, mental disorder, depression, bipolar disorder, schizophrenia, post-traumatic stress disorder, anxiety disorder and behaviors that need interventions. Additionally, the assessment identified Nursing Assistants (NA's) were provided with education on combative care and those with behavioral disturbances.

Review of the in-service calendars dated March 2024 through March 2025 failed to identify scheduled behavioral health training by the facility or by the psychiatry services group.

Review of the behavioral health education dated 3/26/25 identified a Personality Disorders in-service provided by the psychiatry services provider with a sign-in sheet consisting of 19 staff members (the facility employs 164 employees, a compliance rate of 11.5%). The facility failed to provide any other in-services with sign-in sheets on the topic of behavioral health.

Interview with the Administrator on 3/27/25 at 2:03 PM identified, on average, 50 residents residing in the facility had behavioral health needs (average census ranging between 102 and 108). He identified that staff should be receiving behavioral health education, and the education was provided by the psychiatry services provider on a regular basis.

Interview with the Staff Development nurse on 3/27/25 at 3:11 PM identified behavioral health education was provided on a regular basis by the psychiatry services group, and her role is to schedule the education and put the information on the in-service calendar. She could not provide any past in-service sign in sheets where behavioral health education occurred.

Although requested, a policy for behavioral health was not provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 98 of 98 075158