New London Sub-acute And Nursing

Review of the facility's surety bond identified the Resident Trust Accounts were insured for $50,000 effective June 30, 2024, through June 30, 2025.

An interview with the Administrator on 3/20/25 at 3:43 PM identified the facility did not regularly monitor if the Resident Trust Account $50,000 surety bond coverage was adequate and indicated he was unaware that the Resident Trust Account regularly exceeded the $50,000 coverage limit.

The Administrator failed to identify who was responsible for monitoring the Resident Trust Account and indicated he was going to reach out to the Executive [NAME] President to raise the surety bond amount to cover resident funds.

The facility failed to provide a Surety Bond Policy upon request.

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

supervision could be reassigned.

not provided.

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

cognition and was independent with bed mobility, transfers, and ambulation.

The Resident Care Plan dated 10/7/24 identified Resident #84 had a history of

Interventions included anticipating needs and intervene as necessary to protect the rights of others.

An unsigned Resident Monitoring Sheet dated 11/23/24 identified 6:15 PM through 6:30 PM Resident #84 was in the hall.

A nurses note dated 11/23/24 at 7:09 PM identified Resident #84 was walking down the hall pushing an item. (Resident #42) attempted to stop him/her (from further movement) resulting in Resident #84 striking Resident #42 on the right cheek open handed. Resident #84 was placed on 1:1 supervision and returned to his/her room.

The responsible party, physician. DNS, and police were notified.

A facility Reported Event Summary dated 11/26/24 identified on 11/23/24 at approximately 6:30 PM, Resident #84 was pushing a wheelchair in the hallway. Resident #42 stepped in front (of resident #84) to prevent further movement.

This upset Resident #84 who slapped Resident #42 with an open hand on the right side of his/her face. LPN #14 was passing medication in the hallway and observed the altercation but was unable to respond quickly enough to intervene.

The residents were separated and immediately placed on a 1:1 sitter until details could be obtained and assessments by the RN supervisor completed. An assessment identified both residents at baseline with no injuries to Resident #42.

Once details were sorted out, Resident #84 remained on a 1:1 sitter until cleared by the health provider. Resident #84's prescribed Trazadone (an antidepressant) was increased from 25 mg daily to 50 mg. Resident #84 was subsequently transported to an alternate (psychiatric) facility for evaluation and treatment on 11/25/24.

An interview with LPN #14 on 3/24/25 at 11:49 AM identified she was the assigned nurse on 11/23/24 during the 3:00 PM to 11:00 PM shift. LPN #14 indicated while passing medications, she observed Resident #84 pushing a cart down the hall. Resident #42 attempted to stop Resident #84 from pushing the cart at which point, Resident #84 slapped Resident #42 open handed on the side of the face. In response, Resident #42 pushed Resident #84 into the wall. LPN #14 immediately intervened, separated the two residents and notified the nursing supervisor.

An interview with the DNS on 3/24/25 at 1:30 PM identified Resident #84 was pushing an item down the hallway when Resident #42 attempted to stop him/her. Resident #84 slapped Resident #42 in the face. No injuries were noted as a result of the incident.

The DNS further identified he was not aware Resident #42 had also pushed Resident #84 as this detail was not previously reported or documented in any written statements, though it should have been reported at the time of the incident.

Attempts to interview RN #3, the assigned nursing supervisor were unsuccessful.

A review of the facility policy for Abuse directs that the facility does not condone abuse by anyone including staff members and other residents.

Further, abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm of pain or mental anguish that are necessary to attain or maintain physical, mental, and psychosocial well-being.

Willful as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

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

Review of the clinical records for Resident #'s 12, #23, #33, #39, #45, #50, #57, #59, #84, #92 and #254; residents on the secured memory unit, failed to identify clinical criteria for placement, failed to identify initial assessment and/or periodic reassessment for placement, failed to identify involvement by the resident or resident representative, failed to identify a physician order, and failed to document that information for independent egress had been provided for any of the residents residing on the unit.

Interview with The Director of Nursing (DNS) on 3/24/25 at 1:27 PM identified the criteria for placement on the secured memory care unit was a diagnosis of dementia or Alzheimer's and wandering behaviors.

Interview with the DNS and RN #4 on 3/24/25 at 1:30 PM identified there was no written criteria for admission to the secured memory care unit.

There was no initial assessment for placement on the secured memory unit.

There was no re-assessment performed for continued placement to remain on the secured memory care unit.

There was no documentation that the resident or resident representative consented to being admitted to a secure memory care unit.

The facility failed to have a policy for admission to the secured memory care unit.

Additionally, after reviewing the regulation for involuntary seclusion, the DNS and RN #4 identified that the noted residents were involuntary secluded.

Although requested, a facility policy for the secured memory care unit was not provided.

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

Review of the facility's Reportable Events Policy identified that a Class B event, (state classification) including a complaint of resident abuse, should be reported to the State Department of Public Health and an investigation will be conducted by the facility after the discovery of an allegation of abuse.

Review of the facility's Abuse Reporting Policy identified when an allegation of abuse is reported, the facility administrator or his/her designee will notify Department of Public Health; A completed copy of the Reportable Event Form and written statements from witnesses must be provided to the Administrator within 24 hours of the occurrence of said incident.

Review of the Abuse Allegation and Investigation Policy directed, in part, to not allow employees to provide care independently or remove the employee from that unit or from the facility.

• An interview with the Administrator on 3/27/25 at 9:46 AM identified the facility did not include

QAPI as a component of their staff or volunteer training.

Further the DNS identified the facility did not have any QAPI plan for abuse nor was the topic of abuse reviewed during QAPI/Quality Assurance and Assessment (QAA) meetings, stating he was not aware that he should have included abuse during QAPI meetings.

Subsequent to surveyor inquiry, the Administrator noted that a QAPI plan for abuse would be developed and reviewed at future QAPI meetings.

Review of the facility's Quality Assurance Improvement Plan policy identified, in part, that the DNS or Administrator are responsible and accountable for developing, leading and closely monitoring the QAPI program.

Components of the QAPI plan included clinical care, quality of life, and resident choice.

The QAPI plan failed to include how staff communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI program.

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

than two hours after the allegation is made.

including a complaint of resident abuse, should be reported to the State Department of Public Health

facility after the discovery of an allegation of abuse.

Although requested, a policy for reporting to state protective services was not provided.

Connecticut state laws for Mandatory Reporting of Elder Abuse require certain professionals (i.e. mandated reporters) to report suspected abuse, neglect, abandonment, or exploitation of the elderly to the Department of Social Services (DSS) within 72 hours.

They must also report to the department if they suspect an elderly person needs protective services [Connecticut Department of Social Service. (2018).

Mandatory Reporting of Elder abuse Policy No. 2018-R-0068].

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

including a complaint of resident abuse, should be reported to the State Department of Public Health

jeopardy to resident health or facility after the discovery of an allegation of abuse.

The police are to be notified if an assault or safety suspected assault has occurred.

facility administrator or his/her designee will notify the following persons of the incident: Department of Public Health; Ombudsman; Resident Representative; Law Enforcement Officials; and Primary Physician.

Allegations of abuse must be reported no less than 2 hours after the allegation is made. A completed copy of the Reportable Event Form and written statements from witnesses must be provided to the Administrator within 24 hours of the occurrence of said incident.

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

Review of the Care Plan Policy identified, in part, the facility will complete an initial care plan within 21 days of a resident's admission and quarterly thereafter.

The quarterly care plan will be developed no later than 7 days after the comprehensive MDS is completed.

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

without the benefit of utilizing an MAR.

Interview with APRN #1 on 3/26/25 at 12:22 PM identified she was made aware that 22 residents were administered medications by LPN #6, by memory, without the benefit of an MAR, and that she had reviewed all of the medications ordered for the affected residents under her care. APRN #1 stated that for the residents who required blood sugar monitoring, she had ordered blood sugar checks immediately and to continue per the established schedule.

All affected residents were to have vital sign checks every shift for 24 hours to monitor their health status. APRN #1 additionally ordered labs to be checked for the residents who were receiving sodium chloride tablets and that she was to be notified of any abnormalities.

Interview with APRN #2 on 3/26/25 at 12:30 PM identified that she was made aware that 22 resident's medications were administered without the benefit of an MAR, by memory, by LPN #6.

APRN #2 identified she had just observed all of the residents under her care, would review those resident medications, and would determine if further monitoring would be required.

Additionally, APRN #2 identified that she would review the vital signs and blood sugars for her residents and leave orders to be notified for any abnormalities.

Review of the charting and documentation policy dated 6/2023 revised, in part, directed that documentation in the medical record may be electronic, manual or a combination.

The following information is to be documented in the resident medical record: Objective observations, medication administered, treatment or services performed.

Review of the job description for a charge nurse, is that the LPN/RN is responsible for the overall operation and optimal quality of care for the residents on the assigned unit, follows all health, sanitary and infection control policies, and maintains established standards of practice set forth by the facility's administration and nursing policies and procedures.

The direct supervisor is the RN supervisor.

Qualifications included knowledge of nursing theory and practice including the administration of medications.

According to the National Library of Medicine dated 9/4/23 Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration. It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration.

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

10/30/24 220.0 -2 11/6/24 220.8 +0.8 11/13/24 229.6 +8.8 11/18/24 228.6 -1 11/20/24 229.0 +1.6 11/27/24 230.0 +1 11/27/24 223.8

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

F 0684 -6.2

jeopardy to resident health or safety 223.2

220.6 -2.6 12/18/24 228.0 +7.4 1/1/25 226.1 -2.1 1/8/25 225.2 -0.9 1/15/25 219.9 -5.3 1/22/25 226.0 &nbs[TRUNCATED]

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

Review of facility policy titled, Turning and Repositioning Policy, identified in part, the purpose was to promote circulation and relieve pressure from pressure points to maintain skin integrity.

Position changes are to be implemented every 2 to 3 hours and when necessary, and if the resident is dependent on staff for mobility, check for toileting needs during repositioning.

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

Observation and interview with LPN #1 on 3/19/25 11:11 AM identified that Resident #39's assigned NA would have been responsible to apply and maintain application of the belt for the resident while seated in the wheelchair. LPN #1 indicated the NA would know to apply the pelvic positioning belt by referencing her NA assignment information in the resident's Electronic Medical Record (EMR).

Interview and review of the clinical record with the Director of Nursing Services (DNS) on 3/19/25 at 1:17 PM identified Resident #39 had a pelvic positioning belt ordered as the resident tended to slide out of the wheelchair.

The DNS indicated the belt should have been applied by the nursing staff and the NA must have forgotten to apply it.

The DNS identified he would speak with the nursing supervisor about the application of Resident #39's positioning belt.

Observation and Interview with LPN #6 on 3/20/25 at 2:20 PM identified Resident #39 was leaning forward in the wheelchair while self-propelling past the nurse's station using his/her bilateral lower extremities. Resident #39 was observed doing so without the benefit of having his/her pelvic positioning belt applied. LPN #6 indicated Resident #39 needed to have the belt applied but the NA must have forgotten to apply the positioning belt.

Subsequent to surveyor inquiry, LPN #6 applied the pelvic positioning belt for Resident #39.

Interview and review of the clinical record with PT #1 on 3/24/25 at 10:18AM identified Resident #39 had the pelvic positioning belt ordered to help keep proper position when seated in the wheelchair. PT #1 indicated that OT #1 conducted an in-service on 3/12/25 with the nursing staff on the application and usage of the belt.

Review of the clinical record with PT #1 reflected a physician's order was put in place for the pelvic positioning belt on 3/17/25. PT #1 identified that if the pelvic positioning belt was not applied for Resident #39 then his/her positioning in the wheelchair would not be optimal and the resident would be at higher risk for falls. PT #1 further indicated that nursing staff would have been responsible to apply and maintain the application of the pelvic positioning belt for Resident #39 when the resident was seated in the wheelchair.

Review of the facility policy, Physician's Orders, dated 7/23, directed orders must be documented and entered into the clinical record by the licensed nurse with the purpose to provide residents with prompt and accurate treatment.

Review of the facility policy, Nursing Policy and Procedures, dated 7/23, directed physical therapy is provided in accordance with the resident's needs and shall be prescribed by the physician to ensure all resident's rehabilitative services are met.

Although requested, a policy on wheelchair equipment/pelvic positioning belts was not provided.

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

#84 was a 1:1 assist with meals and NA #6 should not have left the resident alone with his/her meal.

need to review NA #6's assignment with her again.

Interview with NA #6 on 3/19/25 at 10:40 AM identified she brought Resident #84 his breakfast tray, put it on the tray table in front of the resident and left the room. NA #6 indicated that although she exited Resident #84's room to serve other breakfast trays on another hallway, she did not let anyone know that she had served Resident #84 his breakfast and left the resident alone in his/her room. NA #6 further stated Resident #84 did not need help with his/her meals and was able to eat by him/herself.

When asked to access the Kardex/care card for Resident #84, NA #6 was unable to locate the resident's care specific information on her tablet and proceeded to ask LPN #1 for assistance.

Interview and review of the clinical record on 3/19/25 at 10:50 AM with LPN #1 and NA #6 identified Resident #84's Kardex/care card indicated the resident was a 1:1 assist with meals and review of the resident's care plan directed the resident required supervision with meals. NA #6 indicated she should have known Resident #84's care specific information before serving the breakfast tray to the resident.

Interview and review of the clinical record with the DNS on 3/19/25 at 1:17 PM identified Resident #84 was a 1:1 assist at mealtime and the resident needed set up, cueing and supervision during meals.

The DNS indicated Resident #84 should not have been served his breakfast tray and then left alone in his/her room.

The DNS identified the NA or LPN should have stayed with Resident #84, or the resident should have been served the meal in a common area.

Additionally, the DNS was unable to indicate why NA #6 could not access Resident #84's care specific information and stated he would need to speak to NA #6 and provide her further training.

Interview and review of the clinical record with OT #1 on 3/24/25 at 10:25 AM identified Resident #84 was a 1:1 assist and needed staff supervision with meals. OT #1 indicated that Resident #84 should have all meals in the dining room but if dining in his/her room then he/she was to be supervised and assisted by staff. OT #1 further identified Resident #84 required help and encouragement to eat and had a potential for choking due to a swallowing difficulty (dysphagia). OT #1 indicated that although she had just recently updated the mealtime guidelines for the nursing staff on this unit, she was unable to indicate why Resident #84 was not supervised and assisted while eating and stated she would need to provide further education to the nursing staff.

Although requested, a policy on dining guidelines/meal supervision was not provided.

Surveyor: Otwoma, [NAME]

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

are meeting their estimated fluid needs and/or identify resident at risk for dehydration.

Additionally,

for signs and symptoms of dehydration.

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

Review of the facility policy, Oxygen Administration, undated, directed that a physician's order is required for continuous administration of oxygen.

The policy further directed that when oxygen therapy is ordered the licensed clinician would verify the physician's order.

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

Review of the intake and output policy dated 6/23 directed to provide an accurate record of the resident's intake and output.

Intake and output will be monitored by the resident's hydration status, risk for dehydration, and/ or physician's order.

Intake and output are documented on each shift beginning with the 11:00 PM to 7:00 AM shift.

Intake and output are totaled daily by the 3:00 PM to 11:00 PM nurse.

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

NA #6 identified NA #6 was unable to access the EMR when requested to determine the current

#84's mealtime guidelines and needed to ask LPN #1 to obtain the information. LPN #1 was able to

NA #6 how to do so herself. LPN #1 identified NA #6 should have been able to retrieve Resident #84's information in the EMR when asked to and indicated the NA needed to receive additional training.

Interview with the Registered Nurse Supervisor (RN #5) on 3/24/25 at 10:42 AM identified that NA #6 should have been able to access Resident #84's care specific information on the care card and [NAME] in the EMR. RN #5 was unable to indicate why NA #6 was unable to operate a device or access Resident #84's EMR information when requested. RN #5 indicated that the facility's nursing staff had been trained on the technology and NA #6 should have had the knowledge and competencies to access the resident's EMR information to provide individualized care to the residents. RN #5 further identified that she would make the DNS aware so additional training could be provided.

Interview with the DNS on 3/24/25 at 10:51AM identified that NA #6 and NA #9 should have been able to access Resident #57 and # 84's care specific information on the care card or [NAME] tab in the EMR.

The DNS indicated that the facility's nursing staff was trained to access the resident specific care information via tablet, laptop or the touch screen wall monitors (located within the units of the facility).

The DNS identified that NA #6 and #9 were provided education and a 4-hour class, which was mandatory, when the facility transitioned to a new EMR system in June 2024.

The DNS indicated he would expect to be notified by the charge nurse or nursing supervisor if a NA was unable to operate a device or access the EMR system and if it had been brought to his attention, he would have provided direct education to ensure NA #6 and NA #9 possessed the necessary skill sets to provide safe care.

The DNS further identified he needed to schedule another EMR training for the NA staff at the facility.

Although requested a policy on EMR training for nursing staff was not provided.

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

opens the medication cart differs from the key that opens the narcotic compartment.

The narcotic

of the key ring to the controlled substance area.

A review of the Medication Storage in the Facility policy dated November 2021 directed, in part, controlled substance inventory is regularly reconciled to the Medication Administration Record.

Controlled substances remaining in the facility after the order has been discontined or the resident has been discharged are retained in the facility in a securely locked area with restricted access until destroyed.

Accountability records for discontinued controlled substances are maintained with the unused supply until they are disposed of or destroyed.

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

units SC at lunch time and Hydralazine 15mg 3 times a day.

were administered at 2:41 PM, 2 hours and 41 minutes after scheduled administration time.

• Resident #72's diagnoses included dementia, hypertension and failure to thrive.

The quarterly MDS assessment dated [DATE] identified Resident #72 as having severe cognitive impairment.

Physician's orders dated 2/15/25 directed to administer Hydralazine 100 mg 3 times a day.

A review of facility documentation on 3/27/25 identified that Hydralazine was administered at 2:42 PM, 2 hours and 42 minutes after scheduled administration time.

• Resident #78's diagnoses included dementia, hypertension, and depressive episodes.

The quarterly MDS assessment dated [DATE] identified Resident #26 as having severe cognitive impairment.

Physician's orders dated 1/5/25 directed to administer Trazadone 25 mg once a day at 12:00 PM.

A review of facility documentation identified that Trazadone was administered at 1:59 PM, 59 minutes after the allowed scheduled administration timeframe.

Interview with APRN #1 on 3/26/25 indicated that she was aware of late medication pass and any medication errors that may have occurred. APRN #1 indicated that the late medications were not significant medication errors.

A review of the Administration of Medications Policies and Procedures policy dated 7/23 directed, in part, medication errors and adverse drug reaction shall be immediately reported to the attending physician, charted in the clinical records and described in the Medication Error Report.

Medications are to be given at the time ordered or within 60 minutes before or after the time designated.

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

Review of the Dining Tray ticket policy directed, in part, the purpose of dining tray tickets is to ensure

needs. A tray card is prepared with the resident's name, room number, diet order, food allergies, food preferences, portion sizes, and adaptive equipment.

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

Observation and Interview with NA #4 on 3/21/25 at 9:30 AM identified that she brought a

that she asked residents if they needed any items or their food reheated when delivering meal trays, and if a resident requested food to be reheated, she would use the microwave in the nourishment room to heat the food for about 30 seconds.

She would then place the back of her hand over and above the food to gauge how warm the food was before adding additional reheating time.

Observation of the nourishment room failed to identify a thermometer located in the room.

Interview with the FSD on 3/21/25 at 11:47 AM identified that nursing staff were permitted to reheat food.

The FSD further indicated that food was to be heated until the temperature was 165 degrees Fahrenheit and verified by the thermometer in the nourishment room. FSD was notified that there was no thermometer in the nourishment room.

Review of the Reheating Food Policy identified that all reheated food must reach 165 degrees Fahrenheit for at least 15 seconds and would be verified by use of a thermometer to check the internal temperature.

Reheated food should be served immediately or held at 135 degrees Fahrenheit or above until served. If using a microwave, food should be heated to 165 degrees Fahrenheit, covered, stirred, and allowed to stand for even heating.

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

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.

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

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 for treatments or services provided and for events, incidents, or accidents involving the resident.

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

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.

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

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.

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

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.

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

Improvement Program.

minimal harm 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

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.

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.

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

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.

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

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.

075158

Form Approved OMB

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