New London Sub-acute And Nursing

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

disorder and mood disorder. Interventions directed to administer psychotropic medications as ordered by

the physician and monitor for side effects and effectiveness every shift. The admission Minimum Data Set assessment dated [DATE REDACTED] identified Resident #2 had a Brief Mental Interview for Mental Status (BIMS) of three (3) out of fifteen (15) indicating poor memory recall. The psychiatric APRN note dated 8/5/25 identified she was asked to evaluate Resident #2 for mood and anxiety, Resident #2 could become angry with an explosive temper without provocation, was hostile with staff members of color and combative with care, was confused and could not recall anything for longer than a few minutes so when Resident #2 becomes agitated it was best to walk away and reapproach after a few minutes. The note identified they would trial lorazepam three (3) times daily to see if it improves the behaviors. A physician's order dated 8/5/25 directed to administer lorazepam oral concentrate 2 mg per mL, give 0.5 mL by mouth three (3) times daily for anxiety/agitation/irritability. Review of the August 2025 MAR identified the lorazepam oral concentrate was not administered to Resident #2 on 8/5/25 at 12:00 PM or 4:00 PM, 8/6/25 at 8:00 AM, 8/7/25 at 4:00 PM or 8/8/25 at 8:00 AM and 12:00 PM. Review of the nurse's notes and eMAR notes dated 8/5/25 through 8/8/25 identified the lorazepam was either unavailable, Resident #2 refused the medication or the resident was sleeping. The notes failed to reflect documentation the nursing supervisor and provider were notified that the lorazepam was omitted. Interview with LPN #1 on 8/19/25 identified although she did not administer the lorazepam to Resident #2 on 8/5/25, 8/6/25 and 8/8/25 she was unaware she had to notify the nursing supervisor for all missed medication administrations and refusals so the nursing supervisor can notify the provider for possible alternative orders. Interview with the DON on 8/19/25 at 3:42 PM identified that she was not aware Resident #2 and Resident #6 did not receive the scheduled narcotics as ordered in July and August 2025. The DON indicated that the pharmacy and provider should have been contacted for all unavailable medications, medication refusals and missed administrations and this should be documented in the clinical record. The DON identified the facility's emergency stock for lorazepam intensol oral concentrate, morphine sulfate oral solution and hydrocodone/acetaminophen tablets had been depleted prior to 6/17/25 and the supply was not refilled. Review of the Administration of Medications policy dated 7/2023 directed, in part, that medications are to be given at the time ordered or within 60 minutes

before or after the time designated. Medication errors and adverse drug reactions shall be immediately reported to the attending physician, charted in the clinical records, and described in Medication Error Report, and incident report if necessary, which is submitted to the State Health Department. Review of the Medication Omission/Withholding policy dated 7/2023 directed, in part, that all medications are to be administered as prescribed by the attending physician unless in the nurses professional judgement the medication(s) should be omitted/withheld. If the nurse makes the decision to omit/withhold medication(s)

the nurse will notify the supervisor who will notify the MD and document in the clinical record. Nurses notes are to include the date, specific time, and pertinent details.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

incident. Interview with the Rehab Manager, Occupational Therapist (OT) #1, on 8/20/25 at 12:44 PM identified Resident #3 does not utilize a walker for ambulation and prior to the 7/26/25 incident, Resident #3 was to be an assist of one (1) for transfers and ambulation for safety due to fluctuating cognition. OT #1 identified that they evaluated Resident # on 8/19/25 per request of the Director of Nursing (DON) and

during the evaluation Resident #1 walked into a wall, so they determined that for safety Resident #3 would remain an assist of one (1) for ambulation and was placed on Physical Therapy (PT) services. Interview with the DON on 8/20/25 at 12:50 PM identified that on 7/26/25 Resident #3 was wandering and agitated prior to the incident and LPN #1 should have waited for assistance prior to leaving Resident #3 and going to a different hallway to her medication cart. The DON identified no one saw Resident #3 get up out of the chair and enter Resident #2's room because he/she was left unattended. Review of the Preventing Resident Abuse policy dated 6/2023 directed, in part, that the facility will assess, care plan and monitor residents with needs and behaviors that may lead to conflict and will assess residents with signs and symptoms of behavior problems and develop and implement care plans that can assist in resolving behavioral issues. Review of the Care Plan policy dated 6/2023 directed, in part, that the interdisciplinary care plan is used to achieve and maintain optimal status for each resident. The care plan will include physical, cognitive and psycho-social problems and will address the resident' needs on an individual basis, as well as identify which discipline is responsible for providing the care and services required.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

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 0730

Observe each nurse aide's job performance and give regular training.

Level of Harm - Minimal harm or potential for actual harm

Based on review of facility documentation, facility policy and interviews for two (2) of five (5) nurse aides reviewed for performance evaluations, the facility failed to ensure annual performance evaluations were completed. The findings include:1. NA #2 had a hire date of 7/13/23 and was due to have his/her annual performance review in 2024 and 2025, however documentation of the performance reviews was not available for review and could not be located. 2. NA #1 had a hire date of 4/30/24, had a probationary employee evaluation on 6/30/24 and was due to have his/her annual performance review on 6/30/25, however documentation of his/her performance review was not available for review in his/her personnel file and could not be located. Interview with the Administrator on 8/21/25 at 1:26 PM identified annual performance evaluations are to be done yearly but that he was unable to locate the performance evaluations for NA #1 and #2. Interview with Human Resources on 8/21/25 at 1:31 PM identified NA #1's annual performance evaluation for 2025 was due on 6/30/25 but that it had been overlooked and not completed. Human Resources identified she was unable to locate NA #2's 2024 annual performance evaluation, stating she believed it may not have been completed by the previous Director of Nursing and for 2025 she had the incorrect month documented for NA #2's hire date, so the evaluation was not completed.

Human Resources identified performance evaluations are required for each nurse aide yearly on their month of hire. Review of the Certified Nurse Aide Evaluation policy directs CNAs to undergo an annual evaluation process to assess their performance, skills, and adherence to facility standards.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

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 0755 Level of Harm - Actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

inquire about the next delivery and the facility was told the script could not be refilled until 6/11/25 so the Assistant Director of Nursing (ADON) approved a fifteen (15) day supply to be billed to the facility, which was processed and delivered on 6/3/25, however, Resident #1 missed six (6) doses of lorazepam from 6/2/25 through 6/3/25. Interview with the Director of Nursing (DON) on 8/18/25 at 1:15 PM identified the facility should not have run out of the morphine or lorazepam. The DON identified that for all doses of medication not administered, the charge nurse was to call the pharmacy to inquire on when the medication would be delivered, then notify the nursing supervisor of the missed administration so the nursing supervisor can contact the provider, and the charge nurses should be following-up with the nursing supervisor and ask if any new orders were obtained.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

that medications are to be given at the time ordered or within 60 minutes before or after the time designated. Medication errors and adverse drug reactions shall be immediately reported to the attending physician, charted in the clinical records, and described in Medication Error Report, and incident report if necessary, which is submitted to the State Health Department. Review of the Medication Omission/Withholding policy dated 7/2023 directed, in part, that all medications are to be administered as prescribed by the attending physician unless in the nurses professional judgement the medication(s) should be omitted/withheld. If the nurse makes the decision to omit/withhold medication(s) the nurse will notify the supervisor who will notify the MD and document in the clinical record. Nurses notes are to include the date, specific time, and pertinent details. Review of the Medication Refusal Policy dated 7/2023 directed, in part, that for medication refusals, the nurse will explain to the resident the possible consequences of medication refusal, and for non-competent confused residents, the nurse will go back and offer the medication again within an hour. The nursing supervisor will notify the MD once 3 consecutive doses of any medication is refused, will document the conversation with the MD in the clinical record and the nurse will properly document the medication refusal on the resident's electronic medical record. Review of the Medication Re-Order Procedure dated 7/2023 directed, in part, that the 3-11 shift nurse is responsible for re-ordering routine medications on a regular basis to ensure that a resident is never without an appropriate available supply of prescribed medications. Medications should be reordered when an eleven (11) day supply remains.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

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

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Minimal harm or potential for actual harm

Based on clinical record reviews, facility documentation, facility policies, and interviews, the facility failed to ensure the facility administered its resources effectively and to ensure effective administrative oversight of staff and resident care to maintain the highest practicable physical, mental and psychosocial well-being of residents. The findings include:The facility administration failed to: Ensure continued compliance with the plan of correction from a prior survey to ensure medications were administered per physician's orders.

Ensure the residents were administered scheduled anxiety and narcotic pain medications. Ensure medications were refilled prior to exhausting the supply and ensure medications were delivered to the facility. Ensure the Advanced Practice Registered Nurse (APRN) was notified of medication omissions.

Ensure annual performance evaluations were completed when due. Ensure the clinical record was complete and accurate. Please cross reference F-F580, F-F730, F-F755, F-F760, F-F842 and F-F865. Based on the deficiencies during the survey, immediate jeopardy and substandard care was identified in the area of Pharmacy Services- Residents Are Free of Significant Medication Errors. The State Agency conducted a survey with an exit date of 6/30/25 with findings of significant medication errors. The Plan of Correction identified the facility would conduct staff education, audits and QAPI to ensure all nursing staff are administering medications according to provider orders and notifying the Registered Nurse (RN) supervisor and provider when medications were administered late, with a correction date of 7/31/25. Interview with the Administrator, Director of Nursing and RN #6 (the Corporate Regional Nurse) on 8/21/25 at 1:28 PM identified although the facility was cited for medication related errors on both their annual survey dated 3/27/25 and most recently, significant medications errors on 6/30/25 for failing to ensure medications were administered at the time the medications were due and failing to notify the nursing supervisor or the provider of the late medication administrations, they were not put back into compliance with their 6/30/25 survey findings as of 8/20/25, as it was identified medications continued to be administered late to residents. Interview failed to identify the facility was able to sustain compliance with the previously cited findings and failed to identify a process for administrative oversight of the facility processes for ensuring timely medication refills, ensuring medications are administered timely and ensuring that providers are notified of missed medication administrations. 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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

off the administer button in error. 2. Resident #2's diagnoses included dementia with behavioral and mood disturbances and anxiety disorder. The Resident Care Plan dated 7/30/25 identified that Resident #2 utilized psychotropic medications related to diagnoses of adjustment disorder, depression, anxiety, Alzheimer's dementia, delusional disorder and mood disorder. Interventions directed to administer psychotropic medications as ordered by the physician and monitor for side effects and effectiveness every shift. A physician's order dated 8/5/25 directed to administer lorazepam oral concentrate 2 mg per mL, give 0.5 mL by mouth three (3) times daily for anxiety/agitation/irritability. Review of the 2025 August MAR identified that the 8/5/25 at 12:00 PM administration of the lorazepam was blank and not signed off.

Although requested a Controlled Drug Record disposition sheet for the lorazepam was not available.

Interview with LPN #1 on 8/19/25 at 10:49 AM identified that she forgot to sign off the lorazepam as not administered on 8/5/25 at 12:00 PM, reporting that she should have checked the clinical record before leaving for her shift to ensure everything was signed off and she should have written a nurse's note to identify the medication was unavailable. Interview with the Director of Nursing (DON) on 8/19/25 at 3:42 PM identified all documentation in a resident's clinical record should be complete and accurate, reporting narcotic medication Controlled Drug Record disposition sheets should always match the resident's MAR for

the same medication. The DON identified that she was unaware of the discrepancies between the Controlled Drug Record disposition sheets and the MARs for Residents #1 and #2 and staff should always be ensuring their work is complete and accurate before leaving the facility. Review of the Charting and Documentation policy dated 6/2023 directed, in part, that documentation in the medical record will be complete and accurate.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

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 0865

Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or potential for actual harm

Based on review of facility documentation, facility policies, and interviews for facility QAPI review, the facility failed to maintain compliance with deficiencies previously cited. The findings include:A complaint survey was completed on 6/30/25 with findings related to significant medication errors and failures in notifying the provider. The facility Plan of Correction (PoC) identified audits would be conducted for three (3) months or until substantial compliance with QAPI oversight. Resident record review identified three (3) residents (Residents #1, 2 and 6) who were not administered scheduled medications, and the provider was not notified of the missed administrations. Resident record review identified three (3) residents (Residents #4, #6 and #15) who were administered scheduled medications late and the provider was not notified of the late administrations. Review of the 7/16/25 QAPI meeting identified the meeting included a review of the 6/30/25 survey results, including medication pass timeliness and noted that audits were ongoing and showed ongoing compliance improvement. A facility re-visit on 8/20/25 for the 6/30/25 findings identified the facility failed to ensure medications were administered and was unable to be put back into compliance. The Director of Nursing identified on 8/20/25 at 3:25 PM while the facility had been completing chart audits for late medication administrations since 6/27/25, she was unaware that late medication administrations were still ongoing this information was not captured on their audits. Review of facility documentation identified the following late medication administrations during the PoC: 7/13/25, 7/17/25, 7/26/25, Resident #6Review of facility documentation identified the following late medication administrations after the PoC: 8/2/25, Resident #4 8/2/25, 8/18/25, Resident #6 8/4/25, 8/11/25, 8/13/25, Resident #15Review of facility documentation identified the following omitted medication administrations during the PoC: 6/30/25 through 7/9/25, 7/26/25, 7/27/25, 7/28/25, Resident #1 7/21/25 through 7/24/25, Resident #6Review of facility documentation identified the following omitted medication administrations after the PoC: 8/5/25 through 8/8/25, Resident #2 Interview and facility documentation review with the Administrator on 8/21/25 at 1:28 PM identified although they were conducting audits for medication administrations, they were random resident audits, and they did not identify that both late and omitted medication administrations were ongoing, and he was unable to explain why. The Administrator was unable to identify why their previous 6/30/25 PoC was ineffective and reported that they will be developing new processes and upcoming audits will be increased to daily to be done by multiple staff. Please cross reference F-F580 and F-F760. Review of the Quality Assurance Improvement Plan (QAPI) policy dated 4/2025 directed, in part, that the Administrator and DNS are responsible and accountable for developing, leading and closely monitoring the QAPI program and assures the facility has adequate resources for QAPI efforts.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet