New London Sub-Acute and Nursing

Inspectors wroteBased on review of the clinical record, facility documentation, facility policies, and staff interviews, for one (1) of three (3) sampled residents reviewed for abuse (Resident #8), the facility failed to protect a resident from abuse when staff failed to implement interventions for a roommate (Resident #7) with known, escalating aggressive and delusional behaviors, resulting in Immediate Jeopardy to resident health and safety. Specifically, despite documented behavioral episodes beginning on 4/3/26 - including agitation, yelling, paranoia, combativeness, and medication refusals - the facility failed to develop a behavior care plan or a care plan addressing medication refusals for Resident #7. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for two (2) of five (5) sampled residents (Resident #1 and #2) reviewed for accident hazards, the facility failed to ensure residents received altered texture diets consistent with physician's orders and International Dysphagia Diet Standardization Initiative (IDDSI) guidelines and were provided supervision during meals as required for residents with dysphagia, creating a choking hazard. Specifically, on 3/19/26 at approximately 1:00 PM, Resident #1, who had diagnoses of dementia and dysphagia who required supervision during meals and was ordered an IDDSI Level 6 diet, was served and consumed a peanut butter and jelly sandwich that was not ordered and not consistent with the prescribed diet. [...]

Inspectors wroteBased on review of the clinical record, facility policy and interviews for two (2) of three (3) sampled residents (Residents #1 and #7) reviewed for accidents and incidents, the facility failed to ensure timely physician notification following significant changes in resident condition and behavioral incidents requiring medical and psychiatric evaluation. For Resident #1, the facility failed to notify the on-call provider or Medical Director following a choking incident requiring the Heimlich maneuver. For Resident #7, the facility failed to notify the provider regarding omitted medications, refusal of as needed medication, escalating behaviors and a behavioral incident involving Resident #7 entering and remaining in another resident's bed despite multiple unsuccessful staff redirection attempts.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #8) reviewed for abuse, the facility failed to ensure the state agency was notified within two (2) hours of an abuse allegation.

Inspectors wroteBased on review of the clinical record, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for modified texture diets, the facility failed to revise the Resident Care Plan (RCP) to identify physician-ordered one-to-one feeding assistance following a choking incident resulting in Resident #1 not being provided one-to-one feeding assistance for meals per physician's order and for one (1) of three (3) residents (Resident #7) reviewed for behaviors, the facility failed to develop an RCP for ongoing behaviors, agitation, and repeated care refusals.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #8) reviewed for abuse, the facility failed to ensure a pain assessment was completed following injuries sustained from a resident to resident incident and failed to ensure Resident #8 was offered or administered as needed pain relief medication when the injuries were identified prior to hospital transfer.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #7) reviewed for behaviors, the facility failed to ensure behavioral symptoms were identified and managed to prevent escalation. Specifically, this failure included the failure to document ineffective interventions, reapproach and administer medication for anxiety, restlessness or agitation, and implement effective interventions for ongoing yelling, paranoia, agitation and wandering behaviors prior to an altercation with another resident.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for two (2) of eleven (11) sampled residents (Residents #11 and #12) reviewed for laboratory testing, the facility failed to ensure abnormal laboratory results were documented as reviewed with the provider and that a follow up assessment of the resident was completed by the nursing supervisor per policy.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for two (2) of five (5) residents (Residents #1 and #2) reviewed for modified texture diets, the facility failed to ensure residents received prescribed diets per physician's orders and the diet manual per International Dysphagia Diet Standardization Initiative (IDDSI) guidelines and failed to ensure staff were competent in the IDDSI modified texture diets.

Inspectors wroteBased on review of the clinical record, facility policy and interviews for six (6) of six (6) sampled residents (Residents #8, 13, 14, 15, 16 and 17) reviewed for comprehensive assessments, the facility failed to ensure the resident comprehensive assessments were completed within fourteen (14) days of the Assessment Reference Date (ARD) as required.

Inspectors wroteBased on review of the clinical record, facility documentation/policies, and interviews, for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure the environment was free from accident hazards when a bathroom grab bar used for transfers dislodged from the wall, resulting in a fall and subsequent rib fractures.

Inspectors wroteBased on clinical record review, facility documentation, facility policy, and interviews, for two (2) of five (5) sampled residents (Resident #1 and Resident #2) reviewed for a safe and sanitary environment, the facility failed to ensure Resident #1 received care in a safe environment when a bathroom grab bar detached from the wall during use, resulting in a fall and rib fractures, and failed to ensure Resident #2 was provided a sanitary sleeping environment when the resident's mattress had a urine odor.

Inspectors wroteBased on clinical record review, facility documentation/policy and interviews, for one (1) of five (5) sampled residents (Resident #2) reviewed for grievances, the facility failed to ensure complaints/concerns reported by a resident representative were documented in the grievance log, investigated, and resolved in writing in accordance with the facility's grievance policy.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policies and interviews for one (1) of five (5) sampled residents (Resident #2) reviewed for respiratory care, the facility failed to ensure Resident #2 who had a physician's order for oxygen was receiving oxygen as ordered.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for three (3) of seven (7) sampled residents (Residents #1, #2 and #6) who were reviewed for medication administration, the facility failed to ensure the residents received scheduled anti-anxiety medication, narcotic pain medication, or both for agitation and comfort as prescribed by the physician. The failures resulted in the finding of Immediate Jeopardy.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of seven (7) sampled residents (Residents #1) reviewed for medication administration, the facility failed to follow up with the pharmacy services to ensure new medication orders were filled and standing orders were refilled prior to exhausting the supply.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for three (3) of seven (7) sampled residents (Residents #1, #2 and #6) who were reviewed for medication administration, the facility failed to notify the provider of medication omissions when the medications were not available.

Inspectors wroteBased 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.

Inspectors wroteBased on review of facility documentation, facility policies, and interviews for facility QAPI review, the facility failed to maintain compliance with deficiencies previously cited.

Inspectors wroteBased on clinical record reviews, observations, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #3) who were reviewed for an allegation of physical abuse, the facility failed to ensure the resident was supervised when ambulating within the facility per the plan of care to prevent a resident-to-resident altercation.

Inspectors wroteBased 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.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for two (2) of three (3) sampled residents (Residents #1 and #2) reviewed for medication administration, the facility failed to ensure complete and accurate documentation of medications in the Medication Administration Record (MAR).

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for eleven (11) of thirteen (13) residents (Resident #1, 2, 4, 5, 6, 7, 8, 9, 12, 13 and 14) reviewed for medication administration, the facility failed to ensure that diabetic, cardiac, anti-seizure, pain and behavioral medications were administered timely per physician's orders. These failures resulted in a finding of Immediate Jeopardy.

Inspectors wroteBased on review of clinical records, facility documentation and interviews for eleven (11) of eleven (11) residents (Resident #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, and #24) reviewed for physician's orders, the facility failed to ensure residents' orders were reviewed and signed by the physician monthly.

Inspectors wroteBased on review of the clinical record, facility policy and interviews for one (1) of eleven (11) residents (Resident #1) reviewed for medication administration, the facility failed to ensure the provider was notified of a change in condition when it was identified that the resident was having difficulty swallowing.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for two (2) of four (4) residents (Resident #4 and #7) reviewed for neglect, the facility failed to ensure allegations of neglect were reported to the State Agency timely.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for two (2) of four (4) residents (Resident #4 and #7) reviewed for neglect, the facility failed to ensure an investigation was completed timely and thoroughly following an allegation of neglect.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for one (1) of four (4) sampled residents (Resident #3) who had an order for a leave of absence with a responsible party only and had left the facility without informing the staff, the facility failed to ensure the front entrance door was secured or monitored to prevent the resident from leaving the facility unattended.

Inspectors wroteBased on observations, review of the clinical records, facility documentation, facility policy, and interviews for 22 of 40 residents (Resident #3, Resident #9, Resident #12, Resident #18, Resident #27, Resident #31, Resident #33, Resident #42, Resident #45, Resident #49, Resident #56, Resident #59, Resident #61, Resident #63, Resident #67, Resident #68, Resident #69, Resident #72, Resident # 74, Resident #78, Resident #81, Resident #92) reviewed during a tour of the secured memory unit, the facility failed to ensure the 5 Rights of medication administration, and professional standards of practice, were adhered to during the administration of medications. These failures resulted in the finding of Immediate Jeopardy.

Inspectors wroteBased on observations, review of the clinical records, facility documentation, facility policy and interviews for 22 of 40 residents (Resident #3, Resident #9, Resident #12, Resident #18, Resident #27, Resident #31, Resident #33, Resident #42, Resident #45, Resident #49, Resident #56, Resident #59, Resident #61, Resident #63, Resident #67, Resident #68, Resident #69, Resident #72, Resident # 74, Resident #78, Resident #81, Resident #92) reviewed during a tour of the secured memory unit, the facility failed to ensure safe medication administration practices during the morning medication pass. These failures resulted in the finding of Immediate Jeopardy. [...]

Inspectors wroteBased on observations, interviews, review of the clinical record, facility documentation, and facility policy for 1 of 6 residents, (Resident #43) reviewed for abuse, the facility failed to thoroughly investigate an allegation of abuse, failed to remove the staff member from the schedule following the allegation, and once the allegation was substantiated by the State Agency again failed to remove the staff member from the schedule to ensure the residents were protected from abuse. These failures resulted in the finding of Immediate Jeopardy.

Inspectors wroteBased on observation, interviews, clinical record reviews, facility documentation, and facility policy for 3 of 6 sampled residents, (Resident #43, Resident #42, and Resident #84) reviewed for abuse, for Resident #43, the facility failed to protect the residents' right to be free from physical abuse by staff, and for Resident #42 and Resident #84, the facility failed to protect the resident's right to be free from physical abuse by a resident.

Inspectors wroteBased on clinical record review, interviews, and review of facility policy for 1 of 2 sampled residents (Resident #43) reviewed for care planning, the facility failed to allow a resident to participate in Resident Care Conferences (RCC).

Inspectors wroteBased on observations, interviews, and review of facility policy for 6 of 6 sampled residents (Resident #2, Resident #7, Resident #43, Resident #70, Resident #79, and Resident #82) reviewed for dignity, the facility failed to provide clean bed and bath linens that were in good condition and in sufficient quantity for performing resident care tasks, and for the environment, the facility failed to ensure a safe and secured area on a locked, memory care unit.

Inspectors wroteBased on observations, review of the clinical records, facility policy, and interviews for 11 of 40 sampled residents (Resident #12, Resident #23, Resident #33, Resident #39, Resident #45, Resident #50, Resident #57, Resident #59, Resident #84, Resident #92 and Resident #254) reviewed for a placement on a secured memory care unit, the facility failed to identify the clinical criteria for the unit, failed to document the resident or representative was included in the decision for placement on the unit, failed to ensure a physician order for placement on the unit, failed to assess for initial placement on the unit, failed to reassess for continued appropriate placement on the unit, and failed to document that information for independent egress had been provided.

Inspectors wroteBased on observation, clinical record reviews, facility documentation, facility policy and interviews for 4 of 6 sampled residents (Resident #42, Resident #43, Resident #45, and Resident #84) reviewed for abuse for Resident #84 and #42, and Resident #84 and #45, the facility failed to ensure resident to resident physical mistreatment was reported to state protective services, for Resident #84 and Resident #43, the facility failed to report resident to resident physical mistreatment to state protective services and failed to report the allegation timely to the state agency, and for Resident #43 for a staff to resident allegation of physical mistreatment, failed to report the allegation to state protective services and failed to report the allegation to the state agency.

Inspectors wroteBased on observations, review of clinical records, facility documentation, facility policy, and interviews for 2 of 3 sampled residents (Resident #20 and Resident #47) reviewed for medication administration, the facility failed to ensure that the medication error rate was less than 5% and for 1 of 5 sampled units, Pavillion Unit, for Residents #1, #24, #37, #79, #65, #60, #45, #72, #31, #78, and # 27, the facility failed to ensure medications were administered at the correct time per the physician's orders.

Inspectors wroteBased on tour of the Dietary Department, staff interview and facility policy, the facility failed to ensure kitchen equipment was maintained in sanitary manner, failed to ensure open food items were dated to include dates opened/expired/use by, and failed to recheck temperatures of a resident's reheated food.

Inspectors wroteBased 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.

Inspectors wroteBased on interviews, facility documentation review, and facility policy, the facility failed to develop a compliance and ethics program and failed to provide staff with compliance and ethics training.

Inspectors wroteBased on observations, interviews, review of the clinical record, facility documentation, and facility policy for 3 of 6 residents, (Resident #42, Resident #43, and Resident #84) reviewed for abuse, for Resident #42 and #84, the facility failed to ensure that a resident-to-resident altercation, and for Resident #43 that a staff-to-resident altercation, involving physical mistreatment was properly reported according to policies, failed to implement policies to ensure a resident was protected from abuse, and failed to establish abuse procedures for coordination with the Quality Assurance and Performance Improvement (QAPI) program.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 sampled residents (Resident #59) reviewed for unnecessary medications, the facility failed to review and revise the Resident Care Plan (RCP).

Inspectors wroteBased on observations, interviews, review of the clinical record, facility documentation, and facility policy for 1 of 3 residents (Resident #4) reviewed for pressure ulcers, the facility failed to turn and reposition a resident with a pressure ulcer according to the physician's order.

Inspectors wroteBased on observations, review of the clinical record, facility policy, and interviews for 1 of 2 sampled residents (Resident #39) reviewed for positioning and mobility, the facility failed to ensure a pelvic positioning belt was applied per the physician's order.

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 3 sampled residents (Resident #57) reviewed for accidents and hazards, the facility failed to provide an assistive device and supervision with ambulation per the physician's order for a resident who was a high fall risk and for 1 of 3 sampled residents (Resident #84) reviewed for dementia care, the facility failed to provide supervision with ambulation at mealtime per the physician's order for a resident with dementia and dysphagia.

Inspectors wroteBased on interviews, record review, and facility policy for 1 of 3 sampled residents (Resident #96) reviewed for pressure ulcers, the facility failed to provide adequate hydration to a resident with a potential for a fluid deficit.

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #50) reviewed for respiratory care, the facility failed to ensure a physician's order was in place when administering continuous oxygen.

Inspectors wroteBased on observations, review of the clinical record, facility policy, and interviews for the only sampled resident, (Resident #66), reviewed for hemolytic treatment, the facility failed to ensure appropriate communication occurred between the hemolytic treatment center and the facility.

Inspectors wroteBased on observations and interviews for 2 of 6 sampled residents reviewed for accidents (Resident #57 and Resident #84), the facility failed to ensure staff competency related to electronic medical record (EMR) use.

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy and interviews for the only sampled resident (Resident #66) reviewed for hemolytic treatments, the facility failed to provide appropriate packaging for medication being sent with a resident for hemolytic treatments and failed to assess a resident for self-administration of medication. Additionally, the facility failed to ensure narcotic keys for the medication cart were safely kept with the charge nurse, failed to ensure bimonthly narcotic audits were conducted, and failed to ensure narcotics for destruction in the Director of Nursing (DNS) office were stored appropriately.

Inspectors wroteBased on observations, review of the clinical record, facility documentation, facility policy, and interviews for 1 of 11 sampled residents (Resident #48) observed in the east dining area during meals, the facility failed to provide adaptive equipment as identified on the meal ticket.

Inspectors wroteBased on observation, clinical record review, facility documentation, facility policy, and interviews, the facility failed to administer its resources effectively and to ensure timely and effective administrative oversight of staff and resident care to maintain the highest practicable physical, mental and psychosocial well-being of residents.

Inspectors wroteBased on observations, clinical record review, review of facility policy, and interviews for 1 of 3 sampled 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.

Inspectors wroteBased on interviews, record reviews, and the facility assessment, the facility failed to provide facility staff with behavioral health education as identified on the annual assessment.

Inspectors wroteBased on review of the facility's Personal Funds Account, review of facility documentation, facility policy and interviews, the facility failed to ensure necessary coverage through a surety bond for the Resident Trust Accounts.

Inspectors wroteBased 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.

Inspectors wroteBased on staff interviews, facility policy, and documentation reviewed for the facility Quality Assurance Improvement Plan (QAPI), the facility failed to include the Infection Preventionist in the Quality Assessment and Assurance (QAA) meetings.

Inspectors wroteBased 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.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for accidents, the facility failed to ensure the resident was safely transferred in the mechanical lift resulting in minor injuries on two (2) separate occasions.

Inspectors wroteBased on clinical record reviews, observations, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), reviewed for wounds, the facility failed to ensure the resident care plan identified an actual skin impairment that required treatment.

Inspectors wroteBased on clinical record reviews, observations, facility documentation, facility policy and interviews for one (1) of three (3) residents, (Resident #1), who were reviewed for wounds, the facility failed to ensure a wound assessment or evaluation was completed for a resident who developed a skin impairment.

Inspectors wroteBased on clinical record review and interviews for one of one resident (Resident # 65) reviewed for dementia care, The facility failed to ensure that the resident and or the resident representative was informed in advance of the risk and benefits of a psychotropic medication and failed to obtain a consent before initiation of a psychotropic medication.

Inspectors wroteBased on clinical record review, review of facility documentation and interview for 1 of 2 sampled residents (Resident #36), the facility failed to provide evidence that recommendations were followed in accordance with professional standards.

Inspectors wroteBased on observation of the kitchen, review of facility documentation, facility policy review, and interviews, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and the facility failed to ensure the dishwasher water temperatures were consistently documented and failed to ensure food was handled in accordance with infection control standards.

Inspectors wroteBased on Facility Assessment review, facility documentation review and interviews, the facility failed to ensure that the Facility Assessment was updated yearly.

Inspectors wroteBased on facility documentation review, facility policy review and interviews, the facility failed to ensure the Medical Director consistently attended the quarterly QA meetings to maintain an effective and comprehensive Quality Assurance and Performance Improvement (QAPI) program.

Inspectors wroteBased on observations, review of facility policy and interviews, the facility failed to document the completion of the legionella mitigation steps as per the facility plan and for 1 sampled resident ( Resident # 12) who utilized a urinary device, the facility failed to store the device in a bag to prevent the spread of infection and for 1 resident ( Resident # 35) who utilized oxygen, the facility failed to store the oxygen and label tubing in the manner that was sanitary and prevent the spread of infection and or 1 of 2 residents ( Resident # 54) reviewed for reviewed for Respiratory Care, the facility failed to ensure that appropriate infection control practices were followed for storage of respiratory equipment .

Inspectors wroteBased on clinical record reviews, review of facility policy and interviews, the facility failed to obtain written signatures for consent or refusal of required vaccinations for 5 of 5 residents) reviewed for vaccinations (Resident #21, #25, #47, #63) and for (Resident #76 the facility failed to provide documentation of screening for eligibility and education provided for pneumococcal vaccination within accordance to facility practice and policy.

Inspectors wroteBased on facility documentation, facility policy and interviews, the facility failed to ensure essential kitchen equipment was maintained in safe working condition.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one resident (Resident # 54) reviewed for skin conditions, non-pressure, the facility failed to ensure that the care plan comprehensive and individualized with goals and interventions to reflected the resident's psoriasis skin condition.

Inspectors wroteBased on clinical record review, review of policy and staff interviews for 1 sample resident (Resident # 337) reviewed for infection, the facility failed to monitor the resident's Vancomycin trough level according to the professional standard when resident was receiving intravenous (IV) Vancomycin medication.

Inspectors wroteBased on clinical record review, review of facility policy and interviews, for 1 of 2 residents reviewed for pressure ulcers (Resident #76), the facility failed to consult the dietician regarding a new pressure area within 7 days per facility policy.

Inspectors wroteBased clinical record review, facility policy and interviews for 1 resident (Resident # 14) reviewed for hospitalizations, the facility failed to obtain a physician order for an increase in oxygen therapy for a resident experiencing a change in condition according to standards of practice and facility policy.

Inspectors wroteBased on clinical record reviews, facility policy and interviews for one resident (Resident # 14) reviewed for hospitalizations, the facility failed to ensure a complete and accurate clinical record for a resident who experienced a change of condition and for one sampled resident ( Resident # 65), reviewed for dental, the facility failed to ensure the resident's dental visit was uploaded to the clinical record within accordance to facility practice.

Inspectors wroteBased on facility documentation review, facility policy review and interviews, the facility failed to maintain an effective, comprehensive, data driven Quality Assurance and Performance Improvement (QAPI) program.

Inspectors wroteBased on facility documentation review, facility policy review, and interviews the facility failed to ensure that the QAPI committee tracked, analyzed, and acted on data obtained.

Inspectors wroteBased on observations, facility policy and interviews during the initial tour of the Dietary Department, the facility failed to discard expired refrigerated food and failed to ensure a sanitary environment.

Inspectors wroteBased on clinical record reviews, review of facility documentation, policy review, and interviews for one of three sampled residents (Resident #35) who was reviewed for an allegation of mistreatment, the facility failed to ensure the allegation of mistreatment was reported to the administrator and state agency at the time the incident occurred.

Inspectors wroteBased on observations, a clinical record review, a review of the facility documentation, a review of the facility policy, and interviews for one sampled resident (Resident #75), the facility failed to consistently document intake and output for a resident who had a suprapubic catheter and received tube feedings, and for one sampled resident (Resident #85), the facility failed to appropriately label dressings following a dressing change.

Inspectors wroteBased on clinical record reviews, review of facility documentation, policy review, and interviews for one of three sampled residents (Resident #22) who was dependent on staff for transfers in and out of the bed via a mechanical lift, the facility failed to provide appropriate supervision of the mechanical lift to prevent an accident with an injury.

Inspectors wroteBased on observations, a clinical record review, a review of facility documentation, staff interviews, and a review of facility the policy, for one sampled resident (Resident #6) reviewed for weight loss, the facility failed to implement dietary recommendations and/or failed to follow physician orders and/or failed to reweigh the resident in accordance with the facility policy.

Inspectors wroteBased on observations, clinical record review, review of facility documentation, review of facility policy, and interviews for one sampled resident (Resident #85) reviewed for infections, the facility failed to identify a discrepancy in the measurement of a Percutaneously Inserted Central Catheter (PICC).