Newhaven Court at Clearview.

“Resident-on-resident abuse incident occurred. Staff failed to provide appropriate supervision and medical attention, and did not implement proper incident response protocols.”

“Multiple medications for residents were removed from original containers and placed in medication cups more than 2 hours before scheduled administration (bedtime 7:00-8:00 pm, found at 8:30 am).”

“Multiple residents were not administered prescribed medications, but staff falsely documented on medication administration records that medications were given at specified times.”

“Multiple residents did not receive prescribed medications on specified dates. Five residents with various prescribed medications (including twice-daily medications, bedtime medications) failed to receive doses that were ordered by their prescribers. This is a repeat violation.”

“Resident sustained multiple falls while on the 2nd floor, including one resulting in hospitalization and surgery. The home did not provide adequate supervision or assistance with transfers to meet the resident's needs despite the resident's assessment and support plan requirements.”

“Staff administered incorrect medications to a resident at approximately 8:30 a.m., not following the prescriber's order for 9:00 a.m. medication administration and failing to administer the correct prescribed medications.”

“A 6 ounce bottle of nail polish remover labeled as extremely flammable and harmful if ingested was found unsecured, unattended, and accessible to residents under the sink in a shared bathroom. A resident in the home was unable to safely handle hazardous materials according to their assessment.”

“Two direct care staff members did not complete required annual training in instruction on meeting resident needs and safe management techniques during the January 2023 to December 2023 training year.”

“One direct care staff member did not complete required annual fire safety training conducted by a fire safety expert during the January 2023 to December 2023 training year.”

“A 6 ounce bottle of nail polish remover labeled as extremely flammable was found unsecured, unattended, and accessible to residents under the sink in a shared bathroom, in violation of requirements to keep flammable materials away from heat sources or hot water heaters.”

“Two direct care staff members did not complete required annual training in instruction on meeting resident needs and safe management techniques during the January 2023 to December 2023 training year.”

“One direct care staff member did not complete required annual fire safety training conducted by a fire safety expert during the January 2023 to December 2023 training year.”

“A 6 ounce bottle of nail polish remover labeled as extremely flammable and harmful if ingested was found unsecured, unattended, and accessible to residents under the sink in a shared bathroom. A resident in the home was unable to safely handle hazardous materials according to their assessment.”

“A 6 ounce bottle of nail polish remover labeled as extremely flammable was found unsecured, unattended, and accessible to residents under the sink in a shared bathroom, in violation of requirements to keep flammable materials away from heat sources or hot water heaters.”

“Resident #1 experienced 38 falls from March 16, 2023 to September 25, 2023, with at least 10 falls resulting in injuries including head trauma, cuts, bruises, and swelling. The home had no fall precautions in place despite the resident's documented high fall risk, worsening cognitive impairment, and balance issues. Staff were instructed not to use an available rollator despite physical therapy documentation of fall risk and the need for assistive devices.”

“Resident #1 experienced 38 falls from March 16, 2023 to September 25, 2023, with at least 10 falls resulting in injuries including head trauma, cuts, bruises, and swelling. The home had no fall precautions in place despite the resident's documented high fall risk, worsening cognitive impairment, and balance issues. Staff were instructed not to use an available rollator despite physical therapy documentation of fall risk and the need for assistive devices.”