Newhaven Court at Lindwood.

“The administrator failed to provide immediate access to staffing schedules upon request by a DHS agent. The home did not provide accurate documentation of staff schedules from August 25 through September 2 until approximately 1:30 p.m., despite the request being made at approximately 9:45 a.m.”

“On August 30, 2025, the home had 99 residents with 40 requiring mobility assistance, necessitating 139 hours of direct care, but only provided 120 hours. On August 31, 2025, the home had 98 residents with 40 requiring mobility assistance, necessitating 138 hours of direct care, but only provided 137 hours.”

“A resident-to-resident abuse incident occurred in the secured dementia care unit at approximately 7:45 pm, involving physical contact (hitting/smacking on the upper arm). The allegation was not verbally reported to the local Area Agency on Aging immediately as required; reporting was delayed until 5/7/2025 when discovered by the Resident Wellness Director.”

“During an argument, one resident scratched another resident's forearm, resulting in visible scratches. The same resident then bent the other resident's wrist backwards, causing red marks. This constitutes physical abuse between residents.”

“Resident #2 was admitted however, the resident's preadmission screening form does not indicate the date the form was completed. This section of the form is blank.”

“There were four 2" X 2" holes in the drywall behind a reclining chair in bedroom #104 and a 4" X 5" hole in the wall behind the bed in bedroom #102.”

“The home's record of annual direct care staff training does not include the duration of the trainings completed during the 1/1/23 - 12/31/23 annual training year.”

“The enabler device on resident #1's bed was unsecured and could be moved back and forth approximately 2"-3", posing an entrapment/fall hazard.”

“Staff member A did not confirm the identity of a resident prior to administering medications, resulting in at least 2 medications prescribed for a different resident being administered to the wrong resident.”

“Staff member A did not confirm resident identity prior to administering medications, resulting in medications being given to the wrong resident. Additionally, staff member B administered medication to a resident via an incorrect route (not subcutaneously at bedtime as prescribed).”

“Staff person B verbally abused resident #1 by telling them to engage in inappropriate behavior, and also engaged in intimidating conduct by throwing keys and abruptly leaving the unit. Additionally, resident #2 engaged in multiple incidents of sexual abuse toward other residents (touching residents over and under clothes) that were not adequately prevented by staff supervision.”

“Staff person B intimidated and threatened retaliation against resident #1 by stating they would tell the resident to engage in inappropriate behavior, and returned to the unit unsupervised after suspension to attempt to coerce the resident into a private conversation, creating an atmosphere of retaliation and intimidation regarding the resident's complaints.”

“Resident #1's assessment dated in 2022 did not include new diagnoses of vascular dementia with violent and aggressive behaviors, paranoia, and hallucinations documented in a physician progress note from 2023. The assessment also failed to reflect 15-minute checks implemented around 2023 due to escalating behaviors and hallucinations, and incorrectly indicated no supervision needs.”

“Resident #1 was discharged from the home on a date in 2023 without providing a 30-day advance written notice to the resident or designated person. Additionally, there was no physician documentation certifying that a delay in discharge would jeopardize the health, safety, or well-being of the resident or others in the home.”