Beechwood Health & Rehabilitation Center

F 0550 Level of Harm - Minimal harm or potential for actual harm

physical contact, RN #1 was concerned the situation could have led to a physical altercation between Resident #1 and Resident #4. The facility Residents' Rights Policy dated 10/26/2022, directed in part, that employees shall treat all residents with kindness, respect and dignity and to assure all residents are treated that way.

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

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Beechwood Health & Rehabilitation Center

31 Vauxhall Street New London, CT 06320

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 0610

Respond appropriately to all alleged violations.

Level of Harm - Minimal harm or potential for actual harm

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to prevent further potential abuse while the investigation was in progress and failed to suspend the alleged staff member during the investigation in accordance with facility policy. The findings include: Resident #2 was admitted to the facility with diagnoses that included mild neurocognitive disorder with behavioral disturbance, and anxiety disorder.

A quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/12/2025 identified Resident #2 had a Brief Interview for Mental Status (BIMS) score of 15 (indicated was alert and oriented) and required staff assistance for personal care. The Resident Care Plan (RCP) dated 7/28/2025 identified Resident #2 had impaired coping and pain. The RCP directed to evaluate the cause of anxiety or fear, provide care in a calm and reassuring manner, and provide medications as ordered. A facility reportable event (RE) form dated 8/31/2025 at 4:40 PM identified an allegation of staff-to-resident abuse without injury. Resident #2 reported that LPN #1 did not provide his/her medications timely, was ignoring Resident #2, and was rough when taking his/her blood pressure (BP). The facility RE report summary dated 9/10/2025 identified Resident #2 made an allegation on 8/31/2025 that LPN #1 had applied the blood pressure cuff roughly and medications were given late, and LPN #1 was suspended pending the outcome of the investigation. The Summary identified LPN #1 was behind with her medication pass when approached by Resident #2. LPN #1 offered to go to Resident #2's room, and Resident #2 was frustrated and refused. LPN #1 obtained Resident #2's BP and the supervisor administered the medications. Staff reported LPN #1 was frustrated with the interaction with Resident #2 and spoke sternly to the resident. A

review of the medical record identified Resident #2 received his/her medications later than scheduled.

Further, the Summary identified the investigation indicated abuse was not substantiated. Interview and

review of LPN #1's time sheet with the DON on 9/22/2025 at 9:53 AM identified the allegation of mistreatment was made on 8/31/2025 at 4:40 PM. Facility documentation review identified LPN #1 worked

in the facility on 9/2/2025 (two days after the allegation was made and eight days prior to the reportable event summary) from 7:00 AM to 11:30 AM. The DON identified that when she saw LPN #1 on the unit on 9/2/2025 she immediately sent her home as the investigation had not yet been completed. The DON stated

she did not know how LPN #1 was scheduled to work on 9/2/2025, and why she worked when she was suspended. The DON stated LPN #1 should not have been working until the investigation was completed.

The facility policy Abuse Prohibition & Quality Assurance/Reporting dated 4/12/2025 directed in part, that as protection for residents, the identified alleged staff member will be suspended pending investigation pending the outcome of the investigation ensuring prohibition and prevention of retaliation.

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

11/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Beechwood Health & Rehabilitation Center

31 Vauxhall Street New London, CT 06320

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 0684

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or potential for actual harm

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse or neglect, the facility failed to provide physician order medications as scheduled. The findings include:Resident #2 was admitted to the facility with diagnoses that included congestive heart failure, mild neurocognitive disorder with behavioral disturbance, and anxiety disorder. A quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 6/12/2025 identified Resident # 2 had a Brief Interview for Mental Status (BIMS) score of 15 and was alert and oriented, and required assistance with personal care. The Resident Care Plan (RCP) dated 7/28/2025 identified impaired coping and pain. Interventions directed to administer medications as ordered. Physician orders dated 8/12/2025, directed to administer the following medications: Bumetanide 1 milligram (mg), 2 tablets once a day for pedal edema (swelling of the feet/lower legs). Celexa 20 mg once a day for depression Oxybutynin Chloride Extended release (ER) 24 hours one (1) tablet daily for urinary retention.

Prednisone eye drops and Systane gel, one (1) drop each eye, for Sjogren syndrome (disease that causes dry eyes and mouth). Iron supplement tablet 240 mg twice daily for chronic kidney disease. Omeprazole ER 20 mg 2 tablets 2 times daily for gastro reflux. Tylenol extra strength 500 mg tablet, give 2 tablets three times a day Cevimeline HCL 30 mg, give 1 capsule three times a day for Sjogren syndrome B-complex Oral Tablets one (1) tablet by mouth Calcitonin Solution 200 units per milliliter(ml) Vitamin D3 1000 units (u) give 2 tablets Cranberry tablets 450 mg give one (1) tablet daily. Vitamin B12 one (1) tablet by mouth Multivitamins with minerals one (1) tablet daily. Record review identified the above medications were scheduled to be administered on 8/31/2025 at 9 AM. A facility reportable event (RE) form dated 8/31/2025 at 4:40 PM LPN #1 did not provide Resident #2's medications timely. The facility RE report summary dated 9/10/2025 identified medications were administered late, and to educate staff regarding Resident #2's needs. Interview with LPN #1 on 9/22/2025 at 9:15 AM identified that she was an agency nurse and was no familiar with the unit, and on 8/31/2025 she had fallen behind on her morning medication pass. LPN #1 was aware Resident #2's medications were scheduled for 9 AM and by 1 PM she had not yet administered the scheduled medications, and stated she had notified the supervisor/RN #3 that she was behind with her medication pass. Interview with RN #3 on 9/22/2025 at 9:04 AM identified on 8/31/2025 she was notified that LPN #1 was very far behind in her medication pass. RN #3 stated she was notified at some time in the afternoon that LPN #1 was late with her medication pass. The DON stated Resident #2 did not have any adverse effect from the late medication administration. RN #3 was unable to explain what support was provided or what interventions were implemented to ensure the medications were administered timely. A

review of facility documents and interview with the DON on 9/22/2025 at 9:53 AM identified although many of the scheduled medications scheduled on 8/31/2025 at 9 AM were daily medications, the medications were administered at 1 PM (4 hours after the scheduled time). The DON stated she would have expected LPN #1 to notify the supervisor when she was late with the 9 AM medication pass before 1 PM, so the supervisor could have helped with the medication pass to ensure residents received their medications timely in accordance with physician orders. The DON stated medications are to be administered within one (1) hour before or after the scheduled time. The facility policy Medication Administration dated 9/13/2024 directed in part, that medications shall be administered in a safe and timely manner.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet