Newaldaya Lifescapes

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, facility records, policy review, and staff interviews, the facility failed to prevent a resident from being physically restrained when a gait belt was placed around the resident's waist and a secured with a second gait belt to the recliner for 1 of 3 residents (Resident #1) reviewed. The facility reported a census of 104.Findings Include:Resident #1's Minimum Data Set assessment dated [DATE] documented an admission date of 12/28/25. The MDS identified a Brief Interview for Mental Status (BIMS) score of 4 indicating severe cognitive impairment. The MDS listed potential indicators of psychosis (mental health symptom involving a disconnection) of hallucinations (Sensing, seeing, or hearing things that are not actually there). Resident #1 required partial/moderate assistance (Helper does less than half the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) for lying to sitting on the side of the bed, sitting to standing,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, policy reviews and staff interviews, the facility failed to ensure the staff who applied lidocaine patches (topical medication that delivers local anesthetic lidocaine through the skin to provide pain relief) signed the Treatment Administration Record (TAR). Instead, another staff member documented the administration of the treatments for 2 of 2 residents reviewed (Residents #16 and #20). The facility reported a census of 102 residents. Findings include: Resident #16's Minimum Data Set (MDS) assessment dated [DATE] reflected they received pain medication in the previous 5 days and had occasional pain. Resident #16's May 2025 Treatment Administration Record (TAR) included an order dated 10/5/24 for lidocaine external patch 5%. The order directed to apply to left hip topically for pain in the morning (AM) and then off at hour of sleep (hs). Resident #16's MDS assessment dated [DATE] reflected they received pain medication in the previous 5 days and had occasional pain.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, electronic health record (EHR) review, personnel file review, policy review and staff interviews the facility failed to demonstrate proper Enhanced Barrier Precautions (EBP) when flushing a Percutaneous Endoscopic Gastrostomy (PEG) tube (a thin, flexible tube inserted into the stomach through a small incision in the abdominal wall also referred to as a g-tube) for 1 of 1 residents reviewed. The facility reported a census of 102 residents. Findings include: Resident #117's Minimum Data Set (MDS) assessment dated [DATE] listed an admission date of 10/29/24. The MDS identified a Brief Interview for Mental Status (BIMS) score of 7, indicating moderately impaired cognition. The MDS included diagnoses of cancer, anemia (low iron level in the blood), quadriplegia (inability to move all four extremities of the body), non-Alzheimer's dementia, and chronic atrial fibrillation (abnormal heart rhythm. Resident #117's EHR reviewed 5/21/25 reflected she had an Infection Prevention Control measure of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, staff and resident interviews, policy review and observations the facility failed to notify a family member about a resident's fall with injury for 1 of 4 residents reviewed (Resident #1). The facility reported a census of 101. Findings include: Resident #1's Minimum Data Set (MDS) assessment dated [DATE], identified a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS included diagnoses of medically complex illness, coronary artery disease (problems with the arteries of the heart), osteoporosis, and anxiety. Resident #1 had a which indicated Resident #1 alert and oriented. The Bedside [NAME] Report dated 1/22/25 directed the staff to check and change Resident #1 and use a Hoyer lift with 2 staff for transfers to the commode. The report included to not leave Resident #1 alone on the commode. Resident #1 utilized a wheelchair and a walker for mobility. The Incident Note dated 1/23/25 at 3:01 AM, Staff B, Licensed Practical Nurse (LPN),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, policy review, resident and staff interview, the facility failed to respect the resident's right and dignity to have a bath twice a week per resident request for 1 of 1 resident reviewed (Resident #98); and failed to provide toileting in a timely manner which resulted in bowel incontinence and emotional distress for 1 of 1 resident (Resident #311). The facility reported a census of 101 residents. Findings include: 1. Resident #98's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Resident #98 required substantial to maximal assistance (a helper does more than half the effort. The helper lifts or holds the trunk or limbs and provides more than half the effort with showering/bathing). The MDS included diagnoses of anemia (low blood iron), hypertension (high blood pressure), urinary tract infection (UTI), diabetes, pneumonia and stage 3 pressure ulcer. The Activities of Daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #54's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The MDS included diagnoses of hypertension (high blood pressure), anxiety, quadriplegia (paralysis of all four extremities), type II diabetes, and schizophrenia (mood disorder that can cause hallucinations and delusions). The MDS documented the resident had a stage 4 pressure ulcer. The Progress Note dated 2/12/24 at 3:00 PM reflected Resident #54's Stage 4 pressure ulcer on his coccyx as healed. During an interview on 6/25/24 at 1:01 PM Staff A, MDS Coordinator, reported she would have to look back at her notes for Resident #54's MDS about his Stage 4 pressure ulcer. During an interview on 6/26/24 at 1:43 PM Staff A reported she made an error when she coded Resident #54 had a stage 4 pressure ulcer. She reported it healed on 2/12/24. She reported the facility followed the MDS policy and also the Resident assessment Instrument (RAI) Manual.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review the facility failed submit a new Pre admission Screening and Resident Review (PASRR) for review for 1 of 1 resident (Resident #72) for review after receiving new diagnoses in his medical record. The facility reported a census of 101 residents. Findings include: Resident #72's Minimum Data Set (MDS) assessment dated [DATE] identified a Staff Assessment for Mental Status indicating he had a memory problem and severely impaired decision-making skills. The MDS included diagnoses of dementia, depression, and psychotic disorder. Record review of a Progress Note for Resident #72 dated 5/8/24 by his Nurse Practitioner documented new diagnosis of: a. Dementia with behavioral disturbance b. Current severe episode of major depressive disorder with psychotic features without prior episode c. Anxiety disorder due to known physiological condition Record review of Resident #72 current PASRR on 6/26/24 lacked diagnoses of: a. Dementia with behavioral disturbance b.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review the facility failed to include the use of psychotropic medications and what to look for when using the medications for 1 of 1 resident (Resident #35) on the Baseline Care Plan upon admission. The reported a census of 101 residents. Findings include: Resident #35's Minimum Data Set (MDS) assessment dated [DATE] identified a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The Progress Note dated 4/19/24 listed Resident #35's admission orders to the facility on 5/16/24. The orders included anti depressants, opioids, and anti anxiety medications. Resident #35's admission Baseline Care Plan dated 5/16/24 lacked documentation that she received psychotropic medications and what side effects for staff to monitor related to the use anti depressants, opioids, and anti anxiety drug class medications present upon admission. During an interview on 6/27/24 at 11:13 AM Staff I, Licensed Practical Nurse (LPN), explained she…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, and policy review the facility failed update the Care Plan to include interventions related to new mental health diagnoses for 1 of 1 resident (Resident #72). In addition, the facility failed to revise the Care Plan for 1 of 1 resident (Resident #31) after initiating antibiotic therapy. The facility reported a census of 101 residents. Findings Include: 1. Resident #72's Minimum Data Set (MDS) assessment dated [DATE] identified a Staff Assessment for Mental Status indicating he had a memory problem and severely impaired decision-making skills. The MDS included diagnoses of dementia, depression, and psychotic disorder. Record review of a Progress Note for Resident #72 dated 5/8/24 by his Nurse Practitioner documented new diagnosis of: a. Dementia with behavioral disturbance b. Current severe episode of major depressive disorder with psychotic features without prior episode c. Anxiety disorder due to known physiological condition Resident #72's Care Plan dated 6/26/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interview, and policy review the facility failed to complete routine pre- and post-dialysis assessments for 1 of 1 resident who received dialysis services at the facility (Resident #33). The facility reported a census of 101 residents. Findings include: Resident #33's Minimum Data Set (MDS) assessment dated [DATE] reflected he received dialysis services. Resident #33's Clinical Physician Orders included the following orders a. Dated 8/16/23: Weekly weights on Wednesdays. b. Dated 6/26/24: Nurse to complete pre/post dialysis assessments on Mondays, Wednesdays, Fridays, and as needed on dialysis days. Resident #33's Weights and Vitals reviewed on 6/27/24 lacked weights on 1/10/24, 1/24/24, 4/10/24, 8/8/24 and 6/5/24. Resident #33's electronic health record (EHR) assessments reviewed on 6/27/24 lacked pre and post dialysis assessments from 4/25/24 to 6/13/24 on Monday, Wednesday and Friday. During an interview on 6/27/24 at 11:09 AM with Staff J, Licensed Practical Nurse (LPN),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.