Newaldaya Lifescapes

Inspectors wroteBased on observations, staff interviews, and the facility's Safe Food Handling policy the facility failed to clean 3 fans in the 2nd floor dining room. The facility reported a census of 97.

Inspectors wroteBased on observation, staff interview, and facility policy review, the facility failed to maintain proper infection control practices during the distribution of resident drinking water. This affected 5 resident rooms observed during water distribution. The facility reported a census of 97 residents.

Inspectors wroteBased on clinical record review, observation, resident interview, staff interview, and facility policy the facility failed to provide the necessary activities of daily living (ADL) care regarding nail care for a dependent resident. This failure resulted in a resident having a brown substance embedded under multiple fingernails over two days. This affected 1 of 2 residents reviewed for personal hygiene (Resident #11). The facility reported a census of 96 residents.

Inspectors wroteBased on clinical record review, observation, resident interview, staff interview, and facility record review, the facility failed to ensure sufficient nursing staff were available to provide care and answer call lights within a 15-minute timeframe. This affected 3 of 3 residents reviewed for sufficient staffing (Residents #49, #65, and #98) in a sample of 1 of 5 resident halls. The facility reported a census of 97 residents.

Inspectors wroteBased on observations, staff interviews, and facility's Safe Food Handling policy the facility failed to cover the garbage containers when not in use. The facility reported a census of 97.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote2. Resident #68 MDS assessment dated [DATE] identified a BIMS score of 5, indicating a severe cognitive loss. The MDS documented Resident #68 required substantial/maximal (the helper does more than half the effort. The helper lifts or holds trunk or limbs and provides more than half the effort) assistance to roll left and right while lying in bed along with sit to lying positions. Resident #68 need total staff assistance with transfers out of bed. The MDS included diagnoses of progressive neurological conditions, non Alzheimer's dementia, and neurocognitive disorder with Lewy Bodies (a condition severe loss of thinking abilities that interfere with daily activities). The Care Plan Focus dated 5/24/24 identified Resident #68 had a potential for falls due to decreased mobility, poor safety awareness, and fatigue. [...]

Inspectors wroteBased 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.

Inspectors wrote2. 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to complete an Annual Minimum Data Set (MDS) assessment in the required timeframe for 1 of 1 resident reviewed (Resident #54). The facility reported a census of 101 residents.

Inspectors wroteBased on clinical record review, Center for Medicare and Medicaid (CMS) Long Term Care (LTC) Facility Resident assessment Instrument (RAI) 3.0 User's Manual review, and staff interview the facility failed to completed a Significant Change in Status Minimum Data Set (MDS) assessment within the required time frame for 1 of 3 residents sampled for hospice care (Resident #96). The facility reported a census of 101 residents.