Newaldaya Lifescapes
Inspection history, citations, penalties and survey trends for this long-term care facility in Cedar Falls, Iowa.
- Location
- 7511 University Avenue, Cedar Falls, Iowa 50613
- CMS Provider Number
- 165465
- Inspections on file
- 20
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Newaldaya Lifescapes during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, Alzheimer’s disease, prior CVA, and anxiety, who required partial/moderate assistance for transfers and ambulation with a gait belt and walker, was found seated in a recliner with one gait belt around the waist and a second belt tightly secured to the side of the chair, preventing the resident from rising. A CNA later admitted placing the belts in this configuration on a night when the resident was hallucinating, trying to get up, and becoming combative, stating he used the second belt as an extender around the recliner, which he acknowledged prevented the resident from standing and did not follow the care guide. Video footage showed the CNA leaning the resident forward and securing the second belt to the recliner, and documentation lacked evidence of attempted non-pharmacological interventions, medical necessity for a restraint, or physician and family notification or consent, despite facility policies and the DON’s expectations that gait belts be used only for transfers/ambulation and that residents remain free from physical restraints used for discipline or staff convenience.
Staff failed to ensure that the person who applied lidocaine patches to two residents documented the administration on the TAR, with an LPN signing off on treatments performed by a CMA. This practice was confirmed through observation, record review, and staff interviews, and was not in accordance with facility policy requiring accurate documentation by the administering staff member.
A resident with multiple complex medical conditions and a PEG tube required Enhanced Barrier Precautions (EBP) for high-contact care activities. During an observed episode of PEG tube site cleaning and flushing, an LPN failed to wear a gown as required by facility policy and CDC guidance, despite clear signage and care plan instructions. Both the LPN and ADON acknowledged the omission, and the LPN's training records indicated prior competency in EBP procedures.
A resident with intact cognition and multiple diagnoses fell and sustained a head injury, but the family was not notified as required by the facility's policy. The LPN informed the PCP but failed to contact the family, believing the injury was minor. The DON acknowledged this failure, which was against the policy mandating family notification after incidents.
A LTC facility failed to assess and reassess residents for bed rail safety and did not provide adequate risk education, leading to a resident's death by asphyxiation. The resident, with severe cognitive impairment, was found wedged between the bed rail and mattress. Staff interviews revealed inadequate training and understanding of bed rail safety, compounded by an incomplete electronic health record system that omitted risk information.
The facility failed to respect the rights of two residents. One resident did not receive the requested twice-weekly baths, with no documentation of refusals or offers, despite having intact cognition. Another resident experienced bowel incontinence and emotional distress due to a non-functioning call light, leading to a delay in toileting assistance. The resident had to call his daughter for help, and the DON was unaware of the issue, despite the facility's policy to treat residents with dignity and respect.
The facility inaccurately coded the MDS assessments for two residents. One resident was incorrectly documented as having a less severe PASRR level than assessed, while another resident's healed pressure ulcer was mistakenly recorded as active. These errors were acknowledged by the MDS Coordinators, indicating a lapse in adherence to the facility's policy for accurate MDS preparation.
A facility failed to update the PASRR for a resident after new diagnoses were documented, including dementia with behavioral disturbance and a severe episode of major depressive disorder with psychotic features. The Social Worker was not informed of these updates, and the facility's PASRR process lacked direction for handling new diagnoses.
A facility failed to document the use of psychotropic medications and necessary side effect monitoring in a resident's Baseline Care Plan upon admission. The resident, with severe cognitive impairment, was admitted with orders for antidepressants, opioids, and anti-anxiety medications. An LPN confirmed that the Baseline Care Plan should include adverse reactions and side effects, which was not done, contrary to facility policy.
The facility failed to update care plans for two residents. One resident's care plan did not include interventions for new mental health diagnoses, despite documented issues such as dementia with behavioral disturbance and major depressive disorder. Another resident's care plan was not revised to include antibiotic therapy for a bacterial infection. An LPN explained the process for updating care plans, but the facility's policy lacked guidance for new diagnoses.
A facility failed to complete routine pre- and post-dialysis assessments for a resident receiving dialysis services. The resident's clinical orders required these assessments, but they were missing from the electronic health record for a period. An LPN acknowledged the oversight was due to the lack of an automated assessment setup in the EHR. The facility's dialysis policy, which required specific assessments and documentation, was not followed.
A facility failed to complete an Annual MDS assessment on time for a resident with cognitive impairment and multiple diagnoses. The delay was due to issues with new electronic charting software, which caused a discharge MDS to appear instead of triggering the annual assessment. The MDS Coordinator confirmed the oversight.
A resident who began hospice care did not have their Significant Change in Status MDS assessment completed within the required timeframe. The assessment was set up but left unfinished, with several sections incomplete and unsigned. Interviews with MDS Coordinators revealed the oversight, and the facility's policy did not specifically address the completion of these assessments.
Improper Use of Gait Belts as a Physical Restraint
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident remained free from physical restraints when a gait belt was used to secure the resident to a recliner. The resident had severe cognitive impairment with a BIMS score of 4 and active diagnoses including Alzheimer’s disease, cerebrovascular accident, and anxiety disorder. The MDS and care plan documented that the resident required partial/moderate assistance for bed mobility, transfers, and walking, and that she experienced hallucinations and disruptive behaviors such as agitation and rummaging. The care plan included interventions such as providing meaningful activities, walking around the unit twice daily with assist of one and a gait belt and walker, and using non-pharmacological approaches like conversation, music, a baby doll, and exercise to address disruptive behaviors. The care plan did not document that the resident frequently attempted to rise unassisted. On the night of the incident, documentation for behavior monitoring indicated no behaviors occurred on the overnight shift, but an incident note later recorded that a staff member used a gait belt inappropriately by fastening it to another gait belt around the resident’s waist while she sat in a recliner. This configuration allowed the resident to move her arms, legs, and torso forward but prevented her from standing up independently, and was described as an unsafe and unauthorized use of a gait belt. A CNA later reported finding the resident in the recliner with one gait belt loosely around her waist and a second belt wrapped tightly around the side of the recliner, preventing her from rising, and required assistance from an RN to remove the secured belt. The CNA who discovered the situation did not know how long the resident had been restrained in this manner. The resident did not appear agitated or scared at that time, and no redness or injuries were noted on assessment. Another CNA admitted to having improperly used the gait belts on the resident on a night when the resident had not slept, was hallucinating, tried to get up, and became combative. He stated he placed a gait belt around the resident’s waist, buckled it in the back, and then used a second gait belt as an extender, looping it around the side of the recliner to prevent her from falling, acknowledging that this action prevented her from rising and that it did not follow the care guide. Video footage confirmed that the CNA leaned the resident forward in the recliner and secured a second gait belt to the recliner while she sat facing the fireplace, after which she could move in the recliner and grab things but could not stand. Facility policies on resident rights and a restraint-free environment stated that residents have the right to be free from physical restraints imposed for discipline or convenience and defined physical restraints to include belts used with a chair that the resident cannot remove and that prevent rising. The facility’s gait belt policy required use of gait belts for transfers and ambulation but did not specify that gait belts must not be used as restraints. The progress notes lacked documentation of attempted interventions, medical necessity for a restraint, physician notification, or family education and consent related to the use of the gait belts in this manner. The DON stated that staff were expected to assess residents for causes of restlessness such as pain, toileting needs, or hunger, and to use ambulation, repositioning, and other non-pharmacological interventions, consulting with the nurse and team members as needed. The DON confirmed that gait belts were to be used only to safely ambulate or steady residents and removed once ambulation was complete, and acknowledged that the resident would not be able to rise if a gait belt was around her waist with a second belt looped around the side of the recliner. The DON reported there was no known emergent situation requiring a physical restraint to permit medically necessary treatment and confirmed that staff were expected not to physically restrain residents. Staff training records showed that the CNA involved had received multiple trainings on gait belt use, resident rights, and dependent adult abuse, yet the resident was still physically restrained using gait belts in a manner that prevented her from standing, without documented medical indication or adherence to restraint policies.
Improper Documentation of Topical Medication Administration
Penalty
Summary
The facility failed to ensure that staff who applied lidocaine patches to residents documented the administration on the Treatment Administration Record (TAR) as required. Instead, another staff member, specifically an LPN, signed off on the administration of the lidocaine patches for two residents, despite not having performed the application themselves. Observations confirmed that a Certified Medication Aide (CMA) applied the patches to both residents, but the LPN documented the completion of the treatment on the TAR. Interviews with staff revealed that this practice had been ongoing, with the LPN routinely signing off treatments completed by the CMA if the CMA forgot to document them. Both residents involved had physician orders for lidocaine patches to be applied for pain management, as reflected in their clinical records and Minimum Data Set (MDS) assessments. Facility policy required that the individual who administered the medication document the administration and prohibited the documentation of false information. The Assistant Director of Nursing and Director of Nursing both confirmed that the expectation was for the person who completed the treatment to document it, and that it was an issue if a nurse signed for a treatment they did not perform.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Care
Penalty
Summary
A deficiency occurred when staff failed to follow Enhanced Barrier Precautions (EBP) during the care of a resident with a percutaneous endoscopic gastrostomy (PEG) tube. The resident, who had a history of cancer, anemia, quadriplegia, non-Alzheimer's dementia, and chronic atrial fibrillation, was identified as requiring EBP due to the presence of an indwelling medical device. Facility policy and CDC guidance required staff to wear gloves and a gown for all high-contact activities, including device care such as cleaning and flushing a PEG tube. During an observed care event, a Licensed Practical Nurse (LPN) cleaned the resident's PEG-tube site and performed a water flush without donning a gown, despite signage and care plan instructions indicating the need for EBP. Staff interviews confirmed awareness of the EBP requirements, and the LPN's personnel file showed documented competency in EBP procedures. The Assistant Director of Nursing (ADON) acknowledged that a gown should have been worn and that gowns were available in the resident's closet. The facility's policy, updated prior to the event, clearly outlined the need for gowns and gloves during high-contact care for residents with indwelling devices, and the EBP status was communicated through door signage and the care plan. Despite these measures, the required PPE was not used during the observed care activity.
Failure to Notify Family of Resident's Fall with Injury
Penalty
Summary
The facility failed to notify a family member about a resident's fall with injury, which was a deficiency identified during the survey. The resident involved had a Minimum Data Set (MDS) assessment indicating intact cognition and was diagnosed with medically complex illness, coronary artery disease, osteoporosis, and anxiety. The resident was alert and oriented, and the care plan required staff to use a Hoyer lift with two staff for transfers and not to leave the resident alone on the commode. An incident occurred where the resident fell and sustained a head injury, but the family was not notified as required by the facility's policy. The incident note revealed that a Licensed Practical Nurse (LPN) only notified the Primary Care Physician (PCP) and failed to inform the resident's family about the fall and the resulting head injury. Interviews with staff confirmed that the LPN did not contact the family, as he believed the injury was minor. The Director of Nursing acknowledged the failure to notify the family, which was against the facility's policy that mandates family notification as soon as possible after an incident. The policy also requires the nurse assessing the incident to notify the family and the doctor, especially in cases of head injuries or unwitnessed falls.
Failure to Assess Bed Rail Safety Leads to Resident Death
Penalty
Summary
The facility failed to properly assess and reassess residents for the safe use of bed rails, and did not provide adequate education on the risks and benefits of bed rail use to residents or their legal representatives. This deficiency was identified for three residents, including one who suffered a fatal incident. The facility's failure to conduct thorough assessments and provide necessary education led to the tragic death of a resident who was found with her head wedged between the bed rail and the mattress, resulting in asphyxiation. The resident involved in the fatal incident had severe cognitive impairment and required substantial assistance with bed mobility and transfers. Despite these needs, the facility's care plan directed the use of bilateral bed rails for bed mobility and independence. The bed rail assessment conducted by the facility did not adequately address the risks of entrapment, and the resident's family was not informed of these risks. The resident's condition, including cognitive decline and physical limitations, made her particularly vulnerable to the dangers associated with bed rail use. Interviews with staff revealed a lack of consistent training and understanding regarding bed rail safety and the importance of assessing the risks and benefits. The facility's transition to an electronic health record system resulted in the omission of detailed risk and benefit information from the bed rail assessment form. This oversight contributed to the facility's failure to adequately inform residents and their families about the potential dangers of bed rail use, ultimately leading to the resident's death.
Removal Plan
- Immediately following the incident, the Administrator and the Director of Nursing began an immediate investigation in the building.
- Meeting held discussed the following regarding a review of the incident: Side Rail Policy reviewed, Bed rail assessment form reviewed - noted the risks and benefits not listed in the electronic charting record form that as the form only included a statement identifying they learned of the risks and benefits.
- Bed rail assessment forms initiated on all residents in the building, as they reassessed, every resident, and notified them of the risks and benefits.
- The facility used the paper form which identified the risks and benefits of using a side rail.
- The facility reevaluated the new admissions using the paper form, which indicated the risks and benefits.
- Maintenance completed side rail and checked the bed functionality as a preventative measure in the entire nursing facility for all beds and rails.
- The facility completes Side Rail assessments quarterly, however the facility completed side rails assessments as a preventative on all current resident in the building until completed.
- Any beds in empty rooms had the side rails removed in order to try other interventions upon admission to facility, prior to side rail use.
Failure to Respect Resident Rights and Provide Timely Care
Penalty
Summary
The facility failed to respect the rights and dignity of Resident #98 by not providing the requested twice-weekly baths. Despite Resident #98's intact cognition and clear preference for an evening bath, the facility's documentation lacked any record of her receiving a bath from 5/24/24 to 6/2/24. Furthermore, there was no documentation of her refusing a bath or being offered one at another time. The Director of Nursing confirmed the absence of such documentation and acknowledged that Resident #98 should have been offered two showers a week, as per the facility's policy. Resident #311 experienced a failure in timely toileting assistance, resulting in bowel incontinence and emotional distress. The resident, who was cognitively intact, reported that his call light was not functioning, causing him to sit in his feces for an hour and a half. He had to call his daughter for help, who then contacted the facility. Although the call light was later fixed, the resident was given a hand bell as a temporary measure. The Director of Nursing was unaware of the call light issue and the resident's distressing experience, despite the facility's policy to treat residents with dignity and respect.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents, leading to discrepancies in their records. Resident #87 was inaccurately coded as a PASRR Level I, despite being assessed as a Level II PASRR, indicating a serious mental illness. This error was acknowledged by the MDS Coordinator during an interview, who admitted to the mistake and indicated a need to correct it. The facility's policy requires timely, accurate, and comprehensive MDS preparation, which was not adhered to in this instance. Similarly, Resident #54's MDS assessment inaccurately documented a stage 4 pressure ulcer, despite a progress note indicating the ulcer had healed months earlier. The MDS Coordinator admitted to the error during interviews, acknowledging that the resident's pressure ulcer had healed. The facility's adherence to the MDS policy and the Resident Assessment Instrument (RAI) Manual was claimed, yet the coding error persisted, highlighting a lapse in accurate documentation.
Failure to Update PASRR for Resident with New Diagnoses
Penalty
Summary
The facility failed to submit a new Pre-admission Screening and Resident Review (PASRR) for a resident after receiving new diagnoses in his medical record. The resident's Minimum Data Set (MDS) assessment indicated memory problems and severely impaired decision-making skills, with diagnoses of dementia, depression, and psychotic disorder. A progress note by the Nurse Practitioner documented new diagnoses, including dementia with behavioral disturbance, a severe episode of major depressive disorder with psychotic features, and an anxiety disorder due to a known physiological condition. However, the current PASRR lacked these new diagnoses. During an interview, the Social Worker explained that she reviewed progress notes quarterly for new diagnoses and relied on communication from nurses for updates. She reported not being informed about the resident's new diagnoses and stated she would submit a referral to PASRR for review. The facility's Social Services PASRR Screens lacked direction on the process for PASRR review when a current resident had new diagnoses.
Failure to Document Psychotropic Medication Use in Baseline Care Plan
Penalty
Summary
The facility failed to include the use of psychotropic medications and the necessary monitoring for side effects in the Baseline Care Plan for a resident upon admission. The resident, identified with a severe cognitive impairment through a BIMS score of 3, was admitted with orders for antidepressants, opioids, and anti-anxiety medications. However, the Baseline Care Plan, dated several weeks after admission, lacked documentation regarding these medications and the side effects staff should monitor. This omission was confirmed during an interview with an LPN, who stated that the Baseline Care Plan should include information on adverse reactions and side effects of psychotropic medications. The facility's policy requires the Baseline Care Plan to include essential healthcare information, such as initial goals based on admission orders and physician orders, but this was not adhered to in this case.
Failure to Update Care Plans for New Diagnoses and Treatments
Penalty
Summary
The facility failed to update the care plan for Resident #72 to include interventions related to new mental health diagnoses. The resident's Minimum Data Set (MDS) assessment identified memory problems and severely impaired decision-making skills, with diagnoses of dementia, depression, and psychotic disorder. A progress note by the Nurse Practitioner on 5/8/24 documented new diagnoses, including dementia with behavioral disturbance, a severe episode of major depressive disorder with psychotic features, and an anxiety disorder due to a known physiological condition. However, the care plan dated 6/26/24 did not reflect these new diagnoses, lacking appropriate interventions and goals. Additionally, the facility did not revise the care plan for Resident #31 after initiating antibiotic therapy. The resident's MDS assessment indicated moderately impaired cognition, and clinical physician orders included an antibiotic medication starting on 6/17/2024 for a bacterial infection. Despite this, the care plan dated 6/26/24 did not include the use of antibiotics or related interventions. During an interview, an LPN explained the process of updating care plans for new diagnoses and antibiotic use, but the care plan policy lacked specific instructions for updating care plans when a resident receives a new diagnosis during their stay.
Failure to Complete Routine Dialysis Assessments
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident who required such services. Specifically, the facility did not complete routine pre- and post-dialysis assessments for a resident receiving dialysis services. The resident's clinical physician orders required pre- and post-dialysis assessments on specific days, but these assessments were missing from the resident's electronic health record for a period of time. Additionally, the facility's dialysis policy required nurses to assess and document vital signs, weights, and monitor the access site before and after dialysis, which was not consistently done. The deficiency was identified through a review of the resident's Minimum Data Set assessment, clinical physician orders, and electronic health record, as well as staff interviews. A Licensed Practical Nurse acknowledged that many pre- and post-dialysis assessments were missed due to the resident's electronic health record not having an automated assessment set up. The facility's dialysis policy outlined specific assessment and documentation requirements that were not followed, contributing to the deficiency.
Failure to Timely Complete Annual MDS Assessment
Penalty
Summary
The facility failed to complete an Annual Minimum Data Set (MDS) assessment within the required timeframe for a resident. The resident, who has moderately cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 8, also has diagnoses of hypertension, anxiety, quadriplegia, type II diabetes, and schizophrenia. The MDS assessment was supposed to be completed by the assessment reference date (ARD) plus 14 days, but it was not completed and locked until much later. The delay was attributed to a change in electronic charting software, which caused a discharge MDS to repeatedly appear, preventing the annual assessment from being triggered. This oversight was acknowledged by the MDS Coordinator during an interview.
Failure to Complete Timely MDS Assessment for Hospice Resident
Penalty
Summary
The facility failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within the required time frame for a resident who began hospice care. The resident's electronic census indicated they started hospice care on May 2, 2024. However, the MDS 3.0 Summary Page showed that the assessment was incomplete, with several sections marked as in-progress and the completion box indicating a deadline of May 23, 2024. The Care Area Assessments (CAA) and Care Plan Decision also had specified completion dates, but the assessment remained unsigned in 603 areas. Interviews with the facility's MDS Coordinators revealed that the assessment was set up but not finished, and although one coordinator completed the assessment, it was not signed and locked to finalize it. The facility's MDS Entry/Computerization Policy, reviewed in April 2024, outlined the procedure for timely and accurate MDS completion but did not specifically address the completion of Significant Change in Status Assessments. The LTC RAI 3.0 User's Manual mandates that such assessments be completed no later than 14 days after a significant change in the resident's status is determined.
Latest citations in Iowa
An LPN, unfamiliar with residents on a medication cart and faced with two residents sharing the same first name, failed to correctly identify a resident and administered a full set of another resident’s medications in addition to the resident’s own ordered morning medications, including PRN oxycodone. The resident, who had severe cognitive impairment and multiple diagnoses including hypertension and Alzheimer’s disease, subsequently experienced declining BP, reported not feeling well, and became increasingly fatigued. The facility’s policy required resident identification before medication administration, and the LPN acknowledged not knowing the residents and finding the EHR photos too small, despite their availability. Hospital records later documented hypotension, treatment with IV fluids, and a drug overdose after accidental ingestion of another resident’s medications plus the resident’s own, with persistent sinus bradycardia requiring admission for further hemodynamic monitoring.
A cognitively impaired, wandering resident with Alzheimer’s disease and behavioral symptoms was care planned as an elopement risk but was able to leave the memory care unit by holding an emergency exit door bar for 15 seconds and exiting into a stairwell and then to the employee parking lot. The door alarm functioned, but staff in the noisy dining room did not hear it while they were feeding multiple residents, including several needing extensive assistance, and only realized the resident was missing when another staff member encountered him outside and brought him back. In addition, several residents who required staff assistance for transfers and toileting experienced prolonged call light response times well beyond the facility’s 15‑minute expectation, including one who reported waiting up to an hour during meals and having an in‑room accident, another observed waiting about 25 minutes while calling out for help, and a third waiting about 17 minutes before a CNA responded.
A cognitively intact resident reported that a CNA ripped her incontinence brief during care and then refused to change it, despite the resident stating she could not wear it due to the tear. The resident became upset and informed housekeeping staff, who then asked an LPN to assist. On assessment, the LPN observed a large rip extending around the back of the brief, changed the brief, and provided peri care at the resident’s request. The resident stated the ripped brief was uncomfortable and that she did not feel treated with dignity or respect. In interviews, the CNA acknowledged telling the resident the torn brief would still work and did not change it, while the DON confirmed the CNA had refused the resident’s request for a brief change, in conflict with the facility’s dignity policy.
A deficiency was identified when a CNA did not follow manufacturer instructions for a mechanical stand while transferring a resident with severe cognitive impairment, a history of hip fracture, dementia, and muscle wasting who required substantial assistance for transfers. The resident’s care plan called for use of a mechanical stand, but during observed toileting and return-to-chair transfers, the CNA repeatedly locked and unlocked only one wheel of the device and did not keep the brakes unlocked during the actual transfer, contrary to the operator’s instructions that brakes be locked only when raising and lowering the resident during ambulation. In an interview, the DON confirmed staff were expected to follow these operator instructions and keep the wheels unlocked during transfers.
A resident with dementia, behavioral symptoms, and multiple psychotropic and cardiovascular medications was discharged to another nursing facility without a thorough or accurate discharge summary. The care plan contained a discharge planning focus but was never updated to reflect the actual discharge, and the EHR lacked documentation of discharge planning, the reason for discharge, or a recapitulation of stay, despite a family member stating they initiated the discharge due to dissatisfaction with care. The discharge instructions contained multiple medication discrepancies and omissions, including missing drugs, incorrect dosages, and absent administration frequencies, and several PRN constipation medications were not listed, contrary to the facility’s written discharge planning policy.
A resident was admitted from a hospital without a completed Preadmission Screening and Resident Review (PASRR) in the medical record, as required prior to admission. The PASRR was only completed several days later by the Hospital Liaison/Admissions Coordinator after a call alerted staff that it was missing. Both the admissions coordinator and the Administrator acknowledged that the facility relies on the hospital to provide the PASRR and that, in this case, it was missed and not done before the resident’s admission.
A resident with Alzheimer's disease, severely impaired cognition, and documented nutrition/hydration risk required partial to moderate assistance with eating and was care planned for assisted feeding with a general diet and thin liquids. During a breakfast observation, the resident was seated in a reclined Broda chair while staff placed food and beverages on an overbed table and attempted to offer chocolate milk and hot cereal without first positioning the resident upright, causing the resident to struggle to reach the cup. Facility policy on feeding required residents needing assistance to be positioned comfortably in an upright position, and the DON stated she expected residents to be upright whenever food or drink was offered, but there was no separate positioning policy in place.
A resident with a left leg fracture, muscle wasting, and impaired mobility was dependent on a mechanical lift for transfers. Staff positioned the lift at the side of the wheelchair instead of straight on, and the lift tipped and struck the resident’s forehead with the sling-holding part, causing a bruise and protruding bump. Staff interviews confirmed the transfer was done from the side and that the resident’s care plan required straight-on positioning for the lift.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance: Several residents did not receive bathing and hygiene assistance as scheduled. One resident with intact cognition and a stroke history was observed unshaven and said staff did not always shave him during showers, while staff noted the bath sheets no longer tracked shaving or nail care. Other residents with severe cognitive impairment or dependence for bathing went extended periods without baths, and one cognitively intact resident reported missing baths and wanting them. Facility records and staff interviews showed bathing schedules were not consistently followed or documented as required.
QAPI program failed to address repeated deficiencies. Review of the facility’s visit history showed repeated F689, Free of Accident Hazards/Supervision/Devices, and F880, Infection Prevention and Control, across multiple annual surveys and complaint investigations. The QAPI plan stated it would review sources of information for gaps or patterns in care systems, and the Administrator acknowledged the repeated deficiencies and said the facility would review and discuss plans to improve.
Significant Medication Error From Misidentification During Med Pass
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors and to follow the 5 rights of medication administration, resulting in one resident receiving another resident’s medications in addition to their own. The resident had diagnoses including hypertension, Alzheimer’s disease, and toxic encephalopathy, with a BIMS score of 3 indicating severe cognitive impairment. On the morning in question, review of the MAR showed the resident received their ordered medications, which included aspirin, calcium carbonate, vitamin C, vitamin D, fluoxetine 20 mg, furosemide 40 mg, galantamine, a lidocaine patch, memantine, acetaminophen, and PRN oxycodone around 8:00 a.m. According to the incident report and nursing progress notes, the LPN (Staff A) administered another resident’s full set of morning medications to this resident while the resident was in the dining room. These additional medications included metoprolol 60 mg, Lyrica 75 mg, oxycodone 7.5/325 mg, furosemide 40 mg, celecoxib 100 mg, Prozac 60 mg, hydroxyzine 10 mg, cetirizine 10 mg, Neuriva, Protonix 20 mg, potassium 99 mg, a multivitamin, and vitamin D3. These medications were given in addition to the resident’s own morning medications and PRN oxycodone. The nurse’s notes documented that the resident’s blood pressure readings declined from 100/50 to 85/48 and then to 73/48, and the resident complained of not feeling well and was increasingly fatigued. Staff A reported during interview that the resident had been screaming and yelling and that she did not realize there were two residents with the same first name in the back hallway. She stated it was her first time working in that hallway after training and that, although resident pictures were available in the EHR to assist with identification, she felt they were small and she did not know the residents. The facility’s medication management policy required staff to identify the resident before administering medications. Staff A’s employee record showed a prior medication occurrence in which she administered the wrong medications (including furosemide and potassium) to a resident, and she had documented previously that she was not familiar with residents when working on that cart. The resident was ultimately sent to the ER, where records documented hypotension on admission, treatment with IV fluids, and a chief complaint of drug overdose after accidental ingestion of another resident’s multiple medications in addition to the resident’s own medications, with continued sinus bradycardia requiring admission for further hemodynamic monitoring.
Elopement of Wandering Resident and Delayed Call Light Responses
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision to prevent an elopement for a cognitively impaired, wandering resident and failure to respond to resident call lights within the facility’s stated 15‑minute expectation. One resident with Alzheimer’s disease, bipolar disorder, and anxiety disorder had a care plan identifying risk for elopement due to wandering and documented behaviors of agitation, aggression, restlessness, and continuous pacing/wandering within the unit. This resident ambulated independently with a walker and had a BIMS score indicating impaired cognition. On the evening of the incident, the resident finished supper in the memory care dining room and then repeatedly walked the hallway with his walker, eventually approaching an emergency exit door at the far end of the hall, away from the dining room. Video and documentation show that the resident stood at the emergency exit door, held the door bar down for the required 15 seconds to release the egress, and then exited through the door into a stairwell and out to the employee parking lot. The door alarm and 15‑second egress functioned, but staff in the dining room did not hear the alarm due to noise from residents, staff conversation, and the television. At the time, two CNAs and one LPN were in the dining room feeding multiple residents, including several who required assistance, and staff reported that the resident was very quick, wandered constantly, and was difficult to keep seated. Staff interviews revealed that one CNA noticed the resident was no longer in the dining room around the same time another staff member reported they were looking for him, and only then did staff recognize the back exit door alarm sounding. A nurse arriving for her shift in the parking lot encountered the resident outside with his walker and escorted him back inside, after which he was assessed and found in stable condition. The deficiency also includes failure to respond to resident call lights within the professional standard of 15 minutes for multiple residents. One resident with intact cognition but dependent or substantial/maximal assistance needs for toileting reported that during meal hours it could take up to an hour for staff to answer the call light, resulting in an in‑room accident. Another resident, alert and oriented but occasionally forgetful and requiring two‑person assistance for transfers, was observed with the call light on for approximately 25 minutes in the morning while repeatedly yelling for help; staff walked past in the hallway without answering the light until a staff member finally entered the room. A third resident, requiring one‑person assistance for transfers, was observed with the call light on for about 17 minutes before a CNA entered to assist. The DON stated that the facility’s expectation is that call lights be answered within 15 minutes, and the facility’s policy directs all staff from all departments to respond to call lights and either assist or obtain appropriate help, but the observed response times exceeded this standard for the residents involved. Staff interviews further described the conditions contributing to these call light delays and supervision gaps. Staff on the memory care unit reported that typical evening staffing consisted of one nurse, one CMA, and two CNAs, and that while this was manageable when routines went smoothly, it became inadequate when residents had behaviors, were sundowning, or when events such as falls or changes in condition occurred. A CMA stated that at least three CNAs were needed on the memory care unit due to multiple residents requiring two‑person assistance, noting that when two CNAs were in a room providing care, they could not monitor the rest of the unit. Staff also reported that the back exit door alarm was faint and difficult to hear from the dining room, and some staff were not fully aware of the configuration of the back stairwell and exit leading to the parking lot. These conditions, combined with high resident care needs and noise levels during meals, contributed to the resident’s elopement and to prolonged call light response times for several residents. Maintenance and administrative staff confirmed that the south/back exit door from the unit led to another unalarmed door and then to the outside employee parking lot, and that the facility did not receive system reports when door alarms were activated. The Administrator was unable to verify when a door alarm went off or when an exit door was breached. The facility’s Wandering Resident policy stated that residents at risk for elopement should receive adequate supervision to prevent accidents and that staff must be vigilant in responding to alarms in a timely manner, and the call light policy required prompt response by all staff. Despite these policies, the documented events show that the resident at risk for elopement was able to leave the secured unit and reach the parking lot without timely staff detection, and that multiple residents experienced call light response times significantly longer than the facility’s stated 15‑minute standard.
Failure to Honor Resident Request for Brief Change and Maintain Dignity
Penalty
Summary
Surveyors identified a deficiency related to resident dignity and respect when a cognitively intact resident’s request for a brief change was not honored. The resident, with a BIMS score of 15 indicating no cognitive impairment, reported being upset because a CNA (Staff N) ripped her brief during care and then refused to change it. The resident self-propelled down the hallway stating she was upset about the ripped brief and that staff would not change it. A housekeeping staff member (Staff M) observed the resident’s distress, was told that the CNA had refused to change the brief despite a large rip, and then asked an LPN (Staff O) to assist with changing it. During the subsequent brief change, Staff O performed hand hygiene, used gloves, removed the resident’s pants and brief, and provided peri care at the resident’s request before applying a new brief and redressing the resident. Observation of the removed brief revealed a large rip on the left side extending past the middle of the resident’s back. The resident stated the brief with the hole was uncomfortable and that she felt staff did not provide her with dignity and respect when her request for a new brief was not honored. Staff O confirmed that the brief had a very large hole and that the resident was very upset, reporting she did not feel treated with dignity or respect and that the ripped brief was uncomfortable. In an interview, Staff N acknowledged caring for the resident that day, stated the resident had been upset and had “behaviors,” and reported that when the resident said she wanted her brief changed because it was ripped, Staff N told her the brief would still work and that urine would not get everywhere, characterizing the tear as “just a little tear.” Staff N stated the resident did not explicitly ask her to change the brief. The DON later stated that Staff N had ripped the brief, the resident had requested a brief change, Staff N said she would not change it, and acknowledged that a lack of dignity occurred when Staff N refused to change the resident’s brief, contrary to the facility’s dignity policy.
Improper Use of Mechanical Stand Brakes During Resident Transfers
Penalty
Summary
Surveyors identified a deficiency related to accident prevention when staff failed to properly use a mechanical stand’s brakes during transfers for one resident. The resident had a Brief Interview for Mental Status (BIMS) score of 7 indicating severe cognitive impairment, required substantial assistance for transfers, and had diagnoses including hip fracture, dementia, and muscle wasting. The care plan documented initiation of a mechanical stand for transfers. During observation, a CNA applied a sling, locked the right wheel of the mechanical stand, lifted the resident from a chair, then unlocked the right wheel and positioned the resident over the toilet. The CNA then lowered the resident onto the toilet and locked the right wheel. After the resident finished, the CNA lifted the resident from the toilet, unlocked the right wheel, positioned the resident over the chair, locked the right wheel, and lowered the resident, thereby failing to keep the mechanical stand brakes unlocked during the transfer as required by the operator’s instructions, which specified that brakes should only be locked when raising and lowering the resident during ambulation. In an interview, the DON stated that staff were expected to follow the operator’s instructions and keep the wheels unlocked during transfers, confirming that the observed practice did not align with the manufacturer’s guidance for safe operation of the mechanical stand.
Failure to Complete Accurate and Thorough Discharge Summary and Documentation
Penalty
Summary
Surveyors identified a failure to complete a thorough and accurate discharge summary and related discharge documentation for one resident who was discharged from the facility. The resident was admitted in early March with moderate cognitive impairment, a Brief Interview for Mental Status (BIMS) score of 08, and documented delusions and behavioral symptoms. Diagnoses included dementia with agitation, anxiety disorder, and depression. Although the care plan contained a discharge planning focus initiated shortly after admission, it did not contain any updates or documentation related to the resident’s actual discharge later that month. The electronic health record (EHR) contained a communication note indicating that transport to another nursing facility was arranged and a health status note stating that the resident was discharged, with physician orders and a face sheet faxed and a report called to the receiving facility. The resident’s EHR did not contain documentation of the discharge planning process, the reason for the discharge, or a recapitulation of the resident’s stay. A family member reported that the family initiated the discharge due to dissatisfaction with care, but there was no documentation in the EHR reflecting that the family initiated the discharge. The Long Term Care Ombudsman reported that no one contacted her during the resident’s stay, although her office did receive notice of the transfer. The facility’s own discharge planning policy required that discharge planning begin on admission, be routinely updated in the comprehensive care plan, and that the evaluation of discharge needs and the final discharge plan be completely documented in the clinical record and discussed with the resident or representative. Review of the resident’s discharge instructions and March medication administration record revealed multiple discrepancies and omissions in the discharge summary. One medication (Amlodipine 10 mg) was listed without any frequency or time of administration. Several medications that the resident was receiving, including Donepezil 10 mg, Lisinopril 5 mg, and Buspirone 10 mg twice daily, were not included on the discharge summary. Other medications were inaccurately documented, such as Memantine, which was ordered as 20 mg once daily but listed as 10 mg twice daily, and Seroquel, ordered as 50 mg twice daily but listed as once daily. Several PRN constipation medications were also omitted. The Regional Nurse Consultant confirmed that the facility’s EHR contained a discharge assessment tool that was not completed for this resident and acknowledged the multiple medication discrepancies on the discharge summary form.
Failure to Complete PASRR Evaluation Prior to Admission
Penalty
Summary
The facility failed to complete a required Preadmission Screening and Resident Review (PASRR) evaluation for a resident with an admission date of 4/22/26. The resident’s electronic health record documented admission from a hospital on 4/22/26, but review of the record showed no PASRR completed at the time of admission. A PASRR form for this resident was later obtained and showed it was completed on 4/27/26 by the Hospital Liaison/Admissions Coordinator, several days after the resident had already been admitted. During interview, the Hospital Liaison/Admissions Coordinator stated that the hospital usually completes the PASRR, acknowledged receiving a call the previous night that the PASRR was not in the chart, and admitted she had missed completing it prior to admission even though it should have been done. The Administrator similarly reported that the facility relies on receiving the PASRR from the hospital admission records and that, in this case, the PASRR was missed and not completed prior to the resident’s admission. This resulted in a deficiency for failure to ensure a PASRR evaluation was completed prior to admission for 1 of 3 reviewed residents, in accordance with PASRR requirements.
Failure to Properly Position Resident Upright During Assisted Feeding
Penalty
Summary
Surveyors identified a deficiency in resident positioning during mealtime for a resident with Alzheimer's disease and severely impaired cognition, as evidenced by a Brief Interview for Mental Status score of 2. The resident’s MDS indicated a need for partial to moderate assistance with eating, and the care plan documented nutrition and hydration risk related to end-stage diagnosis, cognitive limitations, and weakness, with directions for a general diet, thin liquids, and assistance with eating. During a breakfast observation on the Magnolia Unit, the resident was seated in a Broda chair that was reclined back. A dietary aide placed food on the table in front of the resident, and a CNA then placed beverages and food on an overbed table before walking away, while the resident remained reclined with eyes closed and the plate of food untouched. Later in the same observation period, another CNA offered the resident chocolate milk while the Broda chair remained tilted backward, and the resident had to struggle to move her head up and forward to reach the cup. The same CNA then offered hot cereal, which the resident declined by saying “later.” A different CNA subsequently offered another drink of chocolate milk, again without adjusting the reclined position of the Broda chair. Policy review showed the facility’s “Feeding of Residents by Staff” policy required that residents unable to feed themselves be assisted per their care plan and be positioned comfortably in an upright position. In an interview, the DON stated there was no specific positioning policy, that staff received positioning education in training, and that her expectation was that residents be placed in an upright position whenever food or drink was offered.
Mechanical Lift Transfer Caused Resident Forehead Injury
Penalty
Summary
The facility failed to provide a safe and adequate mechanical lift transfer for Resident #18, who had a left leg fracture, muscle wasting, and impaired gait and mobility, but no cognitive impairment based on a BIMS score of 15. The resident’s care plan required two staff members to use a mechanical lift for transfers because the resident was nonweight-bearing on the left leg. The care plan update also directed staff to approach the wheelchair straight on and not from the side, and to have the resident bend the right leg and turn away from the lift during transfers. During a wheelchair transfer, staff positioned the mechanical lift at the side of the wheelchair and began the transfer. The lift tipped and struck the resident’s forehead with the part that held the sling. The resident sustained a bruise and a protruding bump on the left forehead, and the incident documentation noted the resident’s head was hit on the lift. The resident later reported that the lift almost fell to the floor and that additional staff were needed to return it upright. Staff interviews confirmed that the transfer was performed from the side of the wheelchair. One CNA stated the lift may have caught on bars under the wheelchair and acknowledged that staff had been educated not to use the lift from the side. Another CNA stated the lift was used from the side because the resident did not want her leg hit by the lift, and identified the sling-holding part of the lift as the piece that struck the resident’s forehead. The DON stated the proper procedure was to position the mechanical lift directly in front of the wheelchair rather than to the side.
Failure to Provide Scheduled Bathing and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide care and assistance with activities of daily living for 5 of 8 residents reviewed, specifically related to bathing and shaving. Resident #3 had a BIMS score of 15 and was dependent on staff for personal hygiene, with diagnoses including renal insufficiency, stroke, hemiplegia, and seizure disorder. The resident was observed unshaven, stated he was getting showers but not shaved every time, and said he needed help shaving since his stroke. Facility records showed showers were documented without indicating whether shaving was completed, and staff interviews confirmed the bath sheets no longer tracked shaving or nail care, while the DON stated male residents should be offered shaving during showers and it should be documented if completed or refused. Resident #1 had a BIMS score of 4, diagnoses including muscle weakness, diabetes, and hip fracture, and was care planned as an extensive assist for bathing. Review of the follow-up report showed the resident went 17 days without a bath and later 19 days without a bath. Resident #11 had a BIMS score of 3, diagnoses including depression, hypertension, and anemia, and was scheduled for bathing on Wednesday morning and Friday afternoon, but the follow-up report showed gaps of 6 days, 6 days, and 18 days between baths. Resident #27 also had a BIMS score of 3 with depression, hypertension, and anemia, was scheduled for bathing on Monday and Thursday afternoon, and the follow-up report showed the resident went 19 days and then 20 days without a bath, with refusals documented on two occasions. Resident #85 had a BIMS score of 15, diagnoses including hypertension, depression, and need for assistance with personal care, and stated she did not get 2 baths the prior week and wanted them. Her care plan identified her as dependent for bathing, but lacked bathing frequency, and the task list scheduled bathing for Monday morning and Wednesday afternoon. The follow-up report showed multiple extended gaps between baths, including 12 days, 7 days, 18 days, and 7 days. Facility policy stated bathing is intended to promote cleanliness, provide comfort, and observe skin condition, and the Regional Nurse Consultant stated bathing should be completed as scheduled.
QAPI Program Failed to Address Repeated Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive and effective QAPI program and did not have a plan that described the process for conducting QAPI and QAA activities. Review of the DIAL website visit history showed repeated deficient practices identified during the facility’s annual survey and complaint investigation on 3/27/25 and during the annual survey, complaint, and facility-reported incident investigation on 4/19/26. The repeat deficiencies included F689, Free of Accident Hazards/Supervision/Devices, which had been repeated in the previous three consecutive annual surveys, and F880, Infection Prevention and Control, which had been repeated in the previous four consecutive annual surveys. The facility’s QAPI plan stated that it would review sources of information to determine whether gaps or patterns existed in systems of care that could result in quality problems or opportunities for improvement. During an interview on 4/23/26 at 1:28 PM, the Administrator acknowledged the repeated F689 and F880 deficiencies and stated the facility would review and discuss plans to improve.
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