Inspection Reports for NewAldaya Lifescapes
7511 University Ave, Cedar Falls, IA 50613, United States, IA, 50613
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Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 5, 2026
Visit Reason
A complaint investigation for complaint #2678078-C was conducted from December 22, 2025 to January 5, 2026.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.
Complaint Details
Complaint #2678078-C was investigated and found to be unsubstantiated as the facility was in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Jun 23, 2025
Visit Reason
The document is a Plan of Correction submitted following a survey, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the credible allegation and Plan of Correction, resulting in certification effective June 10, 2025.
Inspection Report
Complaint Investigation
Census: 102
Deficiencies: 2
May 22, 2025
Visit Reason
The inspection was conducted as a health recertification survey with an investigation of complaint #128698 from May 19 to May 22, 2025.
Findings
The facility was found not in compliance with 42 CFR Part 483 due to deficiencies in ensuring staff properly applied lidocaine patches and failed to demonstrate proper Enhanced Barrier Precautions when providing high contact resident care. The complaint investigation did not result in a deficiency.
Complaint Details
The investigation of complaint #128698 did not result in a deficiency.
Deficiencies (2)
| Description |
|---|
| Failure to ensure staff who applied lidocaine patches signed the Treatment Administration Record (TAR) for 2 of 2 residents reviewed. |
| Failure to demonstrate proper Enhanced Barrier Precautions (EBP) when flushing a Percutaneous Endoscopic Gastrostomy (PEG) tube for 1 of 1 residents reviewed. |
Report Facts
Census: 102
Deficiency count: 2
Audit frequency: 4
Audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lathan Robson | Administrator | Signed the plan of correction on 6/10/2025. |
| Staff A | Licensed Practical Nurse (LPN) | Signed off administration of lidocaine patches and involved in infection prevention deficiency. |
| Staff B | Assistant Director of Nursing (ADON) | Explained expectations for CMAs to sign off treatments and acknowledged infection prevention issues. |
| Staff C | Certified Medication Aide (CMA) | Observed applying lidocaine patches to residents. |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 31, 2025
Visit Reason
The document is a Plan of Correction submitted following a survey, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance with health requirements, and certification will be effective March 13, 2025.
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 1
Feb 25, 2025
Visit Reason
The inspection was conducted due to complaints and a facility incident report related to resident care and notification issues. Specifically, complaints #126221 and #126384 were substantiated, while complaint #126411 and the facility incident report #126408 were not substantiated.
Findings
The facility failed to notify a resident's family about a fall with injury for one of four residents reviewed. The investigation found that staff did not follow the facility's policy for family notification after the fall incident, resulting in a violation of residents' rights to be informed and participate in treatment decisions.
Complaint Details
Complaint #126221 was substantiated. Complaint #126384 was substantiated. Complaint #126411 was not substantiated. Facility Incident Report #126408 was not substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to notify resident's family about a fall with injury as required by facility policy and residents' rights regulations. |
Report Facts
Total census: 101
Complaints substantiated: 2
Complaints not substantiated: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Licensed Practical Nurse (LPN) | Reported care to Resident #1 and failed to notify family of fall |
| Staff C | Registered Nurse (RN) | Became aware of the fall during shift report and stated Staff B did not notify family |
| Staff A | Certified Nurse Aide | Provided care to Resident #1 during fall incident |
| Staff D | Director of Nursing | Notified of Resident #1's fall and acknowledged failure to notify family |
Inspection Report
Complaint Investigation
Deficiencies: 0
Dec 24, 2024
Visit Reason
Investigation of complaint intakes #123593-C and #124148-I conducted on December 23-24, 2024.
Findings
The Newaldaya Lifescapes Nursing Home was found in compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities. Complaint #123593 and facility reported incident #124148 were not substantiated.
Complaint Details
Complaint #123593 was not substantiated. Facility reported incident #124148 was not substantiated.
Inspection Report
Complaint Investigation
Deficiencies: 0
Aug 5, 2024
Visit Reason
The inspection was conducted as a new investigation of complaint #122228-C and included an onsite revisit of the survey ending June 27, 2024.
Findings
The Newaldaya Lifescapes Nursing Home was found to be in substantial compliance with 42 CFR Part 483 Requirements for Long Term Care Facilities as of the August 5, 2024 visit. Discretionary Denial of Payment for New Admissions did not take effect.
Complaint Details
Investigation of complaint #122228-C conducted during the onsite revisit.
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 4
Jun 27, 2024
Visit Reason
The inspection was conducted due to the facility's annual recertification survey and investigations of complaint #115801-C and facility reported incident #121616-I, with complaint #115801-C and incident #121616-I substantiated.
Findings
The facility was found not in compliance with 42 CFR Part 483 requirements, including failure to respect resident rights, provide timely toileting and bathing, complete comprehensive assessments and care plans, and ensure bed rail safety. Multiple deficiencies were identified related to resident care, assessments, and safety, including a resident death related to bed rail entrapment.
Complaint Details
Complaint #115801-C was substantiated. Facility reported incident #121616-I was substantiated. Complaint #115801-C was unsubstantiated.
Deficiencies (4)
| Description |
|---|
| Failure to respect resident rights including dignity and timely toileting and bathing. |
| Failure to complete comprehensive resident assessments including Minimum Data Set (MDS) and significant change assessments timely and accurately. |
| Failure to develop and revise baseline and comprehensive care plans accurately and timely. |
| Failure to ensure safe use and assessment of bed rails, resulting in resident injury and death. |
Report Facts
Total Census: 101
Resident #98 BIMS score: 15
Resident #54 BIMS score: 8
Resident #35 BIMS score: 3
Resident #73 BIMS score: 4
Resident #31 BIMS score: 11
Resident #68 BIMS score: 5
Resident #72 MDS assessment date: Feb 16, 2024
Resident #54 MDS assessment date: Apr 17, 2024
Resident #35 MDS assessment date: May 23, 2024
Resident #33 MDS assessment date: May 19, 2024
Resident #73 incident date: Jun 16, 2024
Resident #314 bed rails removed date: Jun 24, 2024
Resident #68 bed rails assessment date: May 24, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | MDS Coordinator | Reported on MDS assessments and bed rail assessments |
| Staff B | MDS Coordinator | Reported on Resident #96's significant change assessment |
| Staff I | Licensed Practical Nurse (LPN) | Explained expectations for Baseline Care Plan for Resident #35 |
| Staff C | Registered Nurse (RN) | Documented medication administration and resident condition during fall incident |
| Staff D | Certified Nursing Assistant (CNA) | Reported observations of Resident #73 |
| Staff F | Reported on Resident #73 condition and bed rail use | |
| Staff K | Reported on bed rail assessment and resident education | |
| Staff L | Reported on Resident #73 condition and bed rail use | |
| Staff M | Maintenance staff inspecting beds and rails | |
| Staff N | Licensed Practical Nurse (LPN) | Reported on bed rail assessment questions |
| Staff P | Certified Nursing Assistant (CNA) | Reported on bed rail training |
| Staff R | Certified Nursing Assistant (CNA) | Reported on bed rail education |
| Staff S | Certified Nursing Assistant (CNA) | Reported on residents not using bed rails |
| Staff T | Registered Nurse (RN) | Reported on resident bed rail preferences |
| Staff E | Certified Nursing Assistant (CNA) | Reported on Resident #73 condition |
| Staff G | Social Worker (SW) | Reported on resident progress notes and diagnoses |
| Staff I | Licensed Practical Nurse (LPN)/Nurse Manager | Explained bed rail assessment process |
| Staff T | Registered Nurse (RN) | Reported on resident bed rail preferences |
| Staff O | Certified Nursing Assistant (CNA) | Reported on bed rail assessment |
| Staff F | Registered Nurse (RN) | Assisted resident during fall incident |
| Administrator | Reported on bed rail removal and incident investigation | |
| Director of Nursing | Reported on bed rail removal and incident investigation |
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 23, 2023
Visit Reason
An annual recertification survey and investigation of complaints #109444-C and #110859-C were conducted from March 20, 2023 to March 23, 2023.
Findings
Complaint #109444-C and complaint #110200-C were not substantiated. The facility was found to be in substantial compliance at the time of the survey.
Complaint Details
Complaint #109444-C was not substantiated. Complaint #110200-C was not substantiated.
Inspection Report
Re-Inspection
Deficiencies: 0
Nov 15, 2022
Visit Reason
A revisit of the survey ending September 20, 2022 was conducted on November 15 to November 16, 2022 to verify correction of previous deficiencies.
Findings
All deficiencies were corrected and the facility is in substantial compliance effective September 21, 2022.
Inspection Report
Complaint Investigation
Census: 118
Deficiencies: 1
Sep 20, 2022
Visit Reason
The inspection was conducted from September 12, 2022 to September 20, 2022, resulting from investigation of complaints #106585-C, #107160-C, #107195-C, and facility reported incidents #103365-I, #103677-I, and #107218-I.
Findings
The facility was found to have deficiencies related to accident hazards, supervision, and use of gait belts for residents requiring assistance. Several complaints and incidents were substantiated, including a resident fall resulting in injury. The facility implemented corrective actions including staff education, audits, and policy reinforcement.
Complaint Details
Complaints #106585-C was not substantiated. Complaint #107160-C was substantiated. Complaint #107195-C was substantiated. Facility reported incidents #103365-I, #103677-I, and #107218-I were substantiated.
Deficiencies (1)
| Description |
|---|
| The facility failed to ensure the use of a gait belt and provide a proper mechanical lift for safe transfer for 2 of 8 residents reviewed. |
Report Facts
Resident census: 118
Complaints investigated: 3
Facility reported incidents: 3
Fall Risk Assessment score: 12
Gait belts ordered: 133
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Crystal Gaspar | Administrator | Signed plan of correction and facility representative |
| Staff B | Certified Nursing Assistant (C.N.A.) | Involved in resident fall incident and received counseling |
| Staff C | Licensed Practical Nurse (LPN) | Assessed resident after fall and provided education on gait belt use |
| Staff A | Registered Nurse (RN) | Completed admission assessment and involved in investigation |
| Staff D | Certified Nursing Assistant (C.N.A.) | Assisted resident and involved in fall incident investigation |
| Staff I | Registered Nurse (RN) | Reported resident communication needs during interview |
| Staff J | Nurse | Reported on medication administration and resident care post-fall |
| Staff O | Physical Therapist | Reported on resident assessment and hospital orders |
Inspection Report
Annual Inspection
Census: 110
Deficiencies: 2
Dec 2, 2021
Visit Reason
The inspection was conducted as part of the facility's annual health survey to assess compliance with professional standards and regulatory requirements.
Findings
The facility failed to meet professional standards in medication administration, specifically insulin administration for two residents, and in performing enteral feeding tube placement checks for one resident. Complaints #99262-C and #100179-C were not substantiated.
Complaint Details
Complaints #99262-C and #100179-C were investigated and found not substantiated.
Deficiencies (2)
| Description |
|---|
| Failure to administer insulin per directions for 2 out of 2 residents observed. |
| Failure to perform enteral feeding tube placement check according to current standards of practice for 1 resident. |
Report Facts
Census: 110
Units of insulin administered: 7
Units of insulin ordered: 2
Water volume: 60
MDS assessment date: Aug 20, 2021
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marta Casper | RN, BSN, LNHA, Administrator | Signed the plan of correction |
| Staff A | Licensed Practical Nurse (LPN) | Observed administering insulin incorrectly to Resident #57 |
| Staff B | Licensed Practical Nurse (LPN) | Observed administering insulin incorrectly to Resident #260 |
| Staff D | Licensed Practical Nurse (LPN) | Observed failing to properly check enteral feeding tube placement for Resident #11 |
| Assistant Director of Nursing | Interviewed regarding insulin administration procedures | |
| Director of Nursing | Provided nurse orientation checklist and training information |
Inspection Report
Abbreviated Survey
Census: 93
Deficiencies: 0
Dec 31, 2020
Visit Reason
The Iowa Department of Inspection and Appeals conducted a Focused COVID-19 Infection Control Survey in accordance with Medicare Conditions of Participation and CDC recommended practices. Additionally, allegations related to a complaint were investigated.
Findings
The facility was found to be in compliance with infection control requirements. The complaint investigated was not substantiated.
Complaint Details
Complaint #94954-C was investigated and found to be not substantiated.
Report Facts
Resident Census: 93
Inspection Report
Routine
Census: 112
Deficiencies: 0
Dec 8, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Deficiencies: 0
Oct 28, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on October 27-28, 2020. Additionally, three complaints were investigated during the survey.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19. The complaints investigated were not substantiated.
Complaint Details
Complaints 89570-C, 89573-C, and 91043-C were investigated and found to be not substantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Jun 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals on 6/22/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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