Inspection Reports for
NewAldaya Lifescapes

7511 University Ave, Cedar Falls, IA 50613, United States, IA, 50613

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Deficiencies (last 7 years)

Deficiencies (over 7 years) 4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

9% better than Iowa average
Iowa average: 4.4 deficiencies/year

Deficiencies per year

20 15 10 5 0
2020
2021
2022
2023
2024
2025
2026

Census

Latest occupancy rate 102 residents

Based on a May 2025 inspection.

This facility has shown a decline in demand based on occupancy rates.

Occupancy over time

81 90 99 108 117 126 Dec 2020 Dec 2021 Jun 2024 May 2025 May 2025

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Jan 5, 2026

Visit Reason
A complaint investigation for complaint #2678078-C was conducted from December 22, 2025 to January 5, 2026.

Complaint Details
Complaint #2678078-C was investigated and found to be unsubstantiated as the facility was in substantial compliance.
Findings
The facility was found to be in substantial compliance with no deficiencies cited.

Inspection Report

Plan of Correction
Deficiencies: 0 Date: 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 Date: 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.

Complaint Details
The investigation of complaint #128698 did not result in a deficiency.
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.

Deficiencies (2)
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
NameTitleContext
Lathan RobsonAdministratorSigned the plan of correction on 6/10/2025.
Staff ALicensed Practical Nurse (LPN)Signed off administration of lidocaine patches and involved in infection prevention deficiency.
Staff BAssistant Director of Nursing (ADON)Explained expectations for CMAs to sign off treatments and acknowledged infection prevention issues.
Staff CCertified Medication Aide (CMA)Observed applying lidocaine patches to residents.

Inspection Report

Routine
Census: 102 Deficiencies: 2 Date: May 21, 2025

Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration and infection prevention and control practices at the nursing facility.

Findings
The facility failed to ensure that staff who applied lidocaine patches signed the Treatment Administration Record, with another staff member documenting the administration instead. Additionally, the facility failed to demonstrate proper Enhanced Barrier Precautions when flushing a PEG tube for one resident, as staff did not wear a gown as required.

Deficiencies (2)
Staff who applied lidocaine patches did not sign the Treatment Administration Record; another staff member signed off instead.
Failure to demonstrate proper Enhanced Barrier Precautions when flushing a PEG tube; staff did not wear a gown as required.
Report Facts
Census: 102 Water flush volume: 120 Dates of medication orders: 10/5/24 and 7/12/24 for lidocaine patches

Employees mentioned
NameTitleContext
Staff ALicensed Practical Nurse (LPN)Signed off on lidocaine patch administration and involved in PEG tube care
Staff BAssistant Director of Nursing (ADON)Provided statements regarding treatment documentation and infection control expectations
Staff CCertified Medication Aide (CMA)Applied lidocaine patches and reported documentation practices

Inspection Report

Plan of Correction
Deficiencies: 0 Date: 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 Date: Feb 25, 2025

Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to notify a resident's family about a fall with injury.

Complaint Details
The complaint investigation found that Staff B, LPN, failed to notify Resident #1's family of her fall and head injury on 1/23/25, despite notifying the Primary Care Physician. Staff B admitted the failure and acknowledged the policy requirement. The Director of Nursing confirmed the failure to notify the family at the time of injury.
Findings
The facility failed to notify the family of Resident #1 about her fall with a head injury, despite policy requiring family notification. Staff interviews and policy review confirmed the failure to notify the family, although the Primary Care Physician was informed.

Deficiencies (1)
Failure to notify a resident's family about a fall with injury for 1 of 4 residents reviewed (Resident #1).
Report Facts
Census: 101

Employees mentioned
NameTitleContext
Staff BLicensed Practical Nurse (LPN)Admitted failure to notify Resident #1's family about the fall
Staff CRegistered Nurse (RN)Reported awareness of the fall during shift report and that Staff B did not notify family
Staff DDirector of NursingAcknowledged Staff B failed to notify family at time of injury

Inspection Report

Complaint Investigation
Census: 101 Deficiencies: 1 Date: 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.

Complaint Details
Complaint #126221 was substantiated. Complaint #126384 was substantiated. Complaint #126411 was not substantiated. Facility Incident Report #126408 was 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.

Deficiencies (1)
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
NameTitleContext
Staff BLicensed Practical Nurse (LPN)Reported care to Resident #1 and failed to notify family of fall
Staff CRegistered Nurse (RN)Became aware of the fall during shift report and stated Staff B did not notify family
Staff ACertified Nurse AideProvided care to Resident #1 during fall incident
Staff DDirector of NursingNotified of Resident #1's fall and acknowledged failure to notify family

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Dec 24, 2024

Visit Reason
Investigation of complaint intakes #123593-C and #124148-I conducted on December 23-24, 2024.

Complaint Details
Complaint #123593 was not substantiated. Facility reported incident #124148 was not substantiated.
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.

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: 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.

Complaint Details
Investigation of complaint #122228-C conducted during the onsite revisit.
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.

Inspection Report

Routine
Census: 101 Deficiencies: 9 Date: Jun 27, 2024

Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including resident rights, care planning, assessments, dialysis care, and bed rail safety.

Findings
The facility was found deficient in multiple areas including failure to respect resident rights to bathing preferences, timely toileting assistance, timely and accurate Minimum Data Set (MDS) assessments, accurate coding of assessments, coordination of PASRR assessments, inclusion of psychotropic medication information in care plans, dialysis pre/post assessments, and safe use and assessment of bed rails. The failure to properly assess and educate on bed rail risks resulted in the death of a resident due to asphyxiation from entrapment.

Deficiencies (9)
Failed to respect resident's right and dignity to have a bath twice a week per resident request and timely toileting assistance resulting in bowel incontinence and emotional distress.
Failed to complete an Annual Minimum Data Set (MDS) assessment in the required timeframe for 1 resident.
Failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within the required timeframe for 1 resident.
Failed to accurately code 2 residents' Minimum Data Set (MDS) assessments.
Failed to submit a new Pre-admission Screening and Resident Review (PASRR) for review after receiving new diagnoses for 1 resident.
Failed to include psychotropic medication use and monitoring in the Baseline Care Plan upon admission for 1 resident.
Failed to update the Care Plan to include interventions related to new mental health diagnoses and antibiotic therapy for 2 residents.
Failed to complete routine pre- and post-dialysis assessments for 1 resident receiving dialysis services.
Failed to assess and reassess residents for safe use of bed rails, failed to provide risk and benefit education including entrapment and death risks, resulting in the death of a resident due to asphyxiation from entrapment between bed rail and mattress.
Report Facts
Residents affected: 3 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 2 Residents affected: 1 Residents affected: 1 Residents affected: 1 Residents affected: 2 Facility census: 101 Residents using bed rails: 94 Resident weight: 222

Employees mentioned
NameTitleContext
Staff AMDS CoordinatorReported on MDS assessment issues and bed rail assessment form changes
Staff BMDS CoordinatorReported inaccurate MDS coding and bed rail assessment procedures
Staff GSocial WorkerReported failure to submit PASRR referral for new diagnoses
Staff ILicensed Practical Nurse (LPN)Reported expectations for baseline care plan and care plan updates
Staff JLicensed Practical Nurse (LPN)Reported missed dialysis assessments due to EHR setup
Staff KLicensed Practical Nurse (LPN)Reported bed rail assessment procedures and family education
Staff LCertified Nursing Assistant (CNA)Reported observations related to Resident #73 prior to incident
Staff DCertified Nursing Assistant (CNA)Reported observations related to Resident #73 prior to incident
Staff FRegistered Nurse (RN)Reported observations related to Resident #73 prior to incident
Staff MMaintenanceReported bed inspections and measurements
Staff NLicensed Practical Nurse (LPN)Reported bed rail assessment procedures and training
Staff OCertified Nursing Assistant (CNA)Reported bed rail assessment and training
Staff PCertified Nursing Assistant (CNA)Reported bed rail training
Staff QCertified Nursing Assistant (CNA)Reported bed rail concerns reporting
Staff RCertified Nursing Assistant (CNA)Reported lack of recent bed rail education
Staff SCertified Nursing Assistant (CNA)Reported some residents do not use bed rails
Staff ECertified Nursing Assistant (CNA)Reported observations related to Resident #73 prior to incident
Staff TRegistered Nurse (RN)Reported bed rail procedures and mattress gap interventions
Staff CRegistered Nurse (RN)Documented incident report of Resident #73's death
Staff ILPN/Nurse ManagerReported bed rail assessment limitations

Inspection Report

Annual Inspection
Census: 101 Deficiencies: 6 Date: Jun 27, 2024

Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with regulatory requirements including resident assessments, dialysis care, PASRR coordination, and bed rail safety.

Findings
The facility failed to complete timely and accurate Minimum Data Set (MDS) assessments including annual and significant change assessments, failed to submit updated PASRR reviews after new diagnoses, failed to complete routine dialysis pre- and post-assessments, and failed to properly assess, educate, and monitor residents regarding bed rail safety. These failures contributed to an Immediate Jeopardy situation following the death of a resident due to bed rail entrapment.

Deficiencies (6)
Failed to complete an Annual Minimum Data Set (MDS) assessment in the required timeframe for 1 of 1 resident reviewed.
Failed to complete a Significant Change in Status Minimum Data Set (MDS) assessment within the required timeframe for 1 of 3 residents sampled for hospice care.
Failed to accurately code 2 of 16 residents' Minimum Data Set (MDS) assessments.
Failed to submit a new Pre admission Screening and Resident Review (PASRR) for review after receiving new diagnoses for 1 of 1 resident.
Failed to complete routine pre- and post-dialysis assessments for 1 of 1 resident who received dialysis services.
Failed to assess and reassess residents for safe use of bed rails, failed to provide risks and benefit education including entrapment and death risks, resulting in the death of a resident due to bed rail entrapment.
Report Facts
Residents affected: 1 Residents affected: 1 Residents affected: 2 Residents affected: 1 Residents affected: 1 Residents affected: 3 Residents using bed rails: 94 Resident weight: 222 Bed rail gap: 3

Employees mentioned
NameTitleContext
Staff AMDS CoordinatorReported missed annual MDS assessment and inaccurate coding
Staff BMDS CoordinatorReported incomplete significant change MDS and inaccurate coding
Staff GSocial WorkerReported failure to submit PASRR referral after new diagnoses
Staff JLicensed Practical Nurse (LPN)Reported missed dialysis pre/post assessments due to EHR setup
Staff KLicensed Practical Nurse (LPN)Reported bed rail assessment procedures and limitations
Staff ECertified Nursing Assistant (CNA)Witnessed Resident #73 condition and reported bed rail training
Staff FRegistered Nurse (RN)Assessed Resident #73 at time of incident
Staff MMaintenance DirectorResponsible for bed inspections and maintenance
Staff ILPN/Nurse ManagerAcknowledged limitations of bed rail assessment form
Staff NLicensed Practical Nurse (LPN)Reported bed rail assessment procedures and lack of training
Staff TRegistered Nurse (RN)Reported bed rail assessment and gap management
Staff OCertified Nursing Assistant (CNA)Reported nurse assessments on admission for bed rails
Staff QCertified Nursing Assistant (CNA)Reported concerns about bed rails to charge nurse
Staff RCertified Nursing Assistant (CNA)Reported lack of recent bed rail education
Staff SCertified Nursing Assistant (CNA)Reported some residents do not use bed rails
Staff DCertified Nursing Assistant (CNA)Reported observations of Resident #73 prior to incident
Staff LCertified Nursing Assistant (CNA)Reported observations of Resident #73 prior to incident
Staff CRegistered Nurse (RN)Found Resident #73 at time of incident
Staff BMDS CoordinatorReported inaccurate MDS coding for Resident #87
Director of NursingDirector of Nursing (DON)Reported on bed rail assessment policies and incident investigation
Legal Medical Death InvestigatorReported Resident #73 death consistent with asphyxiation

Inspection Report

Complaint Investigation
Census: 101 Deficiencies: 4 Date: 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.

Complaint Details
Complaint #115801-C was substantiated. Facility reported incident #121616-I was substantiated. Complaint #115801-C was unsubstantiated.
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.

Deficiencies (4)
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
NameTitleContext
Staff AMDS CoordinatorReported on MDS assessments and bed rail assessments
Staff BMDS CoordinatorReported on Resident #96's significant change assessment
Staff ILicensed Practical Nurse (LPN)Explained expectations for Baseline Care Plan for Resident #35
Staff CRegistered Nurse (RN)Documented medication administration and resident condition during fall incident
Staff DCertified Nursing Assistant (CNA)Reported observations of Resident #73
Staff FReported on Resident #73 condition and bed rail use
Staff KReported on bed rail assessment and resident education
Staff LReported on Resident #73 condition and bed rail use
Staff MMaintenance staff inspecting beds and rails
Staff NLicensed Practical Nurse (LPN)Reported on bed rail assessment questions
Staff PCertified Nursing Assistant (CNA)Reported on bed rail training
Staff RCertified Nursing Assistant (CNA)Reported on bed rail education
Staff SCertified Nursing Assistant (CNA)Reported on residents not using bed rails
Staff TRegistered Nurse (RN)Reported on resident bed rail preferences
Staff ECertified Nursing Assistant (CNA)Reported on Resident #73 condition
Staff GSocial Worker (SW)Reported on resident progress notes and diagnoses
Staff ILicensed Practical Nurse (LPN)/Nurse ManagerExplained bed rail assessment process
Staff TRegistered Nurse (RN)Reported on resident bed rail preferences
Staff OCertified Nursing Assistant (CNA)Reported on bed rail assessment
Staff FRegistered Nurse (RN)Assisted resident during fall incident
AdministratorReported on bed rail removal and incident investigation
Director of NursingReported on bed rail removal and incident investigation

Inspection Report

Annual Inspection
Deficiencies: 0 Date: Mar 23, 2023

Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at Newaldaya Lifescapes.

Findings
No health deficiencies were found during the inspection, and the level of harm and residents affected are unknown.

Inspection Report

Annual Inspection
Deficiencies: 0 Date: 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.

Complaint Details
Complaint #109444-C was not substantiated. Complaint #110200-C was not substantiated.
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.

Inspection Report

Re-Inspection
Deficiencies: 0 Date: 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 Date: 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.

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.
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.

Deficiencies (1)
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
NameTitleContext
Crystal GasparAdministratorSigned plan of correction and facility representative
Staff BCertified Nursing Assistant (C.N.A.)Involved in resident fall incident and received counseling
Staff CLicensed Practical Nurse (LPN)Assessed resident after fall and provided education on gait belt use
Staff ARegistered Nurse (RN)Completed admission assessment and involved in investigation
Staff DCertified Nursing Assistant (C.N.A.)Assisted resident and involved in fall incident investigation
Staff IRegistered Nurse (RN)Reported resident communication needs during interview
Staff JNurseReported on medication administration and resident care post-fall
Staff OPhysical TherapistReported on resident assessment and hospital orders

Inspection Report

Annual Inspection
Census: 110 Deficiencies: 2 Date: 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.

Complaint Details
Complaints #99262-C and #100179-C were investigated and found not substantiated.
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.

Deficiencies (2)
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
NameTitleContext
Marta CasperRN, BSN, LNHA, AdministratorSigned the plan of correction
Staff ALicensed Practical Nurse (LPN)Observed administering insulin incorrectly to Resident #57
Staff BLicensed Practical Nurse (LPN)Observed administering insulin incorrectly to Resident #260
Staff DLicensed Practical Nurse (LPN)Observed failing to properly check enteral feeding tube placement for Resident #11
Assistant Director of NursingInterviewed regarding insulin administration procedures
Director of NursingProvided nurse orientation checklist and training information

Inspection Report

Abbreviated Survey
Census: 93 Deficiencies: 0 Date: 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.

Complaint Details
Complaint #94954-C was investigated and found to be not substantiated.
Findings
The facility was found to be in compliance with infection control requirements. The complaint investigated was not substantiated.

Report Facts
Resident Census: 93

Inspection Report

Routine
Census: 112 Deficiencies: 0 Date: 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 Date: 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.

Complaint Details
Complaints 89570-C, 89573-C, and 91043-C were investigated and found to be not substantiated.
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.

Inspection Report

Abbreviated Survey
Deficiencies: 0 Date: 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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