Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cedar Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Martin Health Center, Inc | 1.2 mi | ★★★★★ | 0 | 0 |
| Cedar Falls Health Care Center | 1.5 mi | ★★★★★ | 20 | 0 |
| The Suites At Western Home Communities | 1.7 mi | ★★★★★ | 1 | 0 |
| Pinnacle Specialty Care | 1.8 mi | ★★★★★ | 6 | 0 |
| Harmony House Health Care Center | 5.1 mi | ★★★★★ | 14 | 0 |
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