Cycle 1
Health 2025-05-22 · Fire 2025-05-22
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cedar Falls, IA
Newaldaya Lifescapes
3-star overall rating with 2-star inspections with $132,074 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
7511 University Avenue, Cedar Falls, IA
(319) 268-0401
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
104
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2002-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.58
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
3.16
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
4.51
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.35
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
4.04
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
4.92
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
42%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,102
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9881
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.35% · Performance 22.50% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.85
Baseline 5.78% · Performance 6.98% · Measure score 2.85 · Achievement 2.85 · Improvement 0
Total nurse turnover
4.46
Baseline 50.82% · Performance 45.45% · Measure score 4.46 · Achievement 4.46 · Improvement 1.57
Adjusted total nurse staffing
6.29
Baseline 4.98 hours · Performance 4.87 hours · Measure score 6.29 · Achievement 6.29 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.42% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 167 · Observed rate 9.58% · Lower 95% interval 7.6% |
| Discharge to community | 54.98% |
50.57%
4.4 pts better
|
No Different than the National Rate · Eligible stays 160 · Observed rate 53.13% · Lower 95% interval 48.51% |
| Medicare spending per beneficiary | 0.63 |
1.02
0.4 pts better
|
|
| Drug regimen review with follow-up | 99.03% |
95.27%
3.8 pts better
|
Numerator 102 · Denominator 103 |
| Falls with major injury | 0.97% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 103 |
| Discharge self-care score | 58.82% |
53.69%
5.1 pts better
|
Numerator 50 · Denominator 85 |
| Discharge mobility score | 49.41% |
50.94%
1.5 pts worse
|
Numerator 42 · Denominator 85 |
| Pressure ulcers or injuries, new or worsened | 4.85% |
2.29%
2.6 pts worse
|
Numerator 5 · Denominator 103 · Adjusted rate 6.19% |
| Healthcare-associated infections requiring hospitalization | 6.98% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 5.94% · Lower 95% interval 3.88% |
| Staff COVID-19 vaccination coverage | 7.79% |
8.2%
0.4 pts worse
|
Numerator 24 · Denominator 308 |
| Staff flu vaccination coverage | 37.5% |
42%
4.5 pts worse
|
Numerator 165 · Denominator 440 |
| Discharge function score | 63.53% |
56.45%
7.1 pts better
|
Numerator 54 · Denominator 85 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 53 · Denominator 53 |
| Resident COVID-19 vaccinations up to date | 34% |
25.2%
8.8 pts better
|
Numerator 17 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.5
0.1 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
2.1
1.1 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
94.0%
5.2 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.9% · Q4 100.0% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.2%
4.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.7%
1.9 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.0% · Q3 1.0% · Q4 3.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.3% |
4.0%
1.7 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 5.6% · Q4 0.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 4.0% |
4.9%
0.9 pts better
|
5.4%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 5.7% · Q3 2.3% · Q4 0.0% · 4Q avg 4.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.8% |
20.6%
6.8 pts better
|
19.6%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 15.6% · Q3 10.3% · Q4 10.2% · 4Q avg 13.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.1% |
19.8%
10.3 pts worse
|
16.7%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 30.3% · Q3 31.2% · Q4 29.9% · 4Q avg 30.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.9% |
18.5%
8.6 pts better
|
16.3%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 14.6% · Q3 8.7% · Q4 8.6% · 4Q avg 9.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
18.3%
9.6 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 13.8% · Q3 5.9% · Q4 5.9% · 4Q avg 8.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.7%
1.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
2.5%
1.5 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.2% · Q3 0.0% · Q4 1.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.1% |
26.0%
3.1 pts worse
|
19.8%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.7% · Q2 24.0% · Q3 31.5% · Q4 26.5% · 4Q avg 29.1% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
4.3%
3.1 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 3.2% · Q4 0.9% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.7% |
84.3%
11.4 pts better
|
81.7%
14 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 95.8% · Q3 93.9% · Q4 96.5% · 4Q avg 95.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.6% |
13.1%
2.5 pts worse
|
12.0%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 14.3% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.9%
1.4 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.3% |
73.3%
17 pts better
|
79.7%
10.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.1% |
21.3%
6.2 pts better
|
23.9%
8.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.1% · Observed 12.1% · Expected 19.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-27 · Fire 2024-06-27
10 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-03-23 · Fire 2023-03-23
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-05-28
F · Potential for more than minimal harm
2025-05-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-20
F · Potential for more than minimal harm
2025-05-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-20
F · Potential for more than minimal harm
2024-06-27
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-07-30
E · Potential for more than minimal harm
2024-06-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-07-09
F · Potential for more than minimal harm
2023-03-23
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-06
F · Potential for more than minimal harm
2023-03-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-30
E · Potential for more than minimal harm
2023-03-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-05-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-02-25
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-03-13
K · Immediate jeopardy
2024-06-27
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-27
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-27
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-07-25
D · Potential for more than minimal harm
2024-06-27
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-07-25
B · Minimal harm
2024-06-27
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-07-25
B · Minimal harm
2024-06-27
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-07-25
Penalties and ownership
What sits behind the stars
$132,074
2024-06-27
Fine
Fine · fine $132,074
Fine
Ownership
Cedar Falls Lutheran Home
5% Or Greater Direct Ownership Interest · Organization
Hatch, Shelleen
Operational/Managerial Control · Individual
Jasper, Crystal
Operational/Managerial Control · Individual
O'neill-Gleason, Erin
Operational/Managerial Control · Individual
Ramesh, Pradeep
Operational/Managerial Control · Individual
Scheff, Dawna
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Martin Health Center, INC
Cedar Falls, IA
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Cedar Falls Health Care Center
Cedar Falls, IA
3-star overall rating with 2-star inspections with $129,025 in total fines with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
#3
The Suites at Western Home Communities
Cedar Falls, IA
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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