Inspection Reports for Courtyard Terrace Assisted
717 W 3rd St, Boone, IA 50036, IA, 50036
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 4, 2025, found no deficiencies during the certification visit for the Assisted Living Program. Earlier inspections showed a generally positive compliance record with only occasional deficiencies, such as a staffing background check issue in 2017 and medication administration and documentation concerns in investigations from 2013 and 2014. Complaint investigations substantiated some medication management and reporting deficiencies but did not result in fines, immediate jeopardy findings, or license actions; enforcement actions were not listed in the available reports. Most complaints were unsubstantiated or involved minor issues, with one substantiated complaint related to missing narcotics and medication documentation errors. The facility’s inspection history indicates improvement over time, with the most recent visits showing no regulatory insufficiencies.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
2.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
41% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
13 residents
Based on a September 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Original Licensing
Census: 13
Deficiencies: 0
Sep 4, 2025
Visit Reason
Certification visit conducted to determine compliance with certification rules for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the certification visit for the Assisted Living Program.
Inspection Report
Renewal
Census: 16
Deficiencies: 0
Jul 6, 2023
Visit Reason
Recertification conducted to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification for the Assisted Living Program.
Inspection Report
Renewal
Census: 17
Deficiencies: 0
Nov 21, 2019
Visit Reason
The inspection was conducted as a recertification (renewal) of the Assisted Living Program at the facility.
Findings
There were no regulatory insufficiencies cited during the recertification of the Program.
Report Facts
Number of tenants without cognitive disorder: 16
Number of tenants with cognitive disorder: 1
Total Population of Program at time of on-site: 17
Inspection Report
Renewal
Census: 22
Deficiencies: 1
Oct 23, 2017
Visit Reason
The visit was a recertification inspection to determine compliance with certification for an Assisted Living Program.
Findings
The facility was cited for failing to ensure completion of Department of Human Services (DHS) evaluation of a crime prior to hire for one staff member. The deficiency was corrected on 10/23/2017.
Deficiencies (1)
| Description |
|---|
| Program failed to ensure completion of Department of Human Services (DHS) evaluation of a crime prior to hire for one staff member. |
Report Facts
Number of tenants without cognitive disorder: 22
Number of tenants with cognitive disorder: 0
Total census of Assisted Living Program: 22
Staff reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in finding for failure to complete DHS evaluation prior to hire | |
| Director of Nursing | DON | Interviewed regarding failure to obtain DHS approval prior to Staff A beginning employment |
Inspection Report
Monitoring
Census: 27
Deficiencies: 0
Oct 22, 2015
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to assess compliance with Iowa Administrative Code chapters 481-67 and 481-69 for the Assisted Living Program at Courtyard Terrace.
Findings
No regulatory insufficiencies were found during this evaluation. The review of recertification documents was completed and accepted, and the State Fire Marshal's inspection report and Facility Engineer's approval of evacuation plans were received.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 0
Total Population of Program at time of on-site: 27
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator, Adult Services Bureau | Author of the Final Recertification Monitoring Evaluation Report |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 6
Nov 12, 2013
Visit Reason
The inspection was conducted as a final complaint/incident investigation following a report of a narcotic count discrepancy and missing Hydrocodone tablets at Courtyard Terrace Assisted Living.
Findings
The investigation found regulatory insufficiencies related to medication administration, staffing, and transportation. Specifically, there were issues with narcotic counts being off, incomplete incident reporting, failure to document medication effectiveness, and medication policy noncompliance.
Complaint Details
The complaint involved a narcotic count discrepancy where ten tablets of Hydrocodone were missing. The investigation included interviews with staff and review of medication records. No perpetrator was identified, and the police department closed the investigation pending new information. The complaint was substantiated with findings of regulatory insufficiencies.
Deficiencies (6)
| Description |
|---|
| The incident report of the 9-28-13 incident was not completed by an onsite staff member and was delayed by two days. |
| The established pattern of daily narcotics counts was not completed on two occasions. |
| The medication policy requiring documentation of medication administration and effectiveness on MAR and PRN sheets was not followed. |
| The program failed to document the effectiveness of Hydrocodone medication on at least three occasions. |
| The person in charge at the time of the incident did not prepare and sign the report as required. |
| The program's policies and procedures did not meet minimum standards for reporting incidents including dependent adult abuse. |
Report Facts
Number of tenants without cognitive disorder: 35
Number of tenants with cognitive disorder: 0
Total population: 35
Missing Hydrocodone tablets: 10
Narcotic count on 9-27-13: 22
Narcotic count on 9-28-13: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Denise Elsner | Coordinator | Named as facility coordinator in complaint investigation report |
| Lori Miner | RN BSN | Monitor of the complaint/incident investigation |
| Jim Berkley | Program Coordinator | Author of cover letter for the final complaint/incident investigation report |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 0
Aug 27, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations related to tenant care, including forced dressing, missed showers, refusal of insulin administration, and a tenant fall.
Findings
No regulatory insufficiencies were identified. The investigation found that tenants received appropriate care, staff responded timely and adequately to emergencies, and fire safety procedures were followed. Staff personnel files showed some documentation gaps but no violations were cited.
Complaint Details
The complaint alleged tenants were forced to get dressed, missed showers and insulin administration due to staff refusal, and a tenant fall with inadequate treatment. The investigation found no regulatory insufficiencies and confirmed appropriate care and staff responsiveness.
Report Facts
Total census: 30
Tenants attending group meeting: 22
Dates of tenant falls: 8
Dates of hospitalization: 6
Inspection Report
Monitoring
Census: 32
Deficiencies: 8
Jun 26, 2013
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction and assess compliance with regulatory requirements for the Assisted Living Program at Courtyard Terrace.
Findings
The report identified regulatory insufficiencies related to medication administration, staffing, and transportation. Specific issues included unsecured medications, lack of documentation on medication administration, and driver licensing concerns.
Deficiencies (8)
| Description |
|---|
| Failure to update medication policy to reflect new practice of staff signing each medication individually on MARs. |
| Medications administered by staff were not secured as required by regulation. |
| Number of pills to be administered was not identified on task sheets for multiple tenants. |
| Triamcinolone cream not signed as applied on multiple dates. |
| Medications administered traditionally must be provided by licensed nurse or under nurse delegation; regulatory insufficiency noted. |
| Medications not kept in locked place accessible only to authorized employees. |
| Insufficient number of trained staff to meet tenants' identified needs. |
| Driver did not have valid or appropriate driver's license or commercial driver's license as required by law. |
Report Facts
Total census: 32
Tenants without cognitive disorder: 30
Tenants with cognitive disorder: 2
Tenants attending community meeting: 20
Medication administration observations: 2
Medication administration errors: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Denise Elsner | Assisted Living Coordinator | Named as program coordinator and interviewee regarding medication and transportation practices |
| Maribeth Freland | RN Monitor | Conducted the monitoring visit and made observations |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Apr 24, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation based on allegations regarding medication administration, tenant rights, life safety concerns related to mold, and staff misconduct at Courtyard Terrace Assisted Living Program.
Findings
The investigation found multiple medication administration discrepancies including missing signatures and unaccounted narcotic tablets, but no regulatory insufficiencies related to tenant rights, life safety, or staff misconduct. One tenant died during the investigation period due to unrelated medical issues. No regulatory insufficiencies were noted in tenant rights, life safety, or staff taking money or gifts from tenants.
Complaint Details
The complaint investigation was substantiated with findings of medication administration errors and narcotics protocol issues. Allegations regarding tenant rights, mold in apartments, and staff taking money or gifts were not substantiated.
Severity Breakdown
Regulatory Insufficiency: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Medication administration errors including missing signatures on MARs and unaccounted narcotic tablets. | Regulatory Insufficiency |
| Narcotics protocol not fully followed as per program's registered nurse. | Regulatory Insufficiency |
Report Facts
Total census: 33
Medication administration discrepancies: 7
Narcotic tablets unaccounted for: 101
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angela Eppert | RN/Coordinator | Reported medication administration procedures and tenant clinical information |
| Maribeth Freland | RN Monitor | Conducted the complaint/incident investigation and reviewed medication records |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Jun 17, 2004
Visit Reason
A complaint investigation on-site visit was conducted at Courtyard Terrace to investigate allegations that Tenant #1 wandered away from the program and was found disoriented a few blocks away and was sunburned upon return.
Findings
The investigation found no regulatory insufficiency related to the wandering incident; the tenant was independent in daily activities and not sunburned. However, a regulatory insufficiency was noted regarding the program not fully supporting tenant self-direction and autonomy as required by the Code of Iowa.
Complaint Details
The complaint alleged that Tenant #1 wandered away from the program and was found disoriented and sunburned. The investigation found the tenant was not sunburned and was oriented; the tenant had a managed risk agreement restricting walking areas. No regulatory insufficiency was found related to the wandering incident, but a deficiency was found related to tenant autonomy.
Deficiencies (1)
| Description |
|---|
| The program did not fully support tenant self-direction and tenant autonomy as referred to in the Code of Iowa. |
Report Facts
Current General Population ALP Census: 29
Tenants with mild dementia: 3
Tenants with dementia at GDS 4 or above: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dennis Bock | Administrator | Named in relation to the complaint investigation and interview |
| Mary Oliver | LISW | Monitor conducting the complaint investigation |
Report
File
ScannedReport1312466673075.pdf
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