Inspection Reports for
Westhaven Community
112 West 4th Street, Boone, IA, 50036
Back to Facility ProfileDeficiencies (last 10 years)
Deficiencies (over 10 years)
2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
55% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
17 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 17
Deficiencies: 0
Date: Sep 3, 2025
Visit Reason
The inspection was conducted to investigate complaints #129267-C and #129341-C at the assisted living facility.
Complaint Details
Complaints #129267-C and #129341-C were investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Report Facts
Tenants without cognitive impairment: 17
Tenants with cognitive impairment: 0
Total census: 17
Inspection Report
Routine
Census: 47
Deficiencies: 8
Date: Apr 3, 2025
Visit Reason
The inspection was conducted to evaluate compliance with federal regulations related to resident discharge notifications, bed hold policies, medication administration, respiratory care, medication storage, infection control, and medication error rates.
Findings
The facility failed to notify the Long-Term Care Ombudsman of resident hospital transfers, obtain bed hold consent, accurately transcribe physician oxygen orders, provide oxygen therapy as prescribed, ensure medication error rates below 5%, properly administer insulin flexpen injections, securely store medications, and implement adequate infection prevention and control practices including equipment disinfection and glove use.
Deficiencies (8)
Failed to notify the Long-Term Care Ombudsman of resident discharge/transfers for 2 residents.
Failed to obtain bed hold confirmation for 1 resident hospitalized.
Failed to accurately transcribe physician's oxygen orders for 1 resident.
Failed to provide oxygen therapy as prescribed for 1 resident.
Medication error rate of 8.0% due to improper insulin flexpen administration for 2 residents.
Failed to safely and securely store resident and staff medications.
Failed to disinfect equipment after resident use and failed to ensure proper glove use and hand hygiene to prevent cross contamination.
Failed to follow safe needle handling practices by recapping insulin pen needles.
Report Facts
Census: 47
Medication error rate: 8
Insulin dose: 8
Insulin dose: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Resident Relations Coordinator | Reported on Long-Term Care Ombudsman notification practices |
| Staff K | Business Office | Described bed hold policy and consent follow-up process |
| Staff D | Co-Director of Nursing | Acknowledged challenges with bed hold consent and insulin flexpen policy |
| Staff E | Co-Director of Nursing | Acknowledged challenges with bed hold consent and infection control expectations |
| Staff B | Licensed Practical Nurse | Observed administering oxygen and insulin, described oxygen settings |
| Staff A | Licensed Practical Nurse | Observed administering insulin and blood sugar testing |
| Staff G | Certified Nursing Assistant | Observed providing pericare and resident transfers |
| Staff C | Registered Nurse | Observed administering ear and eye medications |
| Staff F | Registered Nurse | Reported on insulin needle safety devices |
Inspection Report
Renewal
Census: 8
Deficiencies: 0
Date: Dec 31, 2024
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit.
Inspection Report
Deficiencies: 0
Date: May 22, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to a facility survey completed on May 22, 2024.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 30, 2023
Visit Reason
The inspection was conducted to investigate complaints related to inadequate assistance and supervision to prevent accidents and falls for residents R34 and R52.
Complaint Details
The complaint investigation found that the facility failed to provide adequate supervision and assistance to prevent falls for residents R34 and R52. The investigation into R52's fall was incomplete and lacked root cause analysis. Resident R52 sustained a major injury and died after a fall. Resident R34 was injured due to improper transfer assistance by agency staff who did not follow care plan instructions.
Findings
The facility failed to provide adequate supervision and assistance to prevent falls for residents R34 and R52. The investigation into R52's fall was incomplete and lacked a root cause analysis. Resident R52 suffered a major injury and subsequently passed away. Resident R34 sustained an ankle injury due to improper transfer assistance by agency staff.
Deficiencies (3)
Failed to provide adequate assistance and supervision to prevent falls for residents R34 and R52.
Failed to conduct a thorough investigation and determine root cause of resident R52's fall.
Agency CNA did not follow care plan instructions for two-person transfer for resident R34, resulting in injury.
Report Facts
Morse Fall Scale score: 85
Morse Fall Scale score: 50
Incident dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA3 | Certified Nursing Assistant | Involved in improper transfer of resident R34 leading to injury; did not follow two-person transfer protocol. |
| DON1 | Director of Nursing | Confirmed lack of documentation for thorough investigation into R52's falls. |
| DON2 | Director of Nursing | Confirmed agency staff education on transfers and involvement of CNA3 in R34 incident. |
Inspection Report
Routine
Deficiencies: 5
Date: Mar 30, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, care, medication management, fall prevention, and use of psychotropic medications.
Findings
The facility was found deficient in multiple areas including failure to re-evaluate and update a resident's advance directives and code status, inadequate personal hygiene assistance, insufficient investigation and prevention of falls, excessive duration of antibiotic eye ointment administration, and inappropriate use of antipsychotic medication without gradual dose reduction.
Deficiencies (5)
Failure to re-evaluate and update one resident's advance directives and code status wishes, resulting in immediate jeopardy.
Failure to provide personal hygiene assistance to remove facial hair for one resident, impacting self-esteem.
Failure to provide adequate supervision and investigation to prevent falls for two residents, including lack of root cause analysis after a major injury fall.
Failure to ensure one resident was not administered antibiotic eye ointment for an excessive duration, increasing risk of antibiotic resistant infections.
Failure to ensure one resident was free from unnecessary antipsychotic medication; olanzapine was prescribed without adequate indication and without gradual dose reduction attempts.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Morse Fall Scale score: 85
Morse Fall Scale score: 50
BIMS score: 15
BIMS score: 7
BIMS score: 13
BIMS score: 15
BIMS score: 8
Duration of antibiotic eye ointment use (days): 311
Olanzapine dose: 2.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| R1's Family Member | Mentioned in relation to resident's code status and care conferences | |
| MDS Coordinator | Created care plans, attended care conferences, and provided statements on code status and fall investigations | |
| Licensed Practical Nurse 1 | LPN | Reported on resident code status and care conference documentation |
| Medical Director | Provided statements regarding code status and IPOLST signing | |
| Certified Nursing Assistant 3 | CNA | Involved in transfer incident resulting in resident injury |
| Certified Medical Assistant 2 | CMA | Provided statements on resident care and transfer incident |
| Registered Nurse 1 | RN | Provided statements on resident medication and behavior |
| Pharmacy Consultant | PC | Reviewed medication orders and provided recommendations on antibiotic and antipsychotic use |
| Physician Assistant Certified | PAC | Prescribed olanzapine and provided rationale for medication decisions |
| Director of Nursing 1 | DON | Confirmed investigation documentation and education for agency staff |
| Director of Nursing 2 | DON | Confirmed monitoring of antibiotic use and education for agency staff |
Inspection Report
Renewal
Census: 8
Deficiencies: 0
Date: Jun 1, 2022
Visit Reason
Recertification visit conducted to determine compliance with certification of an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit.
Inspection Report
Renewal
Census: 15
Deficiencies: 0
Date: Dec 5, 2019
Visit Reason
Recertification visit conducted to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification visit for the Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder: 12
Number of tenants with cognitive disorder: 3
Total census: 15
Inspection Report
Renewal
Census: 18
Deficiencies: 0
Date: Nov 21, 2017
Visit Reason
Recertification conducted to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification inspection for the Assisted Living Program.
Inspection Report
Complaint Investigation
Census: 15
Deficiencies: 0
Date: Nov 3, 2016
Visit Reason
The inspection was conducted as an investigation of Incident #62892-I at the assisted living program.
Complaint Details
Investigation of Incident #62892-I; no regulatory insufficiencies found.
Findings
No regulatory insufficiencies were cited during the investigation of the incident.
Report Facts
Number of tenants without cognitive disorder: 15
Number of tenants with cognitive disorder: 0
Total census of Assisted Living Program: 15
Inspection Report
Monitoring
Census: 13
Deficiencies: 0
Date: Nov 16, 2015
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were found during this evaluation. The review of recertification documents was completed and accepted, including the State Fire Marshal's inspection report and Facility Engineer's approval of evacuation plans.
Report Facts
Number of tenants without cognitive disorder: 13
Number of tenants with cognitive disorder: 0
Total census of Assisted Living Program: 13
Inspection Report
Monitoring
Census: 14
Deficiencies: 0
Date: Jun 19, 2013
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to assess compliance with Iowa Code and Administrative Code for the Westhaven Community Assisted Living program.
Findings
No regulatory insufficiencies were found during the evaluation. Tenant satisfaction was generally positive, with reports of respectful staff interaction, timely responses, and a clean and safe environment.
Report Facts
Number of tenants without cognitive disorder: 14
Number of tenants with cognitive disorder: 0
Total census of Assisted Living Program: 14
Tenants attending community meeting: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barb Wells | Program Director | Named as Program Director of Westhaven Community Assisted Living |
| Maribeth Freland | RN | Monitor conducting the evaluation |
| Jim Berkley | Program Coordinator | Author of the cover letter for the report |
Inspection Report
Monitoring
Census: 6
Deficiencies: 4
Date: Feb 2, 2012
Visit Reason
The visit was a Final Initial Certification Monitoring Evaluation conducted to review the regulatory compliance and approve the plan of correction for Westhaven Community Assisted Living.
Findings
The report found regulatory insufficiencies that required correction, which were addressed by the facility's plan of correction. The monitoring visit included evaluation of tenant health and cognitive status, nurse review, and tenant satisfaction.
Deficiencies (4)
Lack of documentation of an assessment of Tenant #1's health status every 90 days.
Lack of documentation of an assessment of Tenant #2's health status every 90 days.
Incomplete medical history and physical exam form for Tenant #2, lacking documentation of review of systems.
File lacked documentation of an assessment of Tenant #2's health status every 90 days.
Report Facts
Number of tenants without cognitive disorder: 5
Number of tenants with cognitive disorder: 1
Total census of Assisted Living Program: 6
Days for plan of correction submission: 10
Days for health evaluation completion: 30
Days for nurse review: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the evaluation |
| Nan Sloan | Director of Operations | Facility director named in report |
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