Inspection Reports for
Westhaven Community
112 West 4th Street, Boone, IA, 50036
Back to Facility Profile8 Reports
Inspection Report — Sep 3, 2025
Complaint Investigation
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
Inspection Report — Apr 3, 2025
Routine
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.
Violations (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
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 — Dec 31, 2024
Renewal
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 — May 22, 2024
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 — Mar 30, 2023
Complaint Investigation
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.
Violations (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 — Mar 30, 2023
Routine
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.
Violations (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 — Jun 1, 2022
Renewal
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 — Dec 5, 2019
Renewal
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
4 CMS Surveys
CMS Survey — Mar 30, 2023
Mar 30, 2023
CMS Survey — Mar 30, 2023
Mar 30, 2023
CMS Survey — May 22, 2024
May 22, 2024
CMS Survey — Apr 3, 2025
Apr 3, 2025
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