Inspection Reports for Westhaven Community

112 West 4th Street, IA, 50036

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Inspection Report Summary

The most recent inspection on September 3, 2025, found no deficiencies during the complaint investigation. Earlier inspections were consistently free of regulatory insufficiencies, with only one report in February 2012 citing documentation issues related to tenant health assessments that were subsequently addressed. The main theme of past deficiencies involved incomplete health status documentation and medical records. Complaint investigations in the available reports were either unsubstantiated or found no regulatory issues. The facility’s inspection history shows a pattern of compliance with improvements maintained over time.

Deficiencies (last 9 years)

Deficiencies (over 9 years) 0.4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

91% better than Iowa average
Iowa average: 4.4 deficiencies/year

Deficiencies per year

4 3 2 1 0
2012
2013
2015
2016
2017
2019
2022
2024
2025

Census

Latest occupancy rate 17 residents

Based on a September 2025 inspection.

Census over time

0 6 12 18 24 Feb 2012 Nov 2015 Nov 2017 Jun 2022 Sep 2025

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

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

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
NameTitleContext
Barb WellsProgram DirectorNamed as Program Director of Westhaven Community Assisted Living
Maribeth FrelandRNMonitor conducting the evaluation
Jim BerkleyProgram CoordinatorAuthor 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
NameTitleContext
Lori MinerRN BSNMonitor conducting the evaluation
Nan SloanDirector of OperationsFacility director named in report

Report

Apr 3, 2025

Report

May 22, 2024

Report

Mar 30, 2023

Report

Mar 30, 2023

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