Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Westhaven Community during CMS and state inspections, most recent first.
The facility failed to follow proper infection control practices, including not disinfecting medical equipment and not changing gloves between tasks, leading to potential cross-contamination. An LPN did not clean a spacer and mask after inhaler use, and a CNA did not change gloves after providing pericare. Additionally, insulin needles were improperly recapped, and medical equipment was not disinfected between uses.
A facility failed to accurately transcribe a physician's order for a resident's oxygen therapy, resulting in the omission of the order from the MARs for two months. The resident, on hospice care with conditions like CHF and atrial fibrillation, used oxygen for comfort, but the facility's documentation did not reflect this. Observations and interviews highlighted discrepancies in staff awareness and documentation of the resident's oxygen use.
A resident with multiple diagnoses was observed receiving oxygen at 3 liters, contrary to the physician's order of 2 liters. The MAR sheets showed unauthorized changes to the oxygen setting, and staff interviews revealed a lack of adherence to the prescribed settings. The facility lacked protocols for adjusting oxygen settings, requiring physician contact for changes.
The facility exceeded the acceptable medication error rate with two residents receiving incorrect insulin doses. An LPN failed to follow manufacturer instructions for insulin administration, leading to an 8% error rate. One resident with diabetes and renal insufficiency received an incomplete dose of Novolog insulin, while another with diabetes and macular degeneration received an improperly administered dose of Lispro insulin.
Two residents in an LTC facility received incorrect insulin doses due to improper administration by LPNs. One resident with diabetes and renal insufficiency was given Novolog insulin without following the manufacturer's instructions, resulting in a potential underdose. Another resident with diabetes and macular degeneration received Lispro insulin without proper priming or dose confirmation. The facility lacked specific policies for insulin flexpen use, leading to these significant medication errors.
The facility failed to securely store medications, with over-the-counter drugs found in an unlocked kitchen cupboard and a treatment cart left unlocked with resident-labeled supplies. Additionally, unlabeled inhalers were found in a resident's room. Staff acknowledged the need for secure storage, as per facility policy.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control techniques, leading to potential cross-contamination and infection risks for several residents. During medication administration, a Licensed Practical Nurse (LPN) did not disinfect a spacer and mask used for a resident with chronic obstructive pulmonary disease and heart failure after administering an inhaler. The facility's policy lacked specific instructions for cleaning inhaler administration devices, and the Co-Director of Nursing (DON) expected staff to rinse the mask with water and air dry it, which was not done. In another instance, a Certified Nursing Assistant (CNA) failed to change gloves and sanitize hands after providing pericare and transferring a resident to a commode. The CNA continued to wear the same gloves while handling various items, including a mechanical lift, which was not disinfected after use. The facility's hand washing policy required hand hygiene and glove changes between tasks, which were not followed, leading to potential contamination. Additionally, the facility did not have a policy for insulin flexpen use, resulting in an LPN recapping needles, contrary to the manufacturer's instructions and facility policy. Medical equipment such as carts and blood pressure cuffs were not disinfected between resident use, and staff did not change gloves or sanitize hands between different medication administrations, such as ear and eye drops. These actions violated the facility's standard precautions policy, which required hand hygiene and equipment disinfection to prevent cross-contamination.
Failure to Transcribe Oxygen Order Accurately
Penalty
Summary
The facility failed to provide services that met professional standards by not accurately transcribing a physician's order for a resident's oxygen therapy. The resident, who was admitted with diagnoses including congestive heart failure, atrial fibrillation, and coronary artery disease, was on hospice care and required supplemental oxygen for comfort. Despite having an order for oxygen therapy, the facility did not include this order in the Medication Administration Records (MAR) for March and April 2025, nor was it present in the signed Physician's Order Summary. This oversight resulted in the resident's oxygen usage not being documented as required. Observations and interviews revealed discrepancies in the facility's awareness and documentation of the resident's oxygen use. A portable oxygen concentrator was observed in the resident's room, and the resident confirmed using oxygen as needed. However, the Co-Directors of Nursing were unaware of the resident's oxygen use and the presence of an oxygen concentrator in the room. The facility's failure to transcribe the oxygen order accurately onto the MARs and the Physician's Order Summary led to a deficiency in meeting professional standards of care.
Failure to Adhere to Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to provide oxygen therapy as prescribed by the physician for a resident with intact cognition and multiple diagnoses, including atrial fibrillation, chronic obstructive pulmonary disease, coronary artery disease, and heart failure. The resident was observed receiving oxygen at a setting of 3 liters, contrary to the physician's order of 2 liters to maintain oxygen saturation at or above 89%. The Medication Administration Review (MAR) sheets indicated discrepancies in the recorded oxygen settings, with an unauthorized change to 3 liters documented in February 2025, and no subsequent adjustments or updates to reflect the physician's order. Interviews with staff revealed a lack of awareness and adherence to the prescribed oxygen settings. A Licensed Practical Nurse (LPN) was unable to recall the current oxygen order and noted that the resident typically received 3 liters, based on their assessment of the resident's comfort. The facility lacked a protocol or standing orders for titrating oxygen settings, requiring nursing staff to contact the physician for any changes. The facility's policy on oxygen therapy administration, revised in October 2022, mandates that the oxygen flow rate be set to the prescribed dosage, which was not followed in this case.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in an 8% error rate during observations of medication administration. Two residents were involved in the errors. The first resident, diagnosed with diabetes and renal insufficiency, was supposed to receive 8 units of Novolog insulin. However, the LPN administering the insulin did not follow the manufacturer's instructions, which required the needle to remain in the skin for at least 6 seconds to ensure the full dose was delivered. Instead, the needle was removed after only one second, potentially compromising the effectiveness of the insulin dose. The second resident, diagnosed with diabetes and macular degeneration, was to receive 6 units of Lispro insulin. The LPN did not properly prime the insulin pen or ensure the needle was in place for the required time as per the manufacturer's instructions. The pen was held in place for only 3-4 seconds instead of the recommended 5 seconds, and the LPN did not verify that the dose counter showed zero after administration. These actions led to a failure in ensuring the resident received the correct insulin dosage, contributing to the facility's medication error rate exceeding the acceptable threshold.
Insulin Administration Errors in LTC Facility
Penalty
Summary
The facility failed to administer insulin correctly to two residents, leading to significant medication errors. Resident #31, who has diabetes and renal insufficiency, was observed receiving Novolog insulin via a flexpen. The LPN administering the insulin did not follow the manufacturer's instructions, which require the needle to remain in the skin for at least 6 seconds to ensure the full dose is delivered. Instead, the needle was removed after only one second. The facility lacked a specific policy for insulin flexpen use, and the Co-Director of Nursing was unaware of the proper procedure, relying instead on manufacturer instructions. Similarly, Resident #41, who has diabetes and macular degeneration, was administered Lispro insulin incorrectly. The LPN did not prime the insulin pen properly, as required by the manufacturer's instructions, and did not hold the needle in the skin for the recommended 5 seconds. The LPN also failed to check that the dose counter showed zero after administration, which is necessary to confirm the full dose was given. These actions resulted in the residents potentially receiving incorrect insulin dosages, as the facility did not have adequate procedures in place to ensure proper insulin administration.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure the safe and secure storage of medications, as observed during a survey. Over-the-counter medications such as Pepto-Bismol, Ibuprofen, Tylenol, Tylenol Arthritis, Tums, and allergy relief were found in an unlocked cupboard in a kitchen prep area, which did not have a secured entrance. The Certified Dietary Manager acknowledged these medications were for staff use. Additionally, the 100-hall treatment cart was found unlocked, containing Biofreeze, Nystop powder, Diclofenac cream, and dressing supplies labeled with resident names. Furthermore, in a resident's room, Albuterol and Budesemide inhalers were observed on a bedside table without any labeling. Staff interviews revealed that medications are typically stored on the medication cart or in the medication room, and resident inhalers should be on the medication cart. The Co-Directors of Nursing acknowledged that the over-the-counter medications in the kitchen should have been locked. The facility's undated policy on Medication Labeling and Storage requires medications to be properly labeled and stored in locked carts or cabinets, with unlabeled containers to be destroyed according to state and federal laws.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Boone
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Eastern Star Masonic Home | 0.4 mi | ★★★★★ | 4 | 0 |
| Accura Healthcare Of Ogden, Llc | 6.7 mi | ★★★★★ | 11 | 0 |
| Northridge Village | 12.1 mi | ★★★★★ | 4 | 0 |
| Madrid Home For The Aged | 13.1 mi | ★★★★★ | 7 | 0 |
| Green Hills Health Care Center | 13.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.