Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 7
Sep 29, 2025
Visit Reason
The inspection was conducted due to investigations of Complaints #127567-C and #130336-C and a recertification visit to determine compliance with certification of an Assisted Living Program.
Findings
The program failed to follow established policies and procedures related to narcotic medication accountability, nurse delegation training, tenant evaluations, service plans, and nurse reviews. Multiple discrepancies and documentation deficiencies were identified in medication management and tenant care.
Complaint Details
The visit was complaint-related based on investigations of Complaints #127567-C and #130336-C. Substantiation status is not explicitly stated.
Deficiencies (7)
| Description |
|---|
| Program failed to follow established policy regarding accountability for narcotic medication for 1 of 2 tenants reviewed with narcotic medication. |
| Program failed to ensure newly hired registered nurse completed nurse delegation duties for staff within 60 days of hire affecting 6 caregivers and medication managers. |
| Program failed to adequately evaluate health and functional status for 1 of 4 sample tenants reviewed. |
| Program failed to include all service needs in the service plan for 1 of 4 sample tenants reviewed. |
| Program failed to include information regarding outside services in service plans for 1 of 2 sample tenants who received outside services. |
| Program failed to include review of medications in nurse reviews for 2 of 2 sample tenants reviewed. |
| Program failed to assess, monitor, and document health status of tenants for 2 of 4 sample tenants reviewed. |
Report Facts
Census: 45
Tenants without cognitive impairment: 41
Tenants with cognitive impairment: 4
Caregivers and medication managers affected: 6
Medication refusal doses: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse A | Director of Nursing/Health and Wellness Director | Named in nurse delegation and medication accountability findings; resigned during inspection period |
| Staff H | Medication Manager | Named in medication administration and wound care findings |
| ALP Manager | Interviewed regarding medication discrepancies and tenant care | |
| Pharmacist Chief Operating Officer | Pharmacist COO | Interviewed regarding pharmacy delivery and medication discrepancies |
| Executive Director | Executive Director | Interviewed regarding nurse delegation and staff issues |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Mar 6, 2025
Visit Reason
The inspection was conducted as an investigation of Complaint #121215-C regarding regulatory insufficiencies related to involuntary transfer procedures and tenant document retention.
Findings
The program failed to notify the legal representative and the long-term care ombudsman of the need to involuntarily transfer a tenant (Tenant C1), and failed to retain tenant documents for a minimum of three years as required.
Complaint Details
The visit was complaint-related, investigating Complaint #121215-C. The complaint involved failure to notify the tenant's legal representative and the long-term care ombudsman about an involuntary transfer, and failure to retain tenant documents as required. The complaint was substantiated based on interviews and record reviews.
Deficiencies (3)
| Description |
|---|
| Failed to notify the legal representative of the need to involuntarily transfer a tenant. |
| Failed to notify the office of long-term care ombudsman of the need to involuntarily transfer a tenant. |
| Failed to ensure tenant documents were kept for a minimum of three years after transfer or death. |
Report Facts
Number of tenants without cognitive impairment: 45
Number of tenants with cognitive impairment: 6
Total census: 51
Date of email notifying transfer: May 28, 2024
Transfer move deadline: Jun 7, 2024
Number of former tenants reviewed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Confirmed inability to locate Tenant C1's Occupancy Agreement |
| Director | Director | Confirmed failure to provide involuntary transfer notice per regulations |
Inspection Report
Plan of Correction
Census: 38
Deficiencies: 1
Oct 31, 2023
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program, including investigations of multiple complaints and a revisit for a prior complaint.
Findings
No regulatory insufficiencies were found during the recertification visit or most complaint investigations; however, regulatory insufficiencies were cited during the investigation of Complaint #111922-C related to failure to include a list of fees, charges, and rates describing basic and additional services in the occupancy agreements for two discharged tenants.
Complaint Details
The inspection included investigations of Complaints #115536-C, #113478-C, #111868-C, #111772-C, and #111922-C. The revisit for Complaint #111304-C was determined to be met. The deficiency was cited during the investigation of Complaint #111922-C.
Deficiencies (1)
| Description |
|---|
| Failure to include a list of fees, charges, and rates describing basic services covered and additional services and their related costs in the occupancy agreements for two discharged tenants. |
Report Facts
Number of tenants without cognitive disorder: 36
Number of tenants with cognitive disorder: 2
Total census: 38
Monthly room and board fee for Tenant C1: 3250
Monthly room and board fee for Tenant C2: 4400
Level of care fee for Tenant C2 (initial): 525
Level of care fee for Tenant C2 (July 2023): 875
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding level of care fee assessments and family information |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 5
Mar 3, 2023
Visit Reason
The inspection was conducted as part of the investigation of Complaint #111304-C regarding medication administration and other regulatory compliance issues at Holland Farms Senior Living.
Findings
The facility failed to administer medications according to physician's orders, specifically regarding warfarin management after hospital admissions for Tenant #1. Additionally, the facility failed to update occupancy agreements, tenant documents, service plans, and conduct nurse reviews as required following significant changes in the tenant's condition.
Complaint Details
The investigation was triggered by Complaint #111304-C, which involved concerns about medication administration and regulatory compliance related to Tenant #1's care after hospital admissions.
Deficiencies (5)
| Description |
|---|
| Failed to administer medications according to physician's orders, specifically warfarin management after hospital discharge for Tenant #1. |
| Failed to review and update the occupancy agreement to reflect changes in services or financial arrangements for Tenant #1. |
| Failed to obtain discharge instructions when a tenant returned from the hospital, affecting medication changes documentation for Tenant #1. |
| Failed to update service plans to reflect medication changes after hospital admission for Tenant #1. |
| Failed to complete a nurse review as warranted by a significant change in condition for Tenant #1 after hospital discharge. |
Report Facts
Number of tenants without cognitive disorder: 34
Number of tenants with cognitive disorder: 5
Total census: 39
Room and board fee increase: 1150
Warfarin dosage: 2.5
Warfarin dosage: 5
INR levels: 11.2
INR levels: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse | Interviewed regarding medication administration and discharge instructions for Tenant #1; confirmed failure to receive discharge orders and oversight in medication management. | |
| Executive Director | Interviewed regarding occupancy agreement and financial arrangements; acknowledged failure to update occupancy agreement and lack of signed documentation for Tenant #1. |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Nov 22, 2022
Visit Reason
The inspection was conducted to investigate complaints #108803-C and #104673-C at Holland Farms Senior Living.
Findings
No regulatory insufficiencies were found related to complaint #108803-C. However, deficiencies were cited during the investigation of complaint #104673-C related to failure to ensure all personnel, including contract/agency staff, received appropriate training.
Complaint Details
Complaint #108803-C was not substantiated with regulatory insufficiencies. Complaint #104673-C was substantiated with findings related to staffing training deficiencies.
Deficiencies (1)
| Description |
|---|
| Failed to consistently ensure all personnel including contract/agency staff were appropriately trained to meet tenant needs; specifically, no training documentation for 3 of 4 temporary agency staff reviewed. |
Report Facts
Number of tenants without cognitive impairment: 28
Number of tenants with cognitive impairment: 3
Total census: 31
Temporary agency staff reviewed: 4
Agency staff without training documentation: 3
Agency staff worked since: 53
Inspection Report
Original Licensing
Census: 39
Deficiencies: 3
Nov 9, 2021
Visit Reason
The inspection was conducted as an initial certification visit to determine compliance with certification of an Assisted Living Program.
Findings
The facility was found to have regulatory insufficiencies related to evaluation of tenants within 30 days of occupancy and development and updating of service plans based on evaluations. No regulatory insufficiencies were cited during the onsite infection control visit.
Severity Breakdown
A 140: 1
A 350: 1
A 405: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Evaluation within 30 days of occupancy was not completed for 3 of 4 tenants reviewed. | A 140 |
| Service plans were not developed or updated based on required evaluations for 3 of 4 tenants reviewed. | A 350 |
| Service plans failed to include outside service providers for 4 of 4 tenants reviewed. | A 405 |
Report Facts
Number of tenants without cognitive disorder: 34
Number of tenants with cognitive disorder: 5
Total census of Assisted Living Program: 39
Tenants reviewed for evaluation and service plans: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Debra Yackman | Executive Director | Confirmed findings on 11-8-21 at 3:20 p.m. |
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