Inspection Reports for Homesteaders at Holland Farms
2800 Sunset Drive, Norwalk, IA, 50211
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 29, 2025, identified deficiencies related to nurse delegation training, tenant evaluations, service plan updates, and nurse reviews. Earlier inspections showed a pattern of similar issues, including staff training gaps and incomplete tenant assessments, although the October 31, 2023, inspection found no deficiencies. Deficiencies mainly involved nurse delegation, cognitive and functional evaluations, service planning, and ensuring staff received required dementia-specific education. Complaint investigations were mostly unsubstantiated except for training deficiencies found in 2022 affecting agency and contract staff. The inspection history indicates ongoing challenges with staff training and tenant care documentation, with some improvement noted in 2023 before recent issues reemerged.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
20% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
34 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 10
Date: Sep 29, 2025
Visit Reason
The inspection was conducted as part of an investigation of Complaint #130433-C and the recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Complaint Details
The visit was triggered by Complaint #130433-C regarding regulatory insufficiencies in nurse delegation, tenant evaluations, service plans, and nurse reviews.
Findings
The program failed to ensure nurse delegation training was completed within 60 days by the newly hired registered nurse, failed to complete thorough initial and updated cognitive and functional evaluations for tenants, failed to identify a tenant exceeding admission criteria, failed to develop and update service plans to meet tenant needs, and failed to conduct required nurse reviews related to medication and health status for several tenants.
Deficiencies (10)
Failed to ensure newly hired registered nurse completed nurse delegation duties for staff within 60 days of hire.
Failed to complete thorough initial cognitive assessments for tenants prior to or on date of occupancy.
Failed to complete thorough evaluations after change in condition for tenants.
Failed to identify a tenant as exceeding criteria for admission and retention requiring two-person assistance with transfers.
Failed to develop an initial service plan to meet tenant needs.
Failed to update service plans as needed due to significant change for tenants.
Failed to ensure nurse review regarding tenant medications at least every 90 days or after significant change in condition.
Failed to ensure current health care orders were followed and monitored for wound care.
Failed to assess and document health status of tenants, make recommendations, and monitor progress at least every 90 days and with changes in health status.
Failed to ensure current health care orders for tenants receiving health care professional-directed care.
Report Facts
Total census: 34
Staff affected by nurse delegation deficiency: 6
Dates of nurse employment: RN A worked from 2025-07-08 to 2025-09-09
Occupancy dates: Tenant #3: 2025-07-16; Tenant C1: 2025-08-26; Tenant #4: 2025-08-21
Wound measurement: 6.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse / Director of Nursing / Health and Wellness Director | Failed to complete nurse delegation training within 60 days; resigned abruptly on 2025-09-09 |
| Executive Director | Provided information on RN A's employment and tenant conditions | |
| Staff A | Direct care/medication manager staff who did not receive nurse delegation training | |
| Staff B | Direct care/medication manager staff who did not receive nurse delegation training | |
| Staff D | Direct care/medication manager staff who did not receive nurse delegation training; provided tenant care observations | |
| Staff I | Provided observations about tenant #4's transfer needs | |
| Staff J | Provided wound care observation for Tenant #1 | |
| ALP/D Manager | Assisted Living Program for People with Dementia Manager | Confirmed deficiencies in assessments, service plans, nurse reviews, and tenant care |
Inspection Report
Renewal
Census: 33
Deficiencies: 0
Date: Oct 31, 2023
Visit Reason
The visit was a recertification inspection to determine compliance with certification of an Assisted Living Program for People with Dementia and to investigate Incident #113868-I.
Findings
No regulatory insufficiencies were cited during the recertification visit.
Report Facts
Number of tenants without cognitive disorder: 11
Number of tenants with cognitive disorder: 22
Total census: 33
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Date: Mar 6, 2023
Visit Reason
The inspection was conducted to investigate incidents #111352-I, #111354-I, and complaint #111353-C at the Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Incidents #111352-I, #111354-I, and Complaint #111353-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the incidents and complaint.
Report Facts
Number of tenants without cognitive disorder: 6
Number of tenants with cognitive disorder: 27
Total census: 33
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 3
Date: Nov 22, 2022
Visit Reason
The inspection was conducted to investigate complaints #107315-C, #107709-C, and #107353-C at Homesteaders at Holland Farms, an assisted living program for people with dementia.
Complaint Details
The investigation of complaint #107353-C revealed training deficiencies for agency and contract staff. Complaints #107315-C and #107709-C had no regulatory insufficiencies.
Findings
No regulatory insufficiencies were found for complaints #107315-C and #107709-C. However, deficiencies were cited for complaint #107353-C related to failure to ensure all personnel, including contract/agency staff, received appropriate training and dementia-specific education within required timeframes.
Deficiencies (3)
Failed to consistently ensure all personnel including contract/agency staff were appropriately trained to meet tenant needs, affecting 26 of 26 tenants.
Failed to ensure staff received eight hours of dementia-specific education/training within 30 days of employment, potentially affecting 19 tenants with cognitive impairment.
Failed to ensure all staff including contract/agency staff received dementia-specific continuing education annually, potentially affecting 19 tenants with cognitive impairment.
Report Facts
Tenants without cognitive impairment: 8
Tenants with cognitive impairment: 19
Total census: 27
Agency staff worked since 6/1/22: 53
Agency staff reviewed with no training documentation: 3
Agency staff reviewed: 4
Tenants potentially affected by training deficiencies: 26
Tenants potentially affected by dementia-specific education deficiencies: 19
Inspection Report
Original Licensing
Census: 12
Deficiencies: 8
Date: Nov 9, 2021
Visit Reason
The inspection was conducted as an initial certification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
The facility was found to have multiple regulatory insufficiencies related to staffing, record checks, tenant evaluations, service plans, food service, and dementia-specific education for personnel. The facility submitted a Plan of Correction to address these deficiencies.
Deficiencies (8)
Nurse delegation procedures not met; RN failed to document a review within 60 days of hire to ensure staff competency.
Program failed to complete criminal, child, and dependent adult abuse background checks prior to employment for some staff.
Program failed to evaluate tenant's functional, cognitive, and health status within 30 days of occupancy for some tenants.
Program failed to update service plans based on required evaluations within 30 days for some tenants.
Program failed to update service plans to include outside service providers for some tenants.
Program failed to include a list of person-centered planned and spontaneous activities for tenants unable to plan their own activities.
Program failed to provide training on safe food handling prior to handling food for some staff.
Program failed to provide 8 hours of dementia-specific training within 30 days of employment for some staff.
Report Facts
Number of tenants with cognitive disorder: 12
Number of tenants without cognitive disorder: 0
Staff reviewed for background checks: 12
Staff reviewed for dementia training: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Debra Gutknecht | Executive Director | Signed the report and confirmed findings on multiple occasions |
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