Inspection Reports for
Bickford of Iowa City
3500 Lower West Branch Rd, Iowa City, IA 52245, United States, IA, 52245
Back to Facility Profile9 Reports
Inspection Report — Oct 22, 2025
Routine
Date: Oct 22, 2025
Visit Reason
The inspection was a routine on-site visit to assess compliance with regulatory requirements for an assisted living program serving people with dementia.
Findings
The inspection identified multiple regulatory insufficiencies related to program policies on sexual relationships between tenants with cognitive impairment, criteria for admission and retention of tenants with aggressive behaviors, and nursing review for tenants with significant ongoing pain. Plans of correction were provided for each deficiency.
Violations (3)
Program failed to follow established policy and procedures regarding sexual relationships between tenants with cognitive impairment for 1 tenant.
Program failed to give notice of discharge for exceeding criteria for retention for 1 tenant with ongoing physically aggressive behaviors.
Program failed to ensure adequate nursing assessment and documentation for 1 tenant with significant ongoing pain.
Report Facts
Deficiencies cited: 3
Date survey completed: Oct 22, 2025
Inspection Report — Jul 21, 2025
Complaint Investigation
Date: Jul 21, 2025
Visit Reason
The inspection was conducted following a complaint investigation related to an incident involving the elopement of a tenant (Tenant #1) at the assisted living program.
Complaint Details
The visit was triggered by a complaint investigation of Incident #129102-I involving the elopement of Tenant #1. The investigation found failures in incident reporting and policy adherence related to the elopement.
Findings
The program failed to produce a detailed incident report regarding the elopement of Tenant #1, failed to have the staff in charge complete the incident report, and did not follow the policy on unwitnessed door alarms. Staff delayed responding to the door alarm and failed to account for all tenants promptly.
Violations (3)
The program failed to produce a detailed incident report regarding the elopement of 1 of 1 tenants reviewed (Tenant #1).
The program staff in charge at the time of an elopement involving 1 of 1 tenants reviewed (Tenant #1) did not complete the incident report.
The program failed to follow the policy on unwitnessed door alarms involving 1 of 1 tenants reviewed who eloped (Tenant #1).
Report Facts
Number of tenants without cognitive impairment: 18
Number of tenants with cognitive impairment: 12
Door alarm response time (minutes): 8
Distance tenant was found from building (miles): 1.3
Date of incident: Jun 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Staff present during the incident who failed to produce a detailed incident report and delayed responding to the door alarm | |
| Staff B | Staff present during the incident who failed to produce a detailed incident report and delayed responding to the door alarm | |
| Staff C | Staff who observed Tenant #1 off premises and reported the tenant missing | |
| Divisional Director | Completed the incident report after the fact and confirmed deficiencies in reporting | |
| Executive Director | Notified by staff about the missing tenant and involved in follow-up |
Inspection Report — Jul 1, 2025
Enforcement
Date: Jul 1, 2025
Visit Reason
This citation was issued for failure to follow the program's unwitnessed door alarm policy after a tenant eloped. The survey dates were from July 1 to July 21, 2025.
Findings
The program failed to promptly respond to a door alarm and did not ensure all tenants were accounted for when the door alarm sounded. Tenant #1 eloped and was found offsite by an off-duty paramedic.
Violations (1)
67.2(3) The program failed to follow the policy on unwitnessed door alarms involving Tenant #1 who eloped. Staff did not promptly respond to the door alarm and failed to account for all tenants until an off-duty paramedic located the tenant offsite.
Report Facts
Fine amount: 5000
Inspection Report — Mar 26, 2025
Renewal
Date: Mar 26, 2025
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #124099-C.
Findings
Two regulatory insufficiencies were cited: failure to maintain documentation of routine personal or health-related care task sheets for one tenant, and failure to conduct nurse reviews every 90 days for one tenant receiving personal or health-related care.
Violations (2)
Failed to maintain documentation for 1 of 1 tenants reviewed who required task sheets (Tenant #3).
Failed to conduct nurse reviews every 90 days for 1 of 3 tenants reviewed who received personal or health-related care (Tenant #1).
Report Facts
Number of tenants without cognitive impairment: 8
Number of tenants with cognitive impairment: 20
Days task sheets retained: 7
Nurse review interval: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Confirmed task sheet retention policy and nurse review findings | |
| Executive Director | Confirmed task sheet retention policy and nurse review findings |
Inspection Report — Aug 14, 2024
Complaint Investigation
Date: Aug 14, 2024
Visit Reason
The inspection was conducted as an investigation of complaint #119834-M regarding an allegation of abuse at the assisted living program.
Complaint Details
The complaint investigation revealed that Staff A allegedly abused Tenant #1 on 3/27/24. Four staff witnesses confirmed witnessing the incident but did not immediately report it to management as required by policy. Staff A was suspended on 3/28/24 after the allegation was reported by Staff E. The program failed to complete an Investigation Report form related to the allegation.
Findings
The program failed to ensure implementation of its established abuse and neglect policy concerning one tenant. Staff witnesses did not immediately report the alleged abuse incident as required, and the program did not complete the required investigation documentation.
Violations (1)
Failure to ensure implementation of the established abuse and neglect policy regarding one tenant, including failure to immediately report alleged abuse and incomplete investigation documentation.
Report Facts
Number of tenants without cognitive impairment: 7
Number of tenants with cognitive impairment: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Alleged abuser in the abuse incident | |
| Staff B | Witness to the incident who did not immediately report it | |
| Staff C | Witness to the incident who did not immediately report it | |
| Staff D | Witness to the incident who did not immediately report it | |
| Staff E | Reported the allegation on 3/28/24; no longer employed at the program | |
| Executive Director | Executive Director | Signed note regarding investigation and provided statements about the incident |
Inspection Report — Aug 13, 2024
Enforcement
Date: Aug 13, 2024
Visit Reason
This citation was issued following investigation of an allegation of abuse involving Tenant #1 occurring on 3/27/24. The citation addresses failure to implement the established abuse and neglect policy.
Complaint Details
Type of Action: 119834-M
Findings
The program failed to ensure immediate reporting of an alleged abuse incident by multiple staff witnesses. Staff A was allowed to continue working after the incident until suspension on 3/28/24, and the program did not complete the required Investigation Report form.
Violations (1)
67.2(3) The program failed to implement its abuse and neglect policy by not ensuring immediate reporting of an alleged abuse incident on 3/27/24. Multiple staff witnesses did not report the incident promptly, and the program did not complete the required Investigation Report form.
Report Facts
Fine amount: 500
Inspection Report — Feb 28, 2024
Complaint Investigation
Date: Feb 28, 2024
Visit Reason
The inspection was conducted following investigations of incidents #114814-I, #114815-I and Complaint #116350-C, focusing on regulatory compliance related to staffing, tenant safety, and alarm system functionality.
Complaint Details
The visit was complaint-related, investigating incidents and a complaint involving tenant safety, staffing adequacy, and alarm system failures. Specific incidents included tenant elopements, verbal aggression, and inadequate supervision.
Findings
The facility failed to have sufficient staff to meet tenant needs, retained tenants dangerous to themselves or others, failed to supervise tenants according to service plans resulting in elopement and injury, and had a malfunctioning door alarm system affecting tenant safety.
Violations (4)
The program failed to have sufficient staff available to fully meet the needs of tenants.
The program retained tenants who were dangerous to themselves or others.
The program failed to supervise current tenants according to their service plans resulting in elopement and/or injury.
The program failed to ensure the building's alarm system worked properly, potentially affecting tenants with cognitive impairment.
Report Facts
Number of tenants without cognitive disorder: 19
Number of tenants with cognitive disorder: 16
Global Deterioration Scale score: 6
Number of tenants reviewed for danger to self or others: 4
Number of tenants reviewed for supervision: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reported on tenant toileting and skin issues, and door alarm problems | |
| Staff B | Reported on tenant verbal aggression and door alarm issues | |
| Staff C | Reported on tenant wounds and elopement attempts | |
| Director of Health and Wellness | Director of Health and Wellness | Provided assessments, updated service plans, and confirmed findings |
| Executive Director | Executive Director | Confirmed findings and reported on alarm system issues |
| Licensed Practical Nurse | Licensed Practical Nurse | Documented tenant elopement and alarm failures |
Inspection Report — Feb 26, 2024
Enforcement
Date: Feb 26, 2024
Visit Reason
This citation resulted from investigations and complaints (Investigations 114814-I, 114815-I, 116350-C, 116677-I) conducted from February 26 to 28, 2024, regarding supervision and alarm system failures at Bickford Cottage Iowa City.
Complaint Details
Investigations 114814-I, 114815-I, 116350-C, 116677-I
Findings
The program failed to supervise tenants according to their service plans, resulting in elopements and safety risks for Tenant #1. Additionally, the building's door alarm system was unreliable, failing to alert staff when tenants exited, affecting all 16 tenants with cognitive impairment.
Violations (2)
481-69.29(231C) Staffing: The program failed to supervise Tenant #1 according to his service plan, missing required hourly checks which led to elopements and safety risks. Staff did not consistently monitor Tenant #1 as required despite his cognitive impairment and history of elopements.
481-69.32(2) The program failed to ensure the door alarm system worked properly, resulting in alarms not sounding or staff not receiving alerts when tenants exited the building. This issue affected all 16 tenants with cognitive impairment and compromised their safety.
Report Facts
Fine amount: 5000
Inspection Report — Nov 8, 2022
Renewal
Date: Nov 8, 2022
Visit Reason
The visit was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program serving people with dementia.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #108743-C.
Findings
No regulatory insufficiencies were cited during the complaint investigation. However, deficiencies were cited during the recertification visit related to failure to ensure all personnel received the required eight hours of dementia-specific training within 30 days of employment for 2 of 3 staff members.
Violations (1)
Failure to consistently ensure all personnel received eight hours of dementia-specific training within 30 days of employment, pertaining to 2 of 3 staff members.
Report Facts
Number of tenants without cognitive impairment: 22
Number of tenants with cognitive impairment: 13
Hours of dementia-specific training completed by Staff B within 30 days: 5.5
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