Inspection Reports for
Bickford of Marion
1100 Linden Dr, Marion, IA 52302, United States, IA, 52302
Back to Facility Profile8 Reports
Inspection Report — May 19, 2026
Complaint Investigation
Date: May 19, 2026
Visit Reason
Investigation of Complaint #131255-C regarding program policies and procedures, narcotics protocol, medications, and staffing.
Complaint Details
Complaint #131255-C
Findings
The program failed to develop and implement policies and procedures for incident reports, narcotic medication reconciliation and destruction, medication administration, and staffing consistent with tenant needs. Multiple tenants experienced medication errors, incomplete evaluations, and behavioral management issues. No incident reports were completed for documented injuries and physical aggression.
Violations (7)
481-67.2(1)a Program Policies and Procedures: The program failed to develop and implement a policy and procedure for incident reports that included specific record retention requirements. This systemic failure likely affected all 37 tenants.
481-67.2(1)n Program Policies and Procedures: The program failed to develop and implement a comprehensive narcotic protocol including policies and procedures for narcotic medication reconciliation and destruction. This affected all 35 tenants receiving medications.
481-67.5(2)e(3) Medications: The program failed to administer medications and treatments as prescribed by the resident’s physician, ARNP or PA. One tenant was observed receiving ophthalmic drops in only one eye instead of both as ordered, and medication administration records lacked documentation of administered doses.
481-67.9(4)f Staffing: The program failed to ensure care and services were provided in accordance with the resident’s individual service plan and established staff training guidelines. Behavioral interventions and dementia training were incomplete, and staff failed to implement prescribed interventions for a tenant exhibiting combative behavior.
481-69.22(3) Evaluation of Tenant: The program failed to ensure comprehensive evaluations were completed as required to address significant changes in residents’ physical, behavioral, or clinical conditions. This noncompliance pertained to 2 of 3 current tenants and 3 discharged tenants.
481-69.25(1)o Tenant Documents: The program failed to ensure separate incident reports were completed and maintained when required for tenant injuries and physical aggression towards staff and other residents. This noncompliance pertained to 1 of 3 discharged tenants reviewed.
481-69.26(3) Service Plans: The program failed to ensure service plans were updated within 30 days of tenant occupancy and as needed with significant changes. This noncompliance pertained to 1 of 3 discharged tenants reviewed.
Inspection Report — Jan 7, 2025
Renewal
Date: Jan 7, 2025
Visit Reason
The inspection was a recertification visit conducted to determine compliance with certification rules for a Dedicated Dementia-Specific Assisted Living Program.
Findings
The program failed to administer medications and treatments as prescribed, failed to complete evaluations with significant change, failed to document routine cares on individualized task sheets, failed to update service plans as needed, and failed to have a licensed dietitian review procedures for therapeutic diets and to provide food at required temperatures.
Violations (6)
The program failed to administer medications and treatments as prescribed.
The program failed to complete evaluations as needed with significant change.
The program failed to document routine cares on individualized task sheets.
The program failed to update service plans as needed to reflect the identified needs of the tenants.
The program failed to have a licensed dietitian review procedures for food preparation and service for therapeutic diets.
The program failed to provide food at required temperatures.
Report Facts
Number of tenants without cognitive impairment: 20
Number of tenants with cognitive impairment: 15
Blood glucose readings: 8
Sliding scale insulin units: 13
Dates of blood glucose readings less than 60: 7
Dates of blood glucose readings less than 60: 4
Weight loss: 20
Weight loss: 12
Temperature readings: 46.9
Temperature readings: 126.7
Inspection Report — Dec 18, 2024
Renewal
Date: Dec 18, 2024
Visit Reason
The visit was a recertification visit to determine compliance with certification of an Assisted Living Program.
Findings
The program failed to administer medications and treatments as prescribed to Tenant #4, who experienced a seizure due to hypoglycemia and was found on the floor foaming at the mouth. Several medication administration errors and omissions were documented, including failure to monitor blood glucose as ordered and failure to administer glucose chews when blood glucose was low.
Violations (1)
67.5(2)f(4) Medications: The program failed to administer medications and treatments as prescribed to Tenant #4, who experienced a seizure from hypoglycemia after missed blood glucose monitoring and improper insulin administration. Staff did not document blood glucose checks as ordered and failed to administer glucose chews when blood glucose was below 60.
Report Facts
Fine amount: 4000
Inspection Report — Jun 4, 2024
Complaint Investigation
Date: Jun 4, 2024
Visit Reason
Complaint #116237-C was investigated regarding regulatory insufficiencies related to incident reporting, tenant rights, evaluations, retention criteria, service plans, and building maintenance at Bickford Cottage Marion.
Complaint Details
Complaint #116237-C was investigated and multiple regulatory insufficiencies were identified related to incident reporting, tenant rights, evaluations, retention criteria, service plans, and building maintenance.
Findings
The investigation identified multiple deficiencies including incomplete incident report policies and procedures, failure to follow incident report policies, failure to treat a tenant with dignity and autonomy, incomplete tenant evaluations, failure to discharge a tenant exceeding retention criteria, outdated service plans, and poor building maintenance with stained and frayed carpeting posing safety risks.
Violations (7)
The program failed to have a policy and procedure regarding incident reports that included statements from witnesses.
The program failed to follow their policy and procedure related to the completion of incident reports for Tenant #2.
The program failed to ensure Tenant #1 was treated with consideration, respect, and full recognition of personal dignity and autonomy.
The program failed to complete evaluations as needed with significant change for Tenants #1 and #2.
The program failed to discharge Tenant #2 who required routine two-person assistance with transfers, exceeding retention criteria.
The program failed to update service plans as needed for Tenants #1, #2, and #3.
The program failed to maintain a well-maintained, clean, and safe building; carpets were heavily stained, frayed, and posed a fall risk.
Report Facts
Tenants without cognitive impairment: 22
Tenants with cognitive impairment: 13
Number of tenants reviewed: 3
Number of falls Tenant #2 had in past 180 days: 5
Frequency of carpet cleaning: 3
Inspection Report — Oct 13, 2022
Annual Inspection
Date: Oct 13, 2022
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program and to investigate Complaint #101953-C.
Complaint Details
The inspection included investigation of Complaint #101953-C related to tenant care and incident reporting.
Findings
The inspection identified multiple regulatory deficiencies including failure to follow incident reporting policies, failure to treat a tenant with dignity related to hospital discharge and return, failure to provide nurse delegation training within 30 days for some staff, failure to document nurse's notes by exception, failure to update tenant service plans as needed, and failure to ensure exit doors were alarmed at all times.
Violations (6)
Failure to follow established policies and procedures regarding incident reporting for tenants.
Failure to ensure a tenant was treated with respect, consideration, and dignity related to an emergency room visit and return to the program.
Failure to ensure staff received nurse delegated training within 30 days of employment.
Failure to document nurse's notes by exception for multiple tenants.
Failure to update service plans as needed and ensure service plans reflected the identified needs of tenants.
Failure to ensure the exit doors were alarmed at all times in a dementia-specific program.
Report Facts
Tenants without cognitive impairment: 27
Tenants with cognitive impairment: 11
Staff training delay days: 32
Staff training delay days: 124
30 day notice for discharge: 30
Inspection Report — Sep 2, 2021
Complaint Investigation
Date: Sep 2, 2021
Visit Reason
The inspection was conducted to investigate complaints #98918-C, #98977-I, and #99404-C, and included an onsite infection control survey.
Complaint Details
The investigation of Complaint #99404-C revealed regulatory insufficiencies related to infection control and communicable disease preparedness. Complaints #98918-C and #98977-I were investigated with no regulatory insufficiencies cited.
Findings
No regulatory insufficiencies were found for complaints #98918-C and #98977-I. However, during the investigation of complaint #99404-C and the infection control survey, the program failed to follow its communicable and contagious disease preparedness plan, specifically failing to consistently document daily temperature and symptom monitoring for tenants as required by policy.
Violations (1)
Failure to follow policy and procedures for communicable and contagious disease preparedness plan, including inconsistent documentation of daily temperatures and symptoms for all tenants.
Report Facts
Number of tenants: 28
Date of health check screenings: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Coordinator | Confirmed staff failed to consistently document tenants' temperatures and symptoms as required by policy |
Inspection Report — Mar 4, 2021
Complaint Investigation
Date: Mar 4, 2021
Visit Reason
The inspection was conducted as an onsite infection control survey and investigation of Complaint #92042-C regarding regulatory insufficiencies in program policies and procedures, tenant evaluations, and service plans.
Complaint Details
The investigation was triggered by Complaint #92042-C. The complaint was substantiated with findings related to inadequate policies for head injuries, incomplete evaluations, and outdated service plans for tenants.
Findings
The program failed to establish an accident and emergency response policy that included provisions for head injuries, failed to complete tenant evaluations as needed with significant change, and failed to update service plans accordingly. Specific deficiencies were identified for four tenants, including inadequate response to falls and head injuries, incomplete evaluations after significant health changes, and outdated service plans.
Violations (3)
Failed to establish an accident and emergency response policy that included provisions for head injuries.
Failed to complete tenant evaluations as needed with significant change for 4 tenants reviewed.
Failed to update service plans as needed with significant change for 4 tenants reviewed.
Report Facts
Weight loss: 24
Number of tenants reviewed: 4
Staples received: 5
Inspection Report — Jan 23, 2020
Complaint Investigation
Date: Jan 23, 2020
Visit Reason
The inspection was conducted to investigate Complaint #87457-C, Incident #88018-I, and to perform a recertification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Complaint Details
The visit was triggered by Complaint #87457-C and Incident #88018-I. The complaint involved allegations of tenant mistreatment and failure to provide adequate care. The investigation included interviews, record reviews, and observations. Staff M and Staff N were suspended and Staff N was terminated due to tenant rights violations.
Findings
The program failed to ensure tenants were treated with consideration, respect, and full recognition of personal dignity and autonomy, failed to discharge a tenant requiring routine two-person assistance with transfers, failed to update service plans to reflect tenant needs, failed to ensure staff serving food had proper training, failed to ensure dementia-specific education for staff within 30 days of employment, and failed to administer medications as prescribed by the tenant's physician.
Violations (6)
Program failed to ensure tenants were treated with consideration, respect, and full recognition of personal dignity and autonomy.
Program failed to discharge a tenant who required a routine two-person assist with transfers.
Program failed to update service plans as needed and failed to ensure service plans reflected the identified needs of the tenants.
Program failed to ensure staff who served food had an orientation on sanitation and safe food handling prior to handling food and an annual in-service training on food protection.
Program failed to ensure all staff employed by the program completed eight hours of dementia-specific education and training within 30 days of employment.
Program failed to administer medications as prescribed by the tenant's physician.
Report Facts
Tenants without cognitive disorder: 31
Tenants with cognitive disorder: 7
Tenants with cognitive disorder: 6
Tenants affected by tenant rights deficiency: 8
Staff reviewed for food safety training: 8
Staff required dementia-specific education: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Named in tenant rights violation and abuse allegations; denied allegations but was suspended and terminated. | |
| Staff N | Named in tenant rights violation and abuse allegations; denied allegations but was suspended and terminated. | |
| Staff L | Conducted interviews and reported tenant concerns. | |
| Staff D | Reported concerns regarding Staff N's interactions with tenants. | |
| Staff G | Reported tenant transfer needs and interactions. | |
| Staff F | Reported on tenant shower and transfer incidents. | |
| Director | Interviewed regarding tenant concerns and staff suspensions. | |
| RN Coordinator | Registered Nurse Coordinator | Performed nursing assessments and service plans for tenants as part of plan of correction. |
| Staff B | Received training on food safety and sanitation. | |
| Staff E | Received training on food safety and sanitation. | |
| Staff A | Failed to complete dementia-specific education within 30 days; no longer employed. |
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