Inspection Reports for
Bickford of Sioux City
4020 Indian Hills Dr, Sioux City, IA 51108, United States, IA, 51108
Back to Facility Profile11 Reports
Inspection Report — Apr 29, 2026
Routine
Date: Apr 29, 2026
Visit Reason
The visit was a routine inspection of Bickford Cottage II Sioux City, including investigations of Mandatory Abuse investigation #130976-I with no insufficiencies cited, and complaints #131538 and #131738-C which resulted in regulatory insufficiencies.
Complaint Details
Mandatory Abuse investigation #130976-I with no insufficiencies cited; Complaints #131538 and #131738-C with cited regulatory insufficiencies.
Findings
Two regulatory insufficiencies were cited: failure to consistently administer medications according to physician's orders for one former tenant (Tenant C6), and failure to consistently discharge tenants who exceeded retention criteria due to physical aggression placing others at risk, involving one former tenant (Tenant C5) and one current tenant (Tenant #4).
Violations (2)
481-67.5(2)e(3) Medications: The program failed to consistently administer Tenant C6's Tacrolimus as prescribed, missing multiple doses in March 2026 and failing to order the medication ten days prior as required by the service plan.
481-69.23(1)c(1-2) Criteria for Admission and Retention: The program failed to discharge tenants who exhibited physical aggression placing others at risk, including Tenant C5 and Tenant #4, despite documented incidents and service plans indicating need for intervention.
Inspection Report — Dec 10, 2025
Complaint Investigation
Date: Dec 10, 2025
Visit Reason
The visit was conducted to investigate Incidents #130237-I, #130595-I, #130877-I, Complaint #130719-C, and Incident #130809-M.
Complaint Details
Incidents #130237-I, #130595-I, #130877-I, #130809-M and Complaint #130719-C were investigated.
Findings
Two regulatory insufficiencies were cited related to program policies and procedures for incident and accident reporting, and staffing levels. The program failed to follow established policies for timely incident reporting and did not provide sufficient staffing to meet tenant needs.
Violations (2)
481-67.2(3) Program Policies and Procedures: The program failed to follow established policy regarding incident and accident reporting for one of eight tenants reviewed. An incident report was created four days after the suspected abuse occurred.
481-67.9(1) Staffing: The program failed to provide adequate staff to meet the identified needs of one of eight tenants reviewed. Staffing shortages and early staff departures left insufficient personnel to assist with tenant transfers and care.
Inspection Report — Aug 7, 2025
Recertification
Date: Aug 7, 2025
Visit Reason
The visit was conducted to investigate Incident #128254-I, Complaint #128809-C, and to perform the recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Complaint #128809-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation and recertification visit.
Report Facts
Number of tenants without cognitive impairment: 0
Number of tenants with cognitive impairment: 20
Inspection Report — Feb 25, 2025
Complaint Investigation
Date: Feb 25, 2025
Visit Reason
The inspection was conducted to investigate complaints #124657-C, #126350-I, and #125646-C related to the assisted living program for people with dementia.
Complaint Details
Complaint #125646-C was substantiated with a finding that the service plan for Tenant #3 was not updated to reflect physician-ordered changes for pressure ulcers and related care.
Findings
No regulatory insufficiencies were found for complaints #124657-C and #126350-I. However, a regulatory insufficiency was cited for complaint #125646-C due to failure to update the service plan for Tenant #3 following significant changes in health condition.
Violations (1)
Program failed to update service plans with significant change for Tenant #3, including pressure sore and blister care instructions.
Report Facts
Number of tenants without cognitive impairment: 25
Number of tenants with cognitive impairment: 25
Pressure sore size: 3
Blister size: 2
Inspection Report — Nov 1, 2023
Complaint Investigation
Date: Nov 1, 2023
Visit Reason
The inspection was conducted to investigate complaints related to tenant safety during transportation and tenant rights regarding pest control and staff training.
Complaint Details
The investigation was triggered by complaints #115919-C and 116546-C. No regulatory insufficiencies were found during investigations of incidents #115785-I and 116547-I. The complaint investigation substantiated failures in transportation supervision, pest control response, and staff training compliance.
Findings
The program failed to consistently follow its transportation policy, resulting in a tenant being left unattended on a bus for approximately one hour and 40 minutes in high heat conditions. Additionally, the program did not timely address reported bed bug infestations affecting a tenant and failed to ensure all staff received the required eight hours of dementia-specific education annually.
Violations (3)
Failed to consistently follow the program's transportation policy, leaving Tenant #4 unattended on the bus.
Failed to consistently ensure reported bed bugs were addressed in a timely manner and did not provide alternative sleeping arrangements for Tenant #1.
Failed to consistently ensure all staff received eight hours of dementia-specific education annually.
Report Facts
Duration tenant left unattended: 100
Temperature: 86
Dementia-specific training hours: 3.5
Required dementia-specific training hours: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Admitted to leaving Tenant #4 unattended on the bus | |
| Staff C | Did not complete required eight hours of dementia-specific training | |
| Director | Program Director | Confirmed failures in transportation supervision and pest control response |
Inspection Report — Oct 31, 2023
Enforcement
Date: Oct 31, 2023
Visit Reason
This citation was issued following investigations #115785-I, #115979-C, #226547-I, and #116546-C conducted from October 31, 2023 to November 1, 2023.
Findings
The program failed to consistently follow its transportation policy by leaving Tenant #4 unattended and restrained on the bus for approximately one hour and 40 minutes, resulting in the tenant being taken to the Emergency Room for possible heat exhaustion and dehydration.
Violations (1)
IAC 481-67.2(3) The program failed to consistently follow its transportation policy by leaving Tenant #4 unattended and restrained on the bus for approximately one hour and 40 minutes. Tenant #4 was found on the bus at another building and required emergency medical treatment for possible heat exhaustion and dehydration.
Report Facts
Fine amount: 5500
Inspection Report — Aug 16, 2023
Renewal
Date: Aug 16, 2023
Visit Reason
Recertification visit conducted to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the recertification visit or during investigations #114013-I and 11604-I.
Report Facts
Number of tenants without cognitive impairment: 0
Number of tenants with cognitive impairment: 35
Inspection Report — Mar 16, 2022
Complaint Investigation
Date: Mar 16, 2022
Visit Reason
The inspection was conducted following the investigation of Incident #102863-I involving a tenant elopement and failure to follow resident monitoring policies.
Complaint Details
The visit was complaint-related, investigating Incident #102863-I involving a tenant elopement on 2/28/22. The complaint was substantiated based on findings of policy noncompliance and system failures.
Findings
The facility failed to follow its resident monitoring system policy, resulting in a tenant with dementia eloping without triggering alarms due to a missing watch battery and unauthorized access to door codes. The service plan was not updated to reflect increased supervision needs, and alarm system checks were not properly documented. The alarm system was not fully effective, and staff failed to detect the elopement in a timely manner.
Violations (4)
Failure to follow resident monitoring system policy for Tenant #1 leading to elopement.
Failure to provide adequate and appropriate care, treatment, and services for Tenant #1 with dementia and exit-seeking behavior.
Failure to update service plans to reflect increased supervision needs for Tenant #1.
Failure to ensure an operating alarm system was connected to each exit door in the dementia unit.
Report Facts
Number of tenants: 34
Number of tenants with cognitive disorder: 33
Number of tenants without cognitive disorder: 1
Global Deterioration Score: 5
Number of tenants wearing Watch alarm system: 26
Exit door inspections frequency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse | Reported Tenant #1's watch was missing its battery on the evening of 2/28/22 and confirmed failure of alarm system | |
| Staff C | Former Maintenance Man | Confirmed failure to use HomeFree System Testing Procedure and failure to document alarm system checks |
| Administrator | Confirmed no completed HomeFree System Testing Procedure Checklist was found | |
| Nurse | Confirmed findings related to failure to update service plan and alarm system issues |
Inspection Report — Mar 9, 2022
Enforcement
Date: Mar 9, 2022
Visit Reason
This citation was issued following a survey conducted from March 9 to March 16, 2022, regarding the facility's failure to provide adequate and appropriate care, treatment, and services to a tenant, specifically Tenant #1, who eloped from the facility.
Findings
The facility failed to maintain effective monitoring and alarm systems to prevent Tenant #1, who had moderately severe cognitive decline, from eloping. Staff did not detect the elopement on alarms, and the tenant's safety monitoring watch was missing its battery, rendering it nonfunctional. Documentation and maintenance of the monitoring system were inadequate.
Violations (1)
481-67.3(2) Tenant rights: The program failed to provide adequate and appropriate care, treatment, and services for Tenant #1, who eloped due to ineffective alarm systems and a nonfunctional safety monitoring watch missing its battery. Staff failed to document alarm system checks and did not detect the elopement on their pagers.
Report Facts
Fine amount: 2000
Inspection Report — Sep 30, 2021
Renewal
Date: Sep 30, 2021
Visit Reason
The inspection was a recertification visit to determine compliance with certification of an Assisted Living Program for people with Dementia.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaints #92962-C and #93151-C.
Findings
The inspection identified regulatory insufficiencies related to dependent adult abuse training, background checks prior to employment, retention criteria for tenants requiring two-person assistance, and dementia-specific education for personnel. No deficiencies were found during complaint investigations or infection control survey.
Violations (4)
Failed to provide required two hours of dependent adult abuse training within 6 months of employment for 3 of 7 staff reviewed.
Failed to complete criminal, child, and dependent adult abuse background checks prior to employment for 2 of 7 staff reviewed.
Retained tenants who routinely required the assistance of at least two staff with standing, transfer, or evacuation, contrary to retention criteria.
Failed to provide eight hours of dementia-specific education and training within 30 days of employment for 2 of 7 staff reviewed.
Report Facts
Staff reviewed: 7
Tenants reviewed: 4
Discharged tenants reviewed: 4
Dependent adult abuse training deficiency: 3
Background check deficiency: 2
Dementia training deficiency: 2
Inspection Report — Nov 6, 2019
Renewal
Date: Nov 6, 2019
Visit Reason
The inspection was conducted as a recertification to determine compliance with certification for an Assisted Living Program - Dementia Specific.
Findings
The program failed to consistently discharge tenants who exceeded admission/discharge criteria and did not ensure all personnel received required dementia-specific education within 30 days of employment.
Violations (2)
The Program failed to consistently discharge tenants who exceed admission/discharge criteria.
All personnel employed by or contracting with a dementia-specific program did not receive a minimum of eight hours of dementia-specific education and training within 30 days of employment for 1 of 3 staff reviewed.
Report Facts
Staff reviewed: 3
Staff not compliant: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Did not complete dementia training within 30 days of employment | |
| Staff A | Director | Confirmed Staff B had not completed training within required time period |
Viewing
Loading inspection reports...
