Inspection Reports for
Bickford of West Des Moines
5050 Hawthorne Dr, West Des Moines, IA 50265, United States, IA, 50265
Back to Facility Profile12 Reports
Inspection Report — Jan 26, 2026
Renewal
Date: Jan 26, 2026
Visit Reason
The visit was a recertification (renewal) visit for an Assisted Living Program for People with Dementia and included investigation of Complaint #130762-C and Incident #130871-I.
Complaint Details
Complaint #130762-C and Incident #130871-I were investigated with no insufficiencies cited.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint and incident.
Inspection Report — Oct 15, 2025
Complaint Investigation
Date: Oct 15, 2025
Visit Reason
The inspection was conducted to investigate complaints numbered 129980-C and 130554-C at the assisted living facility.
Complaint Details
Investigation of Complaints 129980-C and 130554-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Report Facts
Tenants without cognitive impairment: 31
Tenants with cognitive impairment: 4
Inspection Report — Jul 9, 2025
Complaint Investigation
Date: Jul 9, 2025
Visit Reason
Investigation of complaints numbered 127855-C, 128455-C, and 128653-C at the assisted living facility.
Complaint Details
Investigation of Complaints 127855-C, 128455-C, and 128653-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Report Facts
Number of tenants without cognitive impairment: 29
Number of tenants with cognitive impairment: 2
Inspection Report — Apr 1, 2025
Renewal
Date: Apr 1, 2025
Visit Reason
The inspection was conducted as 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 investigations of Complaints #121111-C and #121112-C.
Findings
No regulatory insufficiencies were cited during complaint investigations, but one regulatory insufficiency was cited during the recertification visit related to the program retaining a tenant who routinely required two staff to assist with transfers.
Violations (1)
Program retained 1 of 4 tenants reviewed who routinely required two staff to assist with transfers, which is against admission/retention criteria.
Report Facts
Number of tenants without cognitive impairment: 31
Number of tenants with cognitive impairment: 2
Residents reviewed requiring two staff assistance: 1
Date deficiencies corrected by: May 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed and observed regarding Tenant #3's care needs and transfer assistance. | |
| Staff B | Interviewed and agreed Tenant #3 required two staff assistance. | |
| Staff C | Observed assisting Tenant #3 and commented on transfer difficulties. | |
| Staff D | Observed assisting Tenant #3 and involved in transfer attempts. | |
| Staff E | Interviewed about Tenant #3's assistance needs and concerns about staff safety. | |
| Staff F | Agreed with Staff C about transfer difficulties. | |
| Staff G | Staff on duty who responded to Tenant #3's call for assistance. | |
| Staff H | Staff on duty who responded to Tenant #3's call for assistance. | |
| Director of Health and Wellness | Director of Health and Wellness (DHW) | Interviewed and confirmed findings regarding Tenant #3's care and transfer assistance. |
| Physician Assistant-Certified | Physician Assistant-Certified (PA-C) | Reviewed Tenant #3 and ordered therapy services. |
| Divisional Director of Health and Wellness | Provided re-education and will monitor compliance as part of the plan of correction. |
Inspection Report — Sep 12, 2023
Complaint Investigation
Date: Sep 12, 2023
Visit Reason
The inspection was conducted to investigate Incident 110612-I and Complaints #113474-C, 111027-C, and 110601-C at the assisted living facility.
Complaint Details
Investigation of Incident 110612-I and Complaints #113474-C, 111027-C, 110601-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the incident and complaints.
Report Facts
Number of tenants without cognitive impairment: 22
Number of tenants with cognitive impairment: 5
Inspection Report — Jan 23, 2023
Complaint Investigation
Date: Jan 23, 2023
Visit Reason
The inspection was conducted to investigate Complaints #105218-C and 107992-C and to conduct 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 Complaint #108093-C. Deficiencies were cited during the investigation of Complaints #105218-C and 107992-C.
Findings
The Program failed to consistently perform criminal history and background checks prior to employment, failed to ensure all personnel including contract/agency staff were appropriately trained, and failed to ensure staff received eight hours of dementia-specific training annually. These deficiencies potentially affected all 20 tenants.
Violations (3)
Failed to consistently perform criminal history and background checks prior to employment.
Failed to consistently ensure all personnel including contract/agency staff were appropriately trained to meet tenant needs.
Failed to consistently ensure staff received eight hours of dementia-specific training annually.
Report Facts
Number of tenants without cognitive impairment: 12
Number of tenants with cognitive impairment: 8
Tenants potentially affected: 20
Tenants potentially affected: 20
Tenants potentially affected: 20
Agency/contract staff reviewed: 2
Inspection Report — Jun 8, 2022
Plan of Correction
Date: Jun 8, 2022
Visit Reason
The document is a plan of correction related to investigations of incidents and complaints at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigations of Incident #98855-I or Complaints #98402-C, #98848-C, #101334-C, and #103167-C.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 19
Number of tenants with cognitive disorder in General Population Program: 3
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 5
Inspection Report — Apr 26, 2021
Renewal
Date: Apr 26, 2021
Visit Reason
Recertification visit conducted to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the recertification visit, infection control survey, or investigation of incidents. However, deficiencies were found related to dependent adult abuse training, record checks, criteria for admission/retention of tenants, and dementia-specific education for personnel.
Violations (4)
Program failed to provide staff the required two hours of dependent adult abuse training within six months of employment for 3 of 8 staff reviewed (Staff B, Staff C, and Staff E).
Program failed to complete criminal, child, and dependent adult abuse background checks prior to employment for 2 of 8 staff reviewed (Staff C and Staff D).
Program failed to ensure tenants continued to meet criteria for retention of an assisted living program for people with dementia, specifically for 2 of 4 tenants reviewed who required routine two-person assistance with standing, transfer, or evacuation.
Program failed to provide the required eight hours of dementia-specific education and training within 30 days of employment for 3 of 8 staff reviewed (Staff B, Staff D, and Staff E).
Report Facts
Number of tenants without cognitive disorder: 19
Number of tenants with cognitive disorder: 5
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 6
Staff reviewed: 8
Tenants reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in deficiencies related to dependent adult abuse training and dementia-specific education | |
| Staff C | Named in deficiencies related to dependent adult abuse training and record checks | |
| Staff D | Named in deficiencies related to record checks and dementia-specific education | |
| Staff E | Named in deficiencies related to dependent adult abuse training and dementia-specific education | |
| Registered Nurse Coordinator | Registered Nurse Coordinator | Confirmed findings related to tenant care needs and transfers |
Inspection Report — Oct 15, 2020
Complaint Investigation
Date: Oct 15, 2020
Visit Reason
The inspection was conducted as an investigation of Complaint #93587-C regarding regulatory insufficiencies in the Assisted Living Program for People with Dementia.
Complaint Details
Complaint #93587-C was investigated and regulatory insufficiencies were cited related to program policies and procedures for incident reports and communicable disease preparedness.
Findings
The program failed to follow policies and procedures related to communicable disease preparedness, screening of tenants and staff, and enforcement of mask-wearing and social distancing. Several staff failed to properly screen for COVID-19 symptoms, and tenant screenings were not consistently documented.
Violations (1)
Program failed to follow policies and procedures for communicable and contagious disease preparedness and lifting of restricted access, affecting all 32 tenants.
Report Facts
Number of tenants without cognitive disorder in general population: 27
Number of tenants with cognitive disorder in general population: 3
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 4
Number of tenants potentially affected by failure to follow policies: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Judy Swartzel | RN | Led infection control team for return to work procedures after positive COVID-19 tests |
Inspection Report — Sep 23, 2020
Complaint Investigation
Date: Sep 23, 2020
Visit Reason
The inspection was conducted as part of an investigation of Complaint 89775-C regarding the retention of tenants who exceeded the level of care.
Complaint Details
Investigation of Complaint 89775-C found the program retained a tenant (Tenant #1) who required routine two-person assistance with transfers and toileting, exceeding the level of care allowed.
Findings
The program failed to ensure tenants who exceeded the level of care were discharged, specifically Tenant #1 who required routine two-person assistance with transfers and toileting but was retained. Observations and interviews confirmed staff did not routinely transfer Tenant #1 during meals and that the tenant required maximal assistance with all transfers and daily activities.
Violations (1)
Failed to ensure tenants who exceeded level of care were discharged, specifically Tenant #1 requiring routine two-person assistance with standing, transfer, or evacuation.
Report Facts
Number of tenants without cognitive disorder: 35
Number of tenants with cognitive disorder: 3
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Coordinator | Registered Nurse Coordinator (RNC) | Interviewed regarding Tenant #1's transfer status and care needs |
| Program Director | Program Director | Acknowledged Tenant #1's responsiveness and ability to assist |
Inspection Report — Jan 27, 2020
Life Safety
Date: Jan 27, 2020
Visit Reason
The inspection was conducted to evaluate compliance with life safety-emergency policies and structural safety requirements, specifically focusing on the operating alarm system connected to each exit door in a dementia-specific program.
Findings
The facility failed to consistently ensure operating alarm systems were attached and functional on each exit door, resulting in a tenant exiting the building without staff knowledge. The door alarm system was found to be malfunctioning due to a pager system error and lack of maintenance after the responsible maintenance man quit.
Violations (1)
Failure to consistently ensure operating alarm systems attached to each exit door in a dementia-specific program, allowing a tenant to exit without staff knowledge.
Report Facts
Date survey completed: Jan 27, 2020
Date of incident report: Jan 19, 2020
Date of last door alarm check: Nov 21, 2019
Temperature at time of incident: 4
Wind chill: -13
Tenant body temperature: 97.8
Tenant cognitive assessment score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reported tenant found outside, assisted tenant, and provided vital signs information | |
| Staff B | Reported hearing someone calling for help and assisted in locating tenant | |
| Staff C | Notified about pager system malfunction and tenant location | |
| Director | Confirmed no assessment was done immediately after incident and investigated pager system malfunction | |
| Certified Medication Aide (CMA) | Confirmed no physical assessment was completed on night of incident |
Inspection Report — Jan 22, 2020
Enforcement
Date: Jan 22, 2020
Visit Reason
This citation resulted from investigations #87296-C and 88325-I conducted from January 22 to January 27, 2020, regarding an incident where Tenant #1 exited the building without staff knowledge due to a malfunctioning alarm system on the dementia-specific program exit door.
Complaint Details
Investigations #87296-C and 88325-I
Findings
The program failed to consistently ensure operating alarm systems were attached to each exit door in the dementia-specific program, resulting in Tenant #1 leaving the building unnoticed and being found outside in cold weather with bruising and wet clothes.
Violations (1)
69.32(2) An operating alarm system was not consistently connected to each exit door in the dementia-specific program. Tenant #1 exited the building without staff knowledge and was found outside in cold weather with bruising and wet clothes.
Report Facts
Fine amount: 1000
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