Inspection Reports for Bickford of Ames
2418 Kent Ave, Ames, IA 50010, United States, IA, 50010
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 23, 2025, found deficiencies related to medication administration, incident reporting, tenant care, staff training, and service plan documentation. Earlier inspections showed a recurring pattern of issues with medication management, nurse delegation and training, incident reporting, and meeting tenants’ individualized care needs. Complaint investigations frequently cited deficiencies involving medication errors, incomplete or untimely service plans, and failure to consistently follow policies and procedures. Enforcement actions included a $1,000 civil penalty in 2012 for retaining a tenant who exceeded the assisted living level of care, and a $500 civil penalty in 2009 for incomplete employee record checks; no fines or license actions were listed in the most recent reports. The inspection history indicates ongoing challenges in medication administration and staff training, with some fluctuations but no clear sustained improvement over time.
Deficiencies (last 16 years)
Deficiencies (over 16 years)
2.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
41% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
25 residents
Based on a October 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 8
Date: Oct 23, 2025
Visit Reason
The inspection was conducted as a complaint investigation triggered by multiple complaints and incidents involving tenant care and medication administration at Bickford Cottage Ames.
Complaint Details
The investigation was triggered by complaints #130042-C, #130556-C, and #130320-C, and incidents #129801-I and #130066-I. No regulatory insufficiencies were cited during the investigation of complaints #130042-C and #130556-C, but deficiencies were cited during the other investigations.
Findings
The program failed to complete incident reports following tenant falls, did not follow medication administration policies affecting multiple tenants, failed to provide appropriate care and sanitary living conditions, did not respond reasonably to tenant and family requests, and had deficiencies in staff training and documentation. Several tenants experienced medication errors, lack of proper assessments, and inadequate service plans.
Deficiencies (8)
Program staff failed to complete an incident report following a fall of Tenant #2.
Failure to follow established medication administration policy affecting multiple tenants including failure to administer prescribed medications and maintain accurate medication records.
Failure to provide appropriate care and sanitary living conditions, including failure to assess Tenant #2's pain and failure to maintain clean bedding.
Failure to provide reasonable response to requests from tenants and their representatives, including communication and care concerns.
Newly hired nurse failed to ensure all certified and noncertified staff were trained and delegated properly.
Failure to protect Medication Error Report forms and task sheets from loss.
Failure to ensure service plans were developed prior to signing occupancy agreements and taking possession of apartments.
Failure to update service plans within 30 days of significant change, including failure to update for aggressive behaviors and medication refusal.
Report Facts
Total census: 25
Medication errors: 16
Medication errors by Staff E: 11
Medication errors by Staff B: 2
Medication errors total: 16
Medication administration days missed: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Present during Tenant #2 fall and reported HWD was dismissive of pain complaints | |
| Staff B | Medication aide involved in medication administration errors and interviewee regarding medication issues | |
| Staff C | Staff involved in Tenant #2 fall incident and pain reporting | |
| Staff D | Checked Tenant #2's vitals after fall and reported no injuries | |
| Staff E | Made multiple medication errors before removal from medication tasks | |
| Staff F | Reported Tenant #2's pain and need to see doctor | |
| Staff G | Reported concerns about Tenant #2's condition and pain | |
| Staff H | Reported on bed making practices and lack of delegation | |
| Staff I | Reported on catheter care and lack of delegation | |
| Staff J | Reported not being delegated by former HWD | |
| Staff K | Reported Tenant #3 independence and catheter bag emptying | |
| Former Health and Wellness Director | Responsible for medication administration oversight, delegated staff, and involved in medication error reporting | |
| Divisional Director of Health and Wellness | Confirmed findings, involved in oversight and corrective actions | |
| Executive Director | Involved in communication with families and oversight |
Inspection Report
Recertification
Census: 30
Deficiencies: 2
Date: May 29, 2025
Visit Reason
The visit was conducted as a recertification survey to determine compliance with certification rules for an Assisted Living Program for People with Dementia and to investigate Complaint #127410-C.
Complaint Details
Complaint #126990-C was investigated with no regulatory insufficiencies cited. Complaint #127410-C was investigated during the recertification visit and deficiencies were cited related to nurse delegation and medication administration.
Findings
The inspection found regulatory insufficiencies related to nurse delegation procedures, including failure to provide staff training within 30 days of employment for 2 of 4 staff reviewed, and failure to administer eye drops according to training for 1 staff member observed. No deficiencies were cited during the investigation of Complaint #126990-C.
Deficiencies (2)
Program's registered nurse failed to provide training to staff within 30 days of employment for 2 of 4 staff reviewed (Staff A and Staff B).
Program failed to administer eye drops according to training provided; Staff C did not sanitize hands between tenants and touched the eye with the dropper.
Report Facts
Number of tenants without cognitive impairment: 10
Number of tenants with cognitive impairment: 20
Total census: 30
Staff reviewed for training compliance: 4
Staff not trained within 30 days: 2
Tenants observed during medication pass: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kelly Kane | Health and Wellness Director | Named in plan of correction and re-education of staff on nurse delegation and medication administration |
| Staff A | Staff member not trained within 30 days and involved in medication administration deficiency | |
| Staff B | Staff member not trained within 30 days | |
| Staff C | Staff member observed administering eye drops incorrectly |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Date: Feb 20, 2025
Visit Reason
The inspection was conducted to investigate complaints and incidents related to the facility's care and services, specifically Complaint #122671-C and Incidents #126036-I and 124935-C.
Complaint Details
The complaint investigation found that the facility failed to ensure Tenant #2 received medications as ordered, with missed doses of Clonazepam on 7/17/24 through 7/24/25. The Director confirmed the Program's responsibility for medication administration but was unsure why medications were not available.
Findings
No regulatory insufficiencies were found during the incident investigations, but a regulatory insufficiency was cited during the complaint investigation for failing to consistently ensure tenants received adequate and appropriate services, specifically related to medication administration for Tenant #2.
Deficiencies (1)
The Program failed to administer Clonazepam .5 mg as ordered to Tenant #2 on multiple dates and times, despite having responsibility via the service plan to ensure medication administration.
Report Facts
Number of tenants without cognitive impairment: 20
Number of tenants with cognitive impairment: 15
Total census: 35
Missed medication administration dates: 9
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 2
Date: May 1, 2024
Visit Reason
The inspection was conducted to investigate complaints and incidents related to medication administration and care practices at Bickford Cottage Ames.
Complaint Details
The visit was complaint-related involving Mandatory Report #118579-M, Incident #115002-I, Complaint #116715-C, Incident #119906-I, and Complaint #116015. No regulatory insufficiencies were found for the first set of complaints, but deficiencies were cited during the investigation of Incident #119906-I and Complaint #116015.
Findings
The investigation found staff failed to follow medication administration policies, resulting in multiple medication errors involving Tenant #1. Additionally, the program failed to document personal care tasks for Tenant #1 on daily task sheets as required.
Deficiencies (2)
Staff failed to follow established policies regarding medication administration, leading to multiple medication errors involving Tenant #1.
The program failed to document all personal cares on daily task sheets for Tenant #1.
Report Facts
Number of tenants without cognitive impairment: 23
Number of tenants with cognitive impairment: 14
Total census: 37
Medication doses involved in errors: 4
Medication doses involved in errors: 2
Physician orders for Magnesium 64 SR: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Reported medication errors and intervened during medication administration incidents involving Tenant #1 | |
| Staff F | Observed medication administration errors involving Tenant #1 | |
| Staff G | Observed medication administration errors and provided statements during investigation | |
| Staff H | Staff member who attempted to give multiple medication passes at one time, causing medication errors | |
| Director | Confirmed findings of medication administration errors and documentation deficiencies | |
| Registered Nurse Coordinator | Confirmed findings of medication administration errors and documentation deficiencies |
Inspection Report
Renewal
Census: 36
Deficiencies: 1
Date: Jun 28, 2023
Visit Reason
The inspection was a recertification visit to determine compliance with certification rules for an Assisted Living Program, including a revisit for a prior visit completed on 2023-03-23.
Findings
The program failed to ensure that staff were competent to meet tenant individual needs, specifically that one staff member's nurse delegation training documentation was undated and could not confirm training within 30 days of employment.
Deficiencies (1)
The program's delegating nurse failed to ensure staff were competent to meet tenant individual needs; Staff A's delegation documentation was undated and training within 30 days of employment could not be confirmed.
Report Facts
Number of tenants without cognitive impairment: 23
Number of tenants with cognitive impairment: 13
Total census: 36
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 2
Date: Mar 23, 2023
Visit Reason
The inspection was conducted as part of the investigation of Complaint #107558-C, during which a regulatory insufficiency was cited. The visit aimed to assess compliance with program policies and tenant care following reported incidents.
Complaint Details
The investigation of Complaint #107558-C revealed regulatory insufficiencies related to incident reporting and tenant care. No deficiencies were cited during the investigation of Complaint #108440-C.
Findings
The facility failed to ensure incident reports included witness statements and failed to provide adequate care and communication following a tenant's fall. Specifically, there was conflicting information about whether Tenant #2 hit her head during a fall, and the Registered Nurse Coordinator and Program Director were not informed timely, impacting the tenant's care.
Deficiencies (2)
Failure to ensure incident reports included statements from individuals who witnessed the incident.
Failure to provide tenants with adequate care, treatment, and services, specifically related to a fall incident and subsequent communication.
Report Facts
Number of tenants without cognitive disorder: 32
Number of tenants with cognitive disorder: 5
Total census: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in findings related to incident reporting and tenant fall | |
| Staff D | Named in findings related to incident reporting and tenant fall | |
| Staff C | Named in findings related to incident reporting and tenant fall | |
| Staff E | Named in findings related to incident reporting and tenant fall | |
| Program Director | Interviewed regarding incident and communication failures | |
| Registered Nurse Coordinator | Interviewed regarding incident and communication failures |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Date: May 13, 2021
Visit Reason
The inspection was conducted during the investigation of incident 95751-I and included an on-site infection control survey.
Complaint Details
Investigation of incident 95751-I; no regulatory insufficiencies cited.
Findings
No regulatory insufficiencies were cited during the investigation and infection control survey.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 12
Total census: 39
Inspection Report
Plan of Correction
Census: 34
Deficiencies: 0
Date: Oct 30, 2019
Visit Reason
Investigation of Incident #86498-I at an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the investigation. The program has met criteria to be an Assisted Living Program for People with Dementia for the last two recertification visits.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 7
Total census: 34
Inspection Report
Renewal
Census: 38
Deficiencies: 1
Date: Aug 19, 2019
Visit Reason
The recertification visit was conducted to determine compliance with certification for an Assisted Living Program for People with Dementia.
Findings
The program failed to complete criminal, child abuse, and dependent adult abuse background checks prior to employment for 1 of 6 staff reviewed. The deficiency was corrected on 08/19/19.
Deficiencies (1)
Failure to complete criminal, child abuse, and dependent adult abuse background checks prior to employment for 1 of 6 staff reviewed.
Report Facts
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 9
Total Census of Assisted Living Program for People with Dementia: 38
Staff reviewed: 6
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Date: Jan 28, 2019
Visit Reason
The inspection was conducted as an investigation of complaint number 80604-C at Bickford Cottage Ames Assisted Living Program.
Complaint Details
Investigation of complaint 80604-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation. The census included 29 tenants without cognitive disorder and 9 tenants with cognitive disorder, totaling 38 residents.
Report Facts
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 9
Total Population of Program at time of on-site: 38
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Date: Oct 10, 2018
Visit Reason
Investigation of Complaint #78500-C at Bickford Cottage Ames, an Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Complaint #78500-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 10
Total census: 37
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Date: Mar 21, 2018
Visit Reason
Investigation of Complaint #74439-C at Bickford Cottage Ames assisted living program.
Complaint Details
Complaint #74439-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 7
Total census: 36
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Date: Feb 22, 2018
Visit Reason
Investigation of Incident #74211-I at the Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Incident #74211-I; no deficiencies found.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 7
Total census: 35
Inspection Report
Follow-Up
Census: 27
Deficiencies: 1
Date: Nov 6, 2017
Visit Reason
The revisit was conducted to investigate regulatory insufficiencies cited during the investigation of Incident #68812-I and Complaint #68995-C (7/13/17).
Complaint Details
The visit was complaint-related, investigating Incident #68812-I and Complaint #68995-C. The regulatory insufficiency cited was not corrected and was re-cited.
Findings
The program failed to consistently ensure tenants met criteria for admission and retention in the assisted living program, affecting one tenant who required maximal assistance with activities of daily living. The regulatory insufficiency previously cited was determined not to be corrected and was re-cited.
Deficiencies (1)
Program failed to consistently ensure tenants met criteria for admission and retention in an assisted living program, affecting Tenant #1 identified as not meeting retention criteria.
Report Facts
Number of tenants without cognitive disorder: 19
Number of tenants with cognitive disorder: 8
Total population of program at time of on-site: 27
30-day notice date given to Tenant #1: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reported Tenant #2 spent a large part of the day in bed and assisted with tasks | |
| Staff B | Assisted/transferred Tenant #2 from bed to toilet; reported feeding Tenant #2 | |
| Staff C | Assisted/transferred Tenant #2 from bed to toilet | |
| Manager | Confirmed Tenant #1 required maximal assistance and program failed to ensure retention criteria | |
| Registered Nurse Coordinator | RNC | Confirmed Tenant #1 required maximal assistance and program failed to ensure retention criteria |
Inspection Report
Renewal
Census: 27
Deficiencies: 2
Date: Jul 13, 2017
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program, including investigation of incidents #68812-I and complaint #68995-C.
Complaint Details
The visit was complaint-related involving investigation of Incident #68812-I and Complaint #68995-C. The complaint was substantiated as evidenced by findings related to inadequate care and failure to meet admission/retention criteria.
Findings
No regulatory insufficiencies were cited during the recertification visit or investigation of incident #69211-I. However, regulatory insufficiencies were cited during the investigation of Incident #68812-I and Complaint #68995-C, including failure to provide adequate care and treatment as directed by service plans and failure to ensure tenants consistently met criteria for admission and retention.
Deficiencies (2)
Program failed to provide care, treatment and adequate/appropriate services as directed by service plans, affecting Tenant #3 who eloped and was not properly monitored.
Program failed to ensure tenants consistently met criteria for admission and retention in an assisted living program, affecting Tenants #1 and #2.
Report Facts
Census: 27
Number of tenants without cognitive disorder: 19
Number of tenants with cognitive disorder: 8
Date survey completed: Jul 13, 2017
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Date: Dec 27, 2016
Visit Reason
Investigation of Incident 63782 at Bickford Cottage Ames assisted living facility.
Complaint Details
Investigation of Incident 63782; no regulatory insufficiencies found.
Findings
No regulatory insufficiencies were cited during the investigation of Incident 63782.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 12
Total Population of Program at time of on-site: 40
Total census of Assisted Living Program: 40
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 1
Date: Jan 21, 2016
Visit Reason
The inspection was conducted following a complaint alleging that a cognitively impaired tenant was found unattended and not supervised, and that the tenant was not properly evaluated or served according to program requirements.
Complaint Details
Complaint #57428-C involved Tenant #2 found unattended at a grocery store, with allegations of lack of supervision and improper evaluation for admission. All allegations were found not substantiated. Incident #56956-I cited a regulatory insufficiency for incomplete incident reporting related to missing tenant money.
Findings
The investigation found no substantiated allegations regarding staffing, admission criteria, or service plans. However, a regulatory insufficiency was cited related to program policies and procedures, specifically an incomplete incident report concerning missing tenant money.
Deficiencies (1)
Program policies and procedures were not met as an incident report was not completed when Tenant #1 reported $220 missing from the apartment.
Report Facts
Census: 38
Tenants without cognitive disorder: 30
Tenants with cognitive disorder: 8
Civil penalty amount: 500
Reduced civil penalty amount: 325
Missing money amount: 220
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Friberg | Bureau Chief, Adult Services Bureau | Signed the demand letter |
| Rose Boccella | Program Coordinator | Contact person for informal conference and payment of civil penalty |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Date: Sep 30, 2015
Visit Reason
The inspection was conducted as a Final Recertification Monitoring Evaluation and Complaint Revisit for Bickford Cottage Ames, following a complaint investigation.
Complaint Details
Complaint Intake #: 51587-CRV; No regulatory insufficiencies were found during the complaint revisit.
Findings
No regulatory insufficiencies were found during the revisit to the Recertification and investigation of Complaint #51587-C. The census at the time of inspection was 37 residents.
Report Facts
Number of tenants without cognitive disorder: 14
Number of tenants with cognitive disorder: 23
Total Population of Program at time of on-site: 37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed letter regarding the Final Recertification Monitoring Evaluation & Complaint Revisit Report |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 8
Date: Mar 30, 2015
Visit Reason
The inspection was conducted as a Final Recertification and Complaint/Incident Investigation following complaints and incidents reported, including a tenant fall and review of program policies and procedures.
Complaint Details
Complaint #51587-C involved allegations that several tenants exceeded criteria for retention due to unmanageable incontinence and need for two-person assistance for transfers. The complaint investigation found regulatory insufficiencies in program policies, medication administration, staffing communication, record checks, tenant evaluations, and service plans.
Findings
No regulatory insufficiencies were found related to incident #51025-I. Several regulatory insufficiencies were cited related to program policies and procedures, medication administration, staffing communication, record checks, evaluation of tenants, and service plans during the recertification and complaint investigation #51587-C.
Deficiencies (8)
Program policies and procedures were not followed, including failure to use gloves and handwashing during medication administration.
Medications were not administered correctly, including failure to cleanse skin prior to insulin injection and improper handling of medications.
The program failed to have a system for staff communication regarding tenant occurrences and failed to keep written staff communication for three years.
The program failed to request an evaluation from the department of human services for background checks.
Evaluations of tenants were not completed with changes of condition to determine continued eligibility and service needs.
Service plans were not based on evaluations and were not updated when changes were needed.
Nurse reviews were not completed to assess and document tenant health status and monitor progress every 90 days.
Criteria for admission and retention of tenants were not met; several tenants required routine two-person assistance exceeding criteria for retention.
Report Facts
Total census: 33
Number of tenants without cognitive disorder: 24
Number of tenants with cognitive disorder: 9
Number of tenants reviewed for retention criteria: 7
Number of tenants requiring two-person assistance: 2
Number of tenants with documented falls: 9
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 7
Date: Mar 19, 2014
Visit Reason
The inspection was conducted as a Final Complaint/Incident Investigation following allegations that a staff member gave one tenant's medications to another tenant.
Complaint Details
The complaint alleged that a staff member gave one tenant's medications to another tenant. The investigation substantiated multiple medication errors and regulatory insufficiencies related to tenant rights, policies and procedures, staffing, and service plans.
Findings
The investigation found multiple medication errors involving staff administering medications to the wrong tenants, failure to follow medication administration procedures, and inadequate staff communication systems. Several regulatory insufficiencies were noted related to tenant rights, policies and procedures, staffing, and service plans.
Deficiencies (7)
Medication errors where staff administered medications prescribed for one tenant to another tenant.
Failure to follow proper handwashing procedures during medication administration.
Use of a suppository from a deceased tenant without a physician's order and failure to document administration properly.
Lack of a system for written communication from staff to nurses documenting occurrences differing from tenant's normal health status.
Insufficient number of trained staff available at all times to meet tenants' identified needs.
Failure to have a system for certified and noncertified staff to communicate and document occurrences differing from tenant's normal health status.
Service plans did not meet identified needs of tenants, including failure to address aphasia and suicidal thoughts.
Report Facts
Census: 38
Number of tenants without cognitive disorder: 25
Number of tenants with cognitive disorder: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the complaint/incident investigation. |
| Rose Boccella | Program Coordinator, Adult Services Bureau | Author of the cover letter enclosing the Final Complaint/Incident Investigation Report. |
Inspection Report
Monitoring
Census: 31
Deficiencies: 0
Date: Feb 11, 2013
Visit Reason
The visit was a Final Recertification Monitoring Evaluation to assess compliance with Iowa Administrative Code chapters 481-67 and 481-69 and to review recertification documents and the State Fire Marshal's inspection report.
Findings
No regulatory insufficiencies were found during the evaluation. The program did not receive any regulatory insufficiencies during this certification period, and the on-site monitoring evaluation noted no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 26
Number of tenants with cognitive disorder: 5
Total Population of Program at time of on-site: 31
Tenant meeting attendance: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the evaluation |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Date: Nov 13, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation following a tenant fall and fracture of a hip reported at Bickford Cottage Ames.
Complaint Details
The complaint involved a tenant who fell and fractured a hip. The investigation included review of tenant conditions, staff interviews, and service plans. No regulatory insufficiencies were substantiated.
Findings
The investigation found no regulatory insufficiencies. Multiple tenant incidents involving falls and fractures were reviewed, with staff interviews and service plan evaluations confirming appropriate care and timely reporting.
Report Facts
Tenant census: 33
Number of tenants without cognitive disorder: 26
Number of tenants with cognitive disorder: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: Sep 12, 2012
Visit Reason
The inspection was conducted as a final complaint/incident investigation following allegations that program tenants did not receive individualized personal care assistance to meet their needs.
Complaint Details
The complaint alleged that tenants did not receive individualized personal care assistance, the program nurse did not accurately identify tenant needs, initial service plans were not completed timely, required tenant documentation was incomplete, and special diets were not provided. The investigation substantiated the insufficiency related to personal care assistance for Tenant #3 but found no regulatory insufficiencies in other areas.
Findings
The investigation found that Tenant #3 required assistance with personal care tasks that were not consistently met by the program staff, indicating regulatory insufficiency in meeting individualized care needs. Other allegations related to evaluation, service plans, tenant documents, and food service were found to have no regulatory insufficiencies.
Deficiencies (1)
Tenant #3's identified personal care assistance needs were not met by the program.
Report Facts
Total census: 31
Tenants without cognitive disorder: 25
Tenants with cognitive disorder: 6
Date of Complaint/Incident Investigation: September 12 and 13, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed cover letter for the Final Complaint/Incident Investigation Report |
| Maribeth Freland | RN | Monitor who conducted the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Jul 10, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding the retention of a tenant who exceeded the assisted living level of care and exhibited behaviors including exit-seeking, physical aggression, and inappropriate sexual conduct.
Complaint Details
The complaint investigation substantiated that the program retained a tenant who exceeded the assisted living level of care, exhibiting behaviors such as exit-seeking, agitation, physical aggression, and inappropriate sexual conduct. The tenant's behaviors escalated over time, requiring family visits, law enforcement intervention, and eventual transfer to another facility.
Findings
The program retained a tenant for four months despite the tenant's pattern of exit-seeking attempts, agitation with physical aggressiveness toward staff, and inappropriate sexual behavior toward staff and other tenants. The program failed to comply with regulatory requirements, resulting in a $1,000 civil penalty.
Deficiencies (1)
Failure to comply with regulatory requirements related to criteria for exclusion of tenants and policies and procedures, including inability to locate multiple incident reports for monitor review and failure to produce incident reports for unusual occurrences.
Report Facts
Civil penalty amount: 1000
Reduced civil penalty amount: 650
Complaint/Incident Investigation Dates: 3
Program census: 33
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maribeth Freland | RN | Monitor conducting the complaint/incident investigation |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter regarding the civil penalty |
| Rose Boccella | Program Coordinator mentioned for appeal and payment correspondence |
Inspection Report
Monitoring
Census: 35
Deficiencies: 0
Date: Jul 6, 2011
Visit Reason
The visit was a Final Recertification Monitoring Evaluation and Incident Investigation conducted at Bickford Cottage Assisted Living to evaluate regulatory compliance and investigate a reported incident involving a tenant eloping from the program.
Findings
No regulatory insufficiencies were found during this evaluation. The program reported an incident involving a tenant eloping, but the monitoring observation and service plan showed appropriate interventions and no exit-seeking behavior since February 2011.
Report Facts
Tenant count: 28
Tenant count: 7
Total population: 35
Tenant meeting attendance: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | MPH BSN | Monitor conducting the evaluation |
Inspection Report
Renewal
Census: 37
Deficiencies: 1
Date: Jan 22, 2009
Visit Reason
The visit was a final recertification monitoring evaluation conducted to assess compliance with Iowa Code and Administrative Code requirements for assisted living programs, including monitoring, civil penalties, and complaints.
Findings
The report found a regulatory insufficiency related to employee record checks, specifically that the program did not complete applicable employee record checks prior to hiring a staff member. The Plan of Correction was accepted and a civil penalty of $500 was imposed unless appealed.
Deficiencies (1)
The program did not complete applicable employee record checks prior to hire as required by Iowa Code section 135C.33(5).
Report Facts
Civil penalty amount: 500
Number of tenants with dementia or cognitive disorder: 12
Number of tenants without cognitive disorder: 25
Total population: 37
Number of staff files reviewed: 6
Inspection Report
Monitoring
Census: 37
Deficiencies: 0
Date: Jan 16, 2007
Visit Reason
The visit was an on-site recertification monitoring evaluation conducted to assess compliance with Iowa assisted living program regulations.
Complaint Details
There were no substantiated complaints during this certification period.
Findings
The evaluation found no regulatory insufficiencies during the on-site visit. Tenant satisfaction was positive, with tenants reporting good housekeeping, helpful staff, satisfactory food, enjoyable activities, and a feeling of safety.
Report Facts
Current number of tenants without cognitive disorder: 33
Current number of tenants with cognitive disorder: 4
Total Population: 37
Tenant meeting attendance: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the evaluation |
| Ann Martin | RN | Monitor conducting the evaluation |
| Barbara Judkins | Administrator | Facility administrator |
Inspection Report
Monitoring
Census: 32
Deficiencies: 2
Date: Jan 12, 2005
Visit Reason
The on-site monitoring evaluation was conducted as part of the assisted living program's re-certification process to assess compliance with Iowa Code and Administrative Code requirements.
Complaint Details
There was a substantiated complaint in the area of services during this certification period.
Findings
The evaluation found regulatory insufficiencies related to failure to evaluate tenants' functional, cognitive, and health status upon return from hospitalizations and failure to update individualized service plans accordingly. Tenant satisfaction was mixed, with concerns about food quality, housekeeping, and emergency response.
Deficiencies (2)
The program did not evaluate tenant’s functional, cognitive, and health status as needed upon returning from the hospital to determine continued eligibility and needed service modifications.
The program did not update service plans to meet tenant needs after hospital return, in consultation with tenants or legal representatives and a multidisciplinary team.
Report Facts
Tenants without cognitive disorder: 30
Tenants with cognitive disorder: 2
Total tenants: 32
Tenants present at community meeting: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the on-site monitoring evaluation |
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