Inspection Reports for Bickford of Ames

The inspection was conducted as a complaint investigation triggered by multiple complaints and incidents involving tenant care and medication administration at Bickford Cottage Ames.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was conducted to investigate complaints and incidents related to medication administration and care practices at Bickford Cottage Ames.

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.

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.

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.

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.

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.

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.

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.

The inspection was conducted during the investigation of incident 95751-I and included an on-site infection control survey.

No regulatory insufficiencies were cited during the investigation and infection control survey.

Investigation of incident 95751-I; no regulatory insufficiencies cited.

Investigation of Incident #86498-I at an Assisted Living Program.

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.

The recertification visit was conducted to determine compliance with certification for an Assisted Living Program for People with Dementia.

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.

The inspection was conducted as an investigation of complaint number 80604-C at Bickford Cottage Ames Assisted Living Program.

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.

Investigation of complaint 80604-C found no regulatory insufficiencies.

Investigation of Complaint #78500-C at Bickford Cottage Ames, an Assisted Living Program for People with Dementia.

No regulatory insufficiencies were cited during the complaint investigation.

Investigation of Complaint #78500-C found no regulatory insufficiencies.

Investigation of Complaint #74439-C at Bickford Cottage Ames assisted living program.

No regulatory insufficiencies were cited during the complaint investigation.

Complaint #74439-C was investigated and found to have no regulatory insufficiencies.

Investigation of Incident #74211-I at the Assisted Living Program for People with Dementia.

No regulatory insufficiencies were cited during the investigation.

Investigation of Incident #74211-I; no deficiencies found.

The revisit was conducted to investigate regulatory insufficiencies cited during the investigation of Incident #68812-I and Complaint #68995-C (7/13/17).

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.

The visit was complaint-related, investigating Incident #68812-I and Complaint #68995-C. The regulatory insufficiency cited was not corrected and was re-cited.

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.

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.

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.

Investigation of Incident 63782 at Bickford Cottage Ames assisted living facility.

No regulatory insufficiencies were cited during the investigation of Incident 63782.

Investigation of Incident 63782; no regulatory insufficiencies found.

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.

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.

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.

The inspection was conducted as a Final Recertification Monitoring Evaluation and Complaint Revisit for Bickford Cottage Ames, following a complaint investigation.

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.

Complaint Intake #: 51587-CRV; No regulatory insufficiencies were found during the complaint revisit.

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.

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.

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.

The inspection was conducted as a Final Complaint/Incident Investigation following allegations that a staff member gave one tenant's medications to another tenant.

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.

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.

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.

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.

The inspection was conducted as a complaint/incident investigation following a tenant fall and fracture of a hip reported at Bickford Cottage Ames.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was an on-site recertification monitoring evaluation conducted to assess compliance with Iowa assisted living program regulations.

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.

There were no substantiated complaints during this certification period.

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.

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.

There was a substantiated complaint in the area of services during this certification period.