Inspection Reports for Bickford of Burlington
3301 Sterling Dr, Burlington, IA 52601, United States, IA, 52601
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 23, 2025, cited deficiencies related to failure to implement exit door alarm policies, which allowed a tenant to leave the building unnoticed for several minutes. Earlier inspections showed a pattern of issues involving tenant safety, including incomplete evaluations before admission, insufficient staffing to meet tenant needs, and failures in incident reporting and service plan updates. Prior reports also noted concerns with tenant dignity, medication administration, infection control, and staff behavior, but enforcement actions were limited to a few civil penalties, with no license suspensions or immediate jeopardy findings listed in the available reports. Most complaint investigations were unsubstantiated, though some substantiated cases involved elopement risks and inadequate care for tenants with aggressive behaviors. The facility’s inspection history shows ongoing challenges with safety protocols and care planning, with recent findings consistent with earlier issues rather than a clear trend of improvement or worsening.
Deficiencies (last 14 years)
Deficiencies (over 14 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
27 residents
Based on a July 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
Jul 23, 2025
Visit Reason
The inspection was conducted as a complaint investigation following an incident of elopement involving Tenant #1 who left the facility without staff knowledge.
Findings
The program failed to implement its policy regarding exit door alarms, resulting in Tenant #1 leaving the building unnoticed for approximately six minutes. Staff did not perform an accountability check after the door alarm sounded, contrary to policy requirements.
Complaint Details
Investigation of Incident #128590-I involving Tenant #1 leaving the building through the alarmed front exit door without staff knowledge on 5/10/25. Tenant #1 was found uninjured outside by a family member and returned to the program.
Deficiencies (1)
| Description |
|---|
| Failed to implement policy regarding exit door alarms for Tenant #1 related to an incident of elopement. |
Report Facts
Number of tenants without cognitive impairment: 17
Number of tenants with cognitive impairment: 10
Total census: 27
Mini-Mental State Examination (MMSE) score: 16
Mini-Mental State Examination (MMSE) score: 13
Global Deterioration Scale score: 5
Time Tenant #1 was absent from building: 6
Time front exit door was breached: 1506
Time side service exit door opened: 1510
Time side service exit door re-entered: 1512
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Witnessed front door alarm and reset door breach at 3:06 p.m. on 5/10/25; did not perform accountability check. | |
| Staff B | Cook | Notified Staff A about Tenant #1 being returned by family member; opened side service exit door at 3:10 p.m. and re-entered at 3:12 p.m. |
| Staff C | Worked on 5/10/25; confirmed no accountability checks were done after door alarm during her shift. | |
| Executive Director | Verified staff should have followed policy and initiated accountability check after the incident. |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
Jul 23, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to an incident of elopement involving Tenant #1 at Bickford Cottage Burlington.
Findings
The program failed to implement its policy regarding exit door alarms, resulting in Tenant #1 leaving the building unnoticed for approximately six minutes. Staff did not perform the required accountability check after the door alarm sounded, and the tenant was found outside by a family member uninjured.
Complaint Details
The investigation was triggered by Incident #128590-I involving Tenant #1 who left the building through an alarmed exit door without staff knowledge on 5/10/25. The tenant was found outside by a family member and returned safely. Staff failed to conduct an accountability check as required by policy after the door alarm sounded.
Deficiencies (1)
| Description |
|---|
| Failed to implement policy regarding exit door alarms for 1 of 1 tenant reviewed related to an elopement incident. |
Report Facts
Number of tenants without cognitive impairment: 17
Number of tenants with cognitive impairment: 10
Total census: 27
Mini-Mental State Examination (MMSE) score: 16
Mini-Mental State Examination (MMSE) score: 13
Global Deterioration Scale score: 5
Duration Tenant #1 was absent from building: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Witnessed the door alarm sounding and initially assumed Tenant #2 caused it; did not perform accountability check. | |
| Staff B | Cook | Notified caregiver staff after family member returned Tenant #1 to building. |
| Staff C | Confirmed working during incident and noted staff were not checking tenant whereabouts after door alarm. | |
| Executive Director | Executive Director | Verified staff should have followed policy and initiated accountability check after door alarm. |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
Sep 17, 2024
Visit Reason
The inspection was conducted as a complaint investigation into Complaint #120852-C regarding regulatory insufficiencies at Bickford Cottage Burlington.
Findings
The program failed to complete thorough evaluations prior to admission to ensure services were available to meet the needs of one tenant (Tenant C1). Additionally, the preliminary service plan was not developed and signed by all parties prior to occupancy for Tenant C1.
Complaint Details
The complaint investigation found no regulatory insufficiencies related to Incident #120563-I but identified deficiencies during the investigation of Complaint #120852-C involving Tenant C1's admission evaluations and service plan development.
Deficiencies (2)
| Description |
|---|
| Failed to complete thorough evaluations prior to admission to ensure services were available to meet the needs of Tenant C1. |
| Failed to ensure the preliminary service plan was developed and signed by all parties prior to taking occupancy for Tenant C1. |
Report Facts
Total census: 34
Number of tenants without cognitive impairment: 23
Number of tenants with cognitive impairment: 11
Date deficiencies corrected by: Oct 31, 2024
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Mar 18, 2024
Visit Reason
The inspection was conducted to investigate Complaint #119510-C and to perform a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the complaint investigation or the recertification visit.
Complaint Details
Complaint #119510-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 30
Number of tenants with cognitive impairment: 12
Total census: 42
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 0
Sep 26, 2023
Visit Reason
Investigation into Complaint #110186-C regarding the Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Investigation into Complaint #110186-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 31
Number of tenants with cognitive disorder: 9
Total census: 40
Inspection Report
Complaint Investigation
Census: 46
Deficiencies: 3
Sep 29, 2022
Visit Reason
The inspection was conducted as an investigation into complaints #107955-C and #108055-C regarding incidents and tenant safety concerns at the assisted living program for people with dementia.
Findings
The facility failed to complete incident reports for all unusual occurrences involving tenants, failed to ensure tenant dignity and respect, and did not update a tenant's service plan to address significant changes in behavior including verbal, physical, and sexual aggression. Multiple staff interviews and incident reports documented ongoing aggressive and inappropriate behavior between tenants, which staff had to frequently intervene in.
Complaint Details
Investigation into complaints #107955-C and #108055-C revealed incidents involving Tenant #2 and Tenant #3, including allegations of sexual assault, verbal and physical aggression, and failure of staff to adequately document and address these issues.
Deficiencies (3)
| Description |
|---|
| Failure to complete incident reports for all unusual occurrences involving tenants. |
| Failure to ensure tenant was treated with consideration, respect, and full recognition of personal dignity. |
| Failure to update the service plan of a tenant when their needs changed, specifically regarding verbal, physical, and sexual aggression. |
Report Facts
Census: 46
Incident Report Date: Sep 23, 2022
Medication administration time: 400
Service plan date: Sep 12, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Responded promptly to Tenant #3's call for help and wrote incident report dated 9/23/22 | |
| Staff B | Wrote statement about incident on 9/23/22 and assisted Tenant #3 | |
| Staff C | Discovered Tenant #2 masturbating and pushing Tenant #3's head down, made complaint to Director | |
| Staff D | Reported Tenant #3's medication administration and unusual behavior | |
| Staff E | Observed Tenant #2 yelling at Tenant #3 and following her during medication administration | |
| Staff F | Observed aggressive behavior of Tenant #2 toward Tenant #3 in dining room and apartment | |
| Staff G | Reported daily staff intervention due to Tenant #2's aggression toward Tenant #3 | |
| Staff H | Reported locking Tenant #3's door to keep Tenant #2 out during physical therapy | |
| Staff I | Reported Tenant #2's possessiveness and interference with 1:1 care for Tenant #3 | |
| RNC | Registered Nurse Consultant | Confirmed findings on 9/29/22 at 2:30 PM |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 1
Sep 8, 2022
Visit Reason
The inspection was conducted as an investigation into complaints #102752-C, #101471-C, and #101470-C related to the assisted living program for people with dementia.
Findings
No regulatory insufficiencies were found for complaints #102752-C and #101471-C. However, a deficiency was cited for complaint #101470-C regarding insufficient staffing to meet the toileting and care needs of Tenant C1, who required frequent assistance and was not adequately supported during multiple shifts.
Complaint Details
The investigation into Complaint #101470-C found that staff did not meet the identified toileting needs of Tenant C1, who required two-person assistance and frequent toileting care. Staff reported difficulty providing timely incontinence care due to insufficient staffing, especially during overnight shifts. Tenant C1 passed away on 2022-03-17.
Deficiencies (1)
| Description |
|---|
| Failed to ensure a sufficient number of staff available to meet the needs of Tenant C1, including toileting assistance during multiple shifts. |
Report Facts
Census: 45
Missed toileting assistance shifts: 23
Missed toileting assistance shifts: 46
Missed toileting assistance shifts: 30
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 15
Oct 13, 2021
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program for People with Dementia and during the investigation into multiple complaints.
Findings
The program was found deficient in multiple areas including failure to complete incident reports, inconsistent adherence to policies and procedures, inadequate infection control, failure to isolate symptomatic tenants, staff abuse and neglect allegations, inadequate care and services to tenants, failure to respond reasonably to tenant requests, medication administration errors, narcotics protocol violations, incomplete background checks, retention of tenants requiring two-person assistance without proper waivers, incomplete service plans, and failure to conduct nurse reviews after significant changes in tenant condition.
Complaint Details
The inspection was triggered by complaints #93888-C, #95233-C, #96118-C, #97248-C, #97295-C, #97607-C and #97245-C.
Deficiencies (15)
| Description |
|---|
| Failed to complete an incident report for an unusual occurrence involving a tenant eloping through an unsecured window. |
| Failed to consistently follow established policies and procedures including visitor screening and infection control. |
| Allowed symptomatic tenants to attend a New Year's Eve party without isolation or mask use, violating infection control protocols. |
| Staff engaged in inappropriate and abusive behavior toward tenants, including verbal abuse and physical mistreatment. |
| Failed to provide adequate care and services to tenants including insufficient showers, housekeeping, oxygen management, and repositioning. |
| Failed to provide reasonable response to tenant requests related to pet management and environmental concerns. |
| Failed to administer medications at the ordered times to multiple tenants. |
| Failed to follow narcotics protocol including proper documentation and reconciliation of controlled substances. |
| Failed to complete required background checks prior to employment for one staff member. |
| Retained tenants who required routine two-person assistance with transfers without appropriate waivers or documentation. |
| Failed to include physician ordered tasks such as turning/repositioning on the Medication Administration Record for a tenant. |
| Failed to include identified tenant needs and preferences for assistance in service plans for multiple tenants. |
| Failed to complete nurse reviews after significant changes in tenant condition and ensure appropriate interventions. |
| Failed to provide orientation and annual in-service training on food safety and sanitation to food service employees. |
| Failed to provide eight hours of dementia-specific education and training within 30 days of employment for multiple employees. |
Report Facts
Census: 40
Number of tenants without cognitive disorder: 32
Number of tenants with cognitive disorder: 2
Number of tenants with cognitive disorder: 6
Number of tenants without cognitive disorder: 0
Number of staff attending COVID-19 vaccination clinic: 13
Number of tenants attending COVID-19 vaccination clinic: 18
Number of tenants affected by medication administration errors: 5
Number of employees without required food safety training: 6
Number of employees without required dementia training: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff W | Witnessed tenant elopement incident | |
| Staff N | Former Registered Nurse Coordinator | Informed of tenant elopement incident but did not complete incident report |
| Staff T | Assisted in search for eloped tenant; involved in abuse allegation investigation | |
| Staff H | Reported abuse allegation and observed tenant symptoms | |
| Staff J | Reported abuse allegation | |
| Staff K | Alleged to have verbally abused tenants | |
| Staff M | Witnessed abuse and reported missed showers | |
| Staff D | Reported abuse allegation and staffing shortages | |
| Staff G | Reported medication administration and oxygen issues | |
| Staff Q | Reported inability to turn tenant and delayed feeding | |
| Staff E | Reported staffing shortages and tenant care concerns | |
| Staff B | Witnessed narcotic disposal and lacked food safety training | |
| Director | Confirmed multiple findings including abuse investigations, pet policy issues, and training deficiencies | |
| Registered Nurse Coordinator | Involved in medication administration, narcotics protocol, and care planning |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 2
Jul 18, 2019
Visit Reason
The inspection was conducted as an investigation into Incident #83979-I involving a tenant elopement and failure to provide appropriate care.
Findings
The program failed to provide appropriate care to a tenant identified as an elopement risk and failed to fully evaluate tenants' needs. Deficiencies were related to tenant rights and evaluation of tenant needs, including inadequate supervision and failure to follow door alarm procedures.
Complaint Details
The visit was complaint-related, investigating a self-reported incident (#83979-I) involving Tenant #1 who eloped from the facility. The complaint was substantiated by findings of inadequate care and evaluation.
Deficiencies (2)
| Description |
|---|
| Program failed to provide appropriate care to tenant identified as an elopement risk. |
| Program failed to fully evaluate tenants' needs. |
Report Facts
Census of Assisted Living Program for People with Dementia: 43
Number of tenants without cognitive disorder: 36
Number of tenants with cognitive disorder: 1
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 6
Date survey completed: Jul 18, 2019
Date deficiencies corrected by: Aug 23, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tenant #1 | Resident | Subject of the elopement incident and evaluation deficiencies |
| Director | Reported on staff response to door alarm and tenant behaviors | |
| Registered Nurse Coordinator | RNC | Interviewed regarding tenant elopement and care; involved in plan of correction |
| Staff D | Witnessed tenant behavior and door alarm issues | |
| Staff C | Reported on gate door problems and tenant care | |
| Staff E | Reported on pager notifications and tenant care | |
| Staff B | Reported on tenant exit-seeking behaviors | |
| Divisional Director of Resident Services | Provided re-education and oversight in plan of correction |
Inspection Report
Renewal
Census: 45
Deficiencies: 0
Sep 26, 2018
Visit Reason
Recertification survey conducted to determine compliance with the licensing rules for an Assisted Living Program for Persons with Dementia.
Findings
No regulatory insufficiencies were cited during the recertification survey for the Assisted Living Program for Persons with Dementia.
Report Facts
Number of tenants without cognitive disorder: 37
Number of tenants with cognitive disorder: 1
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 7
Total Census: 45
Inspection Report
Renewal
Census: 46
Deficiencies: 2
Oct 19, 2016
Visit Reason
A recertification visit was conducted to determine compliance with certification for an Assisted Living Program, including an investigation of Incident #63652-I.
Findings
The program failed to ensure tenants were consistently treated with consideration, respect, and full recognition of personal dignity and autonomy, particularly regarding personal care choices. Additionally, the program failed to immediately report an allegation of dependent adult abuse to the person in charge or designated agent.
Complaint Details
The complaint investigation involved an incident where Tenant #1 reported that Staff F threw a shoe at him/her and wished he/she was dead. Multiple staff failed to report the allegation immediately to management. The program completed an investigation and counseled involved staff on reporting requirements.
Deficiencies (2)
| Description |
|---|
| The program failed to ensure tenants were consistently treated with consideration, respect, and full recognition of personal dignity and autonomy regarding completion of care, including respecting tenant choice in personal cares. |
| The staff failed to immediately report an allegation of dependent adult abuse to the person in charge or the person's designated agent. |
Report Facts
Number of tenants without cognitive disorder in General Population Program: 38
Number of tenants with cognitive disorder in General Population Program: 1
Total Population of General Population Program: 39
Number of tenants without cognitive disorder in Dementia-Specific Program: 2
Number of tenants with cognitive disorder in Dementia-Specific Program: 5
Total Population of Dementia-Specific Program: 7
Total census of Assisted Living Program: 46
Incident report date: Sep 9, 2016
Incident report date: Oct 13, 2016
Incident report date: Oct 11, 2016
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 1
Oct 28, 2014
Visit Reason
The inspection was conducted as a Final Complaint/Incident Investigation and Recertification Monitoring Evaluation following a complaint regarding regulatory insufficiency in the area of medications at Bickford Cottage Assisted Living.
Findings
The investigation found that the program did not always ensure services were provided in accordance with nurse delegation training, specifically noting a staff member did not wash or sanitize hands during medication administration. An incident investigation regarding tenant safety found no regulatory insufficiency. A Plan of Correction is required for the medication-related deficiency.
Complaint Details
The complaint involved concerns about medication administration practices. The investigation found regulatory insufficiency related to nurse delegation and medication administration. An incident involving a tenant injury was investigated and found to have no regulatory insufficiency.
Deficiencies (1)
| Description |
|---|
| Nurse delegation procedures were not consistently followed; staff failed to wash or sanitize hands during medication administration. |
Report Facts
Number of tenants without cognitive disorder (General Population Program): 34
Number of tenants with cognitive disorder (General Population Program): 1
Total population of General Population Program: 35
Number of tenants without cognitive disorder (Dementia-Specific Program): 2
Number of tenants with cognitive disorder (Dementia-Specific Program): 5
Total population of Dementia-Specific Program: 7
Total census of Assisted Living Program: 42
Duration of medication pass observed: 39
Date of monitoring visit: Oct 28, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Wendy E. Kuhse | RN, BS | Monitor conducting the investigation |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Sep 23, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations that Staff #1 was rough with Tenant #1 during care.
Findings
The investigation included interviews, review of incident reports, and staff training records. No regulatory insufficiencies were identified, and the allegation was not substantiated.
Complaint Details
The complaint alleged that Staff #1 was rough and hurt Tenant #1 during transfers and called Tenant #1 a grouch. Multiple interviews and reviews found no evidence of abuse, and the staff received additional training. The allegation was not substantiated.
Report Facts
Number of tenants without cognitive disorder (General Population Program): 40
Number of tenants with cognitive disorder (General Population Program): 1
Total Population of General Population Program: 41
Number of tenants without cognitive disorder (Dementia-Specific Program): 1
Number of tenants with cognitive disorder (Dementia-Specific Program): 6
Total Population of Dementia-Specific Program: 7
Total census of Assisted Living Program: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Kaltefleiter | RN MS | Monitor conducting the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Jul 23, 2013
Visit Reason
The inspection was conducted as a final complaint/incident investigation following allegations related to tenant rights and staffing at Bickford Cottage Burlington.
Findings
No regulatory insufficiencies were identified during the investigation. Allegations of inappropriate sexual behavior by staff were not substantiated, and no regulatory insufficiencies were noted regarding staffing or tenant safety.
Complaint Details
The complaint involved allegations that a staff member hugged a cognitively impaired tenant and suspected sexual undertones, which were not substantiated. Another complaint involved a cognitively impaired tenant leaving the building unsupervised and sustaining injuries. The investigation found the tenant eloped without staff knowledge, but appropriate protocols were in place and followed after the incident.
Report Facts
Census: 48
Number of tenants without cognitive disorder: 41
Number of tenants with cognitive disorder: 7
Complaint/Incident Intake Numbers: 44624-I, 44610-C, 44563-I
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| James Berkley | Program Coordinator | Contact person for the report |
| Maribeth Freland | RN Monitor | Conducted the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Mar 19, 2013
Visit Reason
The inspection was conducted as a final complaint/incident investigation following a report of a tenant fall resulting in injury and subsequent death at Bickford Cottage Burlington.
Findings
No regulatory insufficiencies were identified during the investigation. The report details the incident, medical evaluations, staff responses, and confirms appropriate protocols were followed.
Complaint Details
The complaint involved a tenant who fell, sustained a head injury with bleeding in the left ear, was taken to the emergency room, and later died. The investigation reviewed tenant files, incident reports, staff statements, hospital information, and fall investigation documents. Staff had appropriate delegations and supervision policies were followed. No regulatory insufficiencies were found.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 36
Number of tenants with cognitive disorder in General Population Program: 2
Total population of General Population Program: 38
Number of tenants without cognitive disorder in Dementia-Specific Program: 1
Number of tenants with cognitive disorder in Dementia-Specific Program: 5
Total population of Dementia-Specific Program: 6
Total census of Assisted Living Program: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lynne Mynatt | Director | Director of Bickford Cottage Burlington, named in report address |
| Stephanie Cummins | MA | Monitor conducting the complaint/incident investigation |
| Jim Berkley | Program Coordinator | Author of cover letter for the report |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Jul 10, 2012
Visit Reason
The inspection was conducted as a Final Complaint/Incident Investigation and Recertification Monitoring Evaluation following a complaint regarding staff assistance to a tenant who fell and was injured.
Findings
The investigation found that Tenant #1 was assisted by staff after a fall resulting in a fractured hip. Staff training on dementia-specific education was reviewed, revealing some personnel did not complete required training within 30 days of employment. No regulatory insufficiencies were noted regarding the incident itself.
Complaint Details
The complaint involved Tenant #1 calling for assistance to use the restroom, falling when staff assisted, and sustaining a fractured hip. The incident was investigated and found substantiated with no regulatory insufficiency noted.
Deficiencies (1)
| Description |
|---|
| Staff #5 did not complete the required eight hours of dementia training within 30 days of employment. |
Report Facts
Total census: 40
Number of tenants without cognitive disorder: 35
Number of tenants with cognitive disorder: 5
Number of tenants attending community meeting: 20
Complaint/Incident Intake Number: 39757
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the investigation |
| Jim Berkley | Program Coordinator | Signed letter regarding certification |
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Apr 2, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations of a staff member failing to timely follow up on a tenant request and yelling at a tenant.
Findings
The investigation found no regulatory insufficiencies. The monitors reviewed medication error reports and clinical records of tenants, finding no concerns. Interviews and record reviews indicated timely medication administration and no inappropriate verbal interactions by staff.
Complaint Details
Complaint/Incident Allegation involved a staff member failing to timely follow up on a tenant request and yelling at a tenant. The investigation found no evidence of inappropriate interaction and no regulatory insufficiencies were noted.
Report Facts
Number of tenants without cognitive disorder: 35
Number of tenants with cognitive disorder: 4
Total Population of General Population Program: 39
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 5
Total Population of Dementia-Specific Program: 5
TOTAL census of Assisted Living Program: 44
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maribeth Freland | RN | Monitor during complaint/incident investigation |
| Joyce Kix | RN | Monitor during complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Nov 8, 2011
Visit Reason
The inspection was conducted as a final complaint/incident investigation regarding allegations of regulatory insufficiencies in staffing, criteria for exclusion of tenants, and structural requirements at Bickford Cottage Burlington.
Findings
The report found regulatory insufficiencies related to staffing, medication administration, tenant safety, and structural issues. A $1,000 civil penalty was assessed. Multiple incidents involving tenant falls, inadequate supervision, and failure to follow care plans were documented.
Complaint Details
The complaint investigation was substantiated with findings of staff failing to adequately supervise tenants, resulting in multiple falls and injuries, failure to administer medications properly, and failure to notify guardians of incidents in a timely manner.
Deficiencies (1)
| Description |
|---|
| Regulatory insufficiencies in staffing, criteria for exclusion of tenants, and structural requirements. |
Report Facts
Civil penalty amount: 1000
Census count: 43
Complaint Intake Number: 36271
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angie Cozadd | Director | Named as Director of Bickford Cottage Burlington, referenced in relation to findings and penalty |
| Maribeth Freland | RN | Monitor during complaint/incident investigation |
| Joyce Kix | RN | Monitor during complaint/incident investigation |
| Jim Berkley | Program Coordinator | Contact for appeal and compliance related to the complaint investigation |
Inspection Report
Monitoring
Census: 46
Deficiencies: 1
Feb 14, 2011
Visit Reason
The visit was conducted as a Final Incident Investigation and Recertification Monitoring Evaluation at Bickford Cottage Assisted Living to review the Plan of Correction and monitor compliance following a reported incident.
Findings
The report found no regulatory insufficiencies during the certification period. Tenant satisfaction was positive, and staff were deemed sufficient and responsive. One tenant incident involving a fall was investigated with no regulatory insufficiencies noted related to the incident or service plans.
Deficiencies (1)
| Description |
|---|
| Service plan did not reflect identified needs of tenant #1 and tenant #2. |
Report Facts
Current number of tenants without cognitive disorder: 38
Current number of tenants with cognitive disorder: 2
Total Population of General Population Program: 40
Total Population of Dementia Specific Program: 6
Total Census of Assisted Living Program: 46
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beth Fleming | Director | Named as facility director in relation to the report and tenant satisfaction |
| Stephanie Cummins | Monitor | Conducted the incident investigation and monitoring visit |
Inspection Report
Monitoring
Census: 39
Deficiencies: 0
Oct 30, 2008
Visit Reason
The visit was a Recertification Monitoring Evaluation Revisit conducted to evaluate compliance with regulatory requirements following a previous certification period.
Findings
No regulatory insufficiencies were found during this visit. The program had previously received a substantiated regulatory insufficiency related to record checks, but no new deficiencies were noted at this revisit.
Report Facts
Current number of tenants without cognitive disorder: 36
Current number of tenants with cognitive disorder: 3
Total Population: 39
Current number of tenants in Dementia Specific Program (DSP) providing specialized care: 7
Current number of tenants without cognitive disorder: 4
Total Population: 7
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 0
Sep 9, 2008
Visit Reason
A complaint investigation on-site visit was conducted at Bickford Cottage Assisted Living on September 9, 2008, to investigate allegations related to tenant care and facility operations.
Findings
No regulatory insufficiencies were identified during the complaint investigation. The report details observations related to tenant wandering, incontinence, service plans, and exit door alarm system, with no deficiencies noted.
Complaint Details
Complaint #19691 involved allegations that Tenant #1 is incontinent and wanders in and out of other tenants' rooms at all times, Tenant #2 sits in their room and does nothing and needs more help than received, and the program's back door has not been locked for two months due to an electronic issue. Monitoring observations found staff interventions and door repairs ongoing, with no regulatory insufficiencies noted.
Report Facts
Current number of tenants without cognitive disorder: 39
Current number of tenants with cognitive disorder: 2
Total Population: 41
Current number of tenants in Dementia Specific Program providing specialized care: 4
Current number of tenants without cognitive disorder in Dementia Specific Program: 3
Total Population: 7
Tenant #1 age: 91
Tenant #2 age: 82
Date Tenant #1 admitted: Feb 16, 2004
Date Tenant #2 admitted: Nov 3, 2006
Date of cognitive evaluation Tenant #1: Jun 23, 2008
Date of cognitive evaluation Tenant #2: Aug 27, 2008
Inspection Report
Monitoring
Census: 48
Deficiencies: 1
Aug 26, 2008
Visit Reason
The visit was a Final Recertification Monitoring evaluation conducted by the Iowa Department of Inspections and Appeals to assess compliance with assisted living program regulations, specifically monitoring regulatory insufficiencies and the program's Plan of Correction.
Findings
The report identified a Regulatory Insufficiency related to incomplete employee record checks, specifically the failure to complete required criminal history and dependent adult abuse checks prior to hiring. The Plan of Correction was accepted and a civil penalty of $500 was assessed.
Severity Breakdown
Regulatory Insufficiency: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The program did not complete a Department of Public Safety criminal history check and a Department of Human Services dependent adult abuse check of potential employees prior to hire. | Regulatory Insufficiency |
Report Facts
Civil penalty amount: 500
Current number of tenants without cognitive disorder: 43
Current number of tenants in Dementia Specific Program: 5
Total census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal Chase | RN BSN MPH | Monitor conducting the evaluation |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed conclusion letter regarding penalty and Plan of Correction |
Inspection Report
Monitoring
Census: 40
Deficiencies: 0
Jul 28, 2004
Visit Reason
The visit was a re-certification monitoring evaluation conducted to assess compliance with Iowa assisted living program regulations at Bickford Cottage of Burlington.
Findings
The on-site monitor found no regulatory insufficiencies during the evaluation. Tenant and family interviews indicated overall satisfaction with the program, staff, environment, and responsiveness of administration.
Report Facts
Current number of tenants without cognitive disorder: 33
Current number of tenants with cognitive disorder: 7
Total General Population: 40
Current number of tenants in Dementia Specific Program: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Parks | RN | Monitor conducting the on-site monitoring evaluation |
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