Inspection Reports for Bickford of Burlington

The inspection was conducted as a complaint investigation following an incident of elopement involving Tenant #1 who left the facility without staff knowledge.

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.

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.

The inspection was conducted as a complaint investigation related to an incident of elopement involving Tenant #1 at Bickford Cottage Burlington.

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.

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.

The inspection was conducted as a complaint investigation into Complaint #120852-C regarding regulatory insufficiencies at Bickford Cottage Burlington.

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.

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.

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.

No regulatory insufficiencies were cited during the complaint investigation or the recertification visit.

Complaint #119510-C was investigated and found to have no regulatory insufficiencies.

Investigation into Complaint #110186-C regarding the Assisted Living Program for People with Dementia.

No regulatory insufficiencies were cited during the complaint investigation.

Investigation into Complaint #110186-C found no regulatory insufficiencies.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was triggered by complaints #93888-C, #95233-C, #96118-C, #97248-C, #97295-C, #97607-C and #97245-C.

The inspection was conducted as an investigation into Incident #83979-I involving a tenant elopement and failure to provide appropriate care.

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.

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.

Recertification survey conducted to determine compliance with the licensing rules for an Assisted Living Program for Persons with Dementia.

No regulatory insufficiencies were cited during the recertification survey for the Assisted Living Program for Persons with Dementia.

A recertification visit was conducted to determine compliance with certification for an Assisted Living Program, including an investigation of Incident #63652-I.

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.

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.

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.

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.

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.

The inspection was conducted as a complaint/incident investigation following allegations that Staff #1 was rough with Tenant #1 during care.

The investigation included interviews, review of incident reports, and staff training records. No regulatory insufficiencies were identified, and the allegation was not substantiated.

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.

The inspection was conducted as a final complaint/incident investigation following allegations related to tenant rights and staffing at Bickford Cottage Burlington.

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.

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.

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.

No regulatory insufficiencies were identified during the investigation. The report details the incident, medical evaluations, staff responses, and confirms appropriate protocols were followed.

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.

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.

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.

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.

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.

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/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.

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.

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.

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.

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.

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.

The visit was a Recertification Monitoring Evaluation Revisit conducted to evaluate compliance with regulatory requirements following a previous certification period.

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.

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.

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 #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.

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.

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.

The visit was a re-certification monitoring evaluation conducted to assess compliance with Iowa assisted living program regulations at Bickford Cottage of Burlington.

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.