Inspection Reports for Bickford of Davenport

The inspection was conducted as a complaint investigation related to regulatory insufficiencies at Bickford Cottage Davenport, specifically Complaint #129204-C.

The program failed to complete required functional, cognitive, and health evaluations for 5 tenants, retained a bed-bound tenant contrary to admission criteria, and did not complete nurse reviews every 90 days for 2 tenants receiving prescription medications.

The investigation was triggered by Complaint #129204-C. The complaint was substantiated as regulatory insufficiencies were cited regarding tenant evaluations, retention of a bed-bound tenant, and nurse review failures.

The inspection was conducted as an investigation into Complaint #125932-C and Complaint #125018-C regarding regulatory insufficiencies at the assisted living program.

The program failed to follow established policies for incident reporting related to a tenant injury and retained tenants who were bed bound or displayed dangerous behaviors including verbal and physical aggression despite interventions.

The investigation was triggered by complaints #125932-C and #125018-C. The findings included failure to follow incident reporting policies and retention of tenants with unsafe behaviors or conditions.

The inspection was conducted as an investigation of Complaint #123497-C and Mandatory Report #122759-M.

No regulatory insufficiencies were cited during the investigation of the complaint and mandatory report.

Investigation of Complaint #123497-C and Mandatory Report #122759-M found no regulatory insufficiencies.

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

The program was found to have multiple regulatory insufficiencies including failure to conduct health assessments prior to admission and within 30 days of occupancy for certain tenants, failure to evaluate tenant health status annually or with significant change, retention of tenants requiring two-person assistance for transfers, and retention of a tenant displaying unmanageable aggression.

There were no regulatory insufficiencies cited during the investigation into Complaint #117601-C, Complaint #119817-C, and Complaint #120048-C.

The inspection was conducted as a complaint investigation related to multiple complaints (#111838-C and #111846-C) concerning tenant care and safety issues at Bickford Cottage Davenport, an assisted living program for people with dementia.

The investigation found regulatory insufficiencies including failure to provide adequate and appropriate care for a tenant with exit seeking behaviors, failure to evaluate functional, cognitive, and health status after significant changes, failure to develop individualized service plans, and failure to ensure all personnel, including contract staff, received appropriate dementia-specific training.

The investigation was triggered by complaints #111838-C and #111846-C. No regulatory insufficiencies were cited during the investigation of Complaint #111633-C. Tenant #1 exhibited multiple incidents of aggression, exit seeking, and wandering into other tenants' apartments uninvited, requiring multiple 911 calls and hospital transports.

The inspection was conducted as a complaint investigation into multiple complaints (#108383-C, #108255-C, #107202-C, #107132-C, and #105750-C) regarding the assisted living program.

The investigation found regulatory insufficiencies related to tenant rights violations where tenants were not consistently treated with respect and dignity, and failures in documentation of routine personal or health-related care on task sheets for tenants receiving hospice care. Additionally, the program failed to retain tenant records for the required minimum of three years.

The complaint investigation involved multiple complaints (#108383-C, #108255-C, #107202-C, #107132-C, and #105750-C). No regulatory insufficiencies were found for complaints #108383-C, #108255-C, and #107202-C. Regulatory insufficiencies were cited for complaints #107132-C and #105750-C.

The inspection was conducted as a recertification visit combined with complaint investigations for an Assisted Living Program for People with Dementia.

The facility was found deficient in multiple areas including failure to provide required dependent adult abuse training within six months of hire, failure to maintain incident reports for discharged tenants, failure to have all parties sign service plans, failure to update service plans to reflect identified needs and preferences, and failure to provide eight hours of dementia-specific education within 30 days of employment.

The inspection included investigations of Complaint #101520-C and Complaint #97727-C.

The investigation was conducted due to Incident #89498-M involving medication diversion from tenants, including medications for Tenant #1.

The program failed to consistently follow established policies and procedures related to medication management and nurse delegation. Specifically, medication diversion was identified involving Tenant #1, with missing Tramadol tablets and inadequate documentation of medication destruction and nurse delegation.

The complaint investigation was substantiated based on findings of medication diversion and failure to follow policies regarding abuse and neglect reporting and medication disposal. The program self-reported the allegation and failed to provide requested investigative documentation.

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

The program was found deficient in nurse delegation procedures, specifically the newly hired registered nurse failed to delegate tasks to existing staff within 60 days of employment and failed to ensure newly hired staff received training within 30 days. Additionally, the program failed to update tenant service plans when changes were needed.

Recertification conducted to determine compliance with certification for an Assisted Living Program - Dementia Specific.

No regulatory insufficiencies were cited during the recertification inspection.

A recertification visit was conducted to determine compliance with certification for an Assisted Living Program. Incident #55743-I was also investigated as part of the complaint/incident investigation.

The Program failed to comply with regulatory requirements related to Program policies and procedures, Criteria for Admission and Retention, Service Plans, and Nurse Review. Specific deficiencies included medication destruction and administration, admission and retention criteria, service plan maintenance, and nurse review documentation.

Complaint Intake #55743-I was investigated along with the recertification visit. The complaint involved regulatory insufficiencies related to Program policies and procedures, including medication administration and destruction.

The inspection was conducted as a Final Complaint/Incident Investigation following complaints #51666-I and #50744-I regarding incidents involving tenants at Bickford Cottage Davenport.

Regulatory insufficiencies were identified in the areas of Program Policies and Procedures and Staffing, including failure to follow policies on narcotic medication counts, incident reporting, nurse notification, and staff training documentation.

The investigation involved incidents #50744-I and #51666-I. Incident #50744-I pertained to Tenant #1 with no regulatory insufficiencies found. Incident #51666-I involved two tenants (#2 and #3) with regulatory insufficiencies identified for Tenant #3. The complaint investigation substantiated regulatory insufficiencies related to medication management, incident reporting, and staffing.

The inspection was conducted as a Final Complaint/Incident Investigation based on complaints regarding missing money and a fall with injury at Bickford Cottage Davenport, Iowa.

The investigation found that Tenant #1 reported missing money and the program failed to properly document the incident or follow policies. Tenant #2 suffered a fall resulting in a head injury and a non-stable cervical fracture, with appropriate emergency response and notification documented. Regulatory insufficiency was cited related to policies and procedures for reporting incidents.

Complaint/Incident Intake #45965-I involved Tenant #2 who fell and suffered a head injury. Complaint/Incident Intake #46113-I involved Tenant #1 reporting missing money. The complaints were investigated with interviews, file reviews, and observations. The missing money complaint was substantiated with findings of inadequate documentation and policy adherence. The fall incident was documented with appropriate emergency response and no regulatory insufficiency noted.

The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction and ensure compliance with regulatory requirements for the Assisted Living Program at Bickford Cottage of Davenport.

The report found regulatory insufficiencies related to food safety and sanitation training, life safety alarm systems, structural requirements, and record checks. The program had deficiencies in staff training, alarm system operation, and documentation of required background checks.

The inspection was conducted as a complaint/incident investigation following reports that a tenant was found outside the program and taken to an emergency room by an unknown person. The investigation focused on regulatory insufficiencies in staffing, evaluation, service plans, nurse review, and policies and procedures.

The investigation found multiple regulatory insufficiencies including inadequate staffing to meet tenant needs, incomplete evaluations and service plans, lack of nurse reviews for significant changes, and failure to follow policies and procedures related to incident reporting and tenant supervision. Tenant #1 was found to have left the program unsupervised multiple times, resulting in safety risks.

Complaint/Incident Intake #44173-I involved a tenant found outside the program and taken to an emergency room by an unknown person. The tenant was missing until the ER contacted the program. The tenant exited the building without staff knowledge on two occasions and was involved in multiple incidents including pulling fire alarms and elopement attempts.

The inspection was conducted as a complaint/incident investigation regarding tenant safety and use of personal pad alarm systems at Bickford Cottage Davenport.

The investigation found multiple incidents where tenants fell or were at risk of falling, with delayed or inadequate staff response to pad alarms. Several tenants were found to have experienced injuries due to falls, and staff did not consistently place or respond to pad alarms as required. Regulatory insufficiencies were identified related to tenant care, treatment, and staff response to requests.

Complaint/Incident Intake #38616-I involved investigation of tenant falls and staff response to personal pad alarms. The complaint was substantiated with findings of regulatory insufficiencies in tenant care and staff responsiveness.

The inspection was conducted as a complaint and incident investigation following allegations of inappropriate conduct involving Tenant #1 at Bickford Cottage Assisted Living.

The investigation found no regulatory insufficiencies. Tenant #1 alleged being molested by a staff member, but after interviews, record reviews, and internal investigation, no evidence supported the incident. The program took steps to ensure tenant safety.

The complaint involved Tenant #1 alleging molestation by Staff #3. The investigation included interviews with tenants, staff, the tenant's guardian, and review of medical and personnel records. No regulatory insufficiencies were substantiated.

The inspection was conducted as a complaint/incident investigation based on allegations regarding tenant requests for assistance, medication administration errors, staff training on catheter care, service plan compliance, and notification release policies.

No regulatory insufficiencies were identified during the investigation. The monitor reviewed multiple tenant records and program policies and found no violations despite the allegations.

The complaint alleged delays or lack of response to tenant emergency calls, coercion of a tenant by corporate management, medication dose errors, inadequate staff training on urinary catheter care, failure to follow individualized service plans for lab testing, and refusal to allow release of notification requiring 30-day notice and payment. None of these allegations resulted in regulatory insufficiencies.

The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction and ensure compliance with regulatory requirements for the Assisted Living Program at Bickford Cottage.

The evaluation found that the program had no regulatory insufficiencies during the certification period. However, deficiencies were noted related to dementia-specific education for program personnel, with some staff lacking required dementia education in 2011.

A complaint/incident investigation was conducted at Bickford Cottage Assisted Living due to allegations of staff using profanity, verbal and physical abuse, and mistreatment of tenants.

The investigation found multiple incidents where staff #1, #2, and #3 verbally and physically abused tenants, including yelling, humiliating, pushing tenants, and using profanity. Several tenants were negatively affected, and staff actions were contrary to established interventions. The program was assessed regulatory insufficiencies related to staffing and tenant rights violations.

Complaint Intake #33160-M involved allegations that Staff #1, #2, and #3 used profanity, raised voices, frightened tenants, physically abused tenants by grabbing and pushing, and verbally humiliated tenants. Specific incidents involved tenants #1, #2, #3, and #4 with diagnoses including dementia and cognitive impairments. Staff actions were contrary to established service plans and interventions. Some staff were terminated following the investigation.

The visit was conducted as a final incident investigation, complaint investigation, and recertification monitoring evaluation at Bickford Cottage, Davenport, IA, triggered by Incident #26595-I and Complaint #25297-C.

No regulatory insufficiencies were identified during the recertification monitoring evaluation. The complaint investigation included allegations about a tenant fall and odor issues related to a pet. The investigation found no regulatory insufficiencies related to the fall or odor complaints.

Complaint #25297-C alleged a tenant had a pet that urinated and defecated in the apartment causing odor and skin tears to the tenant. Several staff were alleged to have refused to spend time in the apartment due to odor. The investigation found that cleaning, deodorizing, and repairs were scheduled and odor issues were addressed with the tenant's family. No regulatory insufficiencies were found related to the complaint.

The visit was a final recertification monitoring evaluation conducted to assess compliance with Iowa assisted living program regulations and to evaluate tenant care and service plans.

The evaluation found multiple regulatory insufficiencies including failure to consistently update tenant evaluations and service plans as needed with changes in condition, and inadequate nurse delegated staff training. Tenant satisfaction was generally positive, but some concerns were noted regarding emergency response and food quality.

There were substantiated complaints during the certification period related to Evaluation of Tenant, Criteria for Exclusion of Tenant, and Service Plans.