Inspection Reports for Bickford of Fort Dodge
1536 20th Ave N, Fort Dodge, IA 50501, United States, IA, 50501
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 27, 2025, identified deficiencies related to updating service plans after significant changes and completing comprehensive nurse reviews every 90 days or after significant changes. Earlier inspections showed a mix of findings, including substantiated complaints about tenant care, staff training, failure to report incidents timely, and issues with tenant mistreatment and documentation. Main themes across deficiencies involved care plan updates, nurse reviews, tenant care and assistance, staff training, and incident reporting. Several complaint investigations were substantiated, including neglect, failure to prevent falls, abuse allegations, and delayed reporting of elopements, while many others were unsubstantiated. The inspection history shows ongoing challenges with care documentation and staff oversight, with some improvement in recent complaint investigations but persistent issues in care plan management.
Deficiencies (last 15 years)
Deficiencies (over 15 years)
1.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
59% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
23 residents
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Census: 23
Deficiencies: 2
Aug 27, 2025
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program, following a previous complaint investigation.
Findings
The program failed to update service plans following significant changes for 2 of 4 sampled tenants and failed to complete comprehensive nurse reviews every 90 days or after significant changes for 3 of 3 sampled tenants, including review of prescription medications.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #129366-C.
Deficiencies (2)
| Description |
|---|
| The program failed to update service plans following significant changes for tenant one and tenant two. |
| The program failed to complete comprehensive nurse reviews every 90 days or after a significant change, including review of prescription medications, for three of the three sample tenants (Tenant #1, Tenant #2, and Tenant #4). |
Report Facts
Tenants without cognitive impairment: 16
Tenants with cognitive impairment: 7
Total census: 23
Sample tenants reviewed: 4
Sample tenants for nurse review: 3
Days for nurse review frequency: 90
Plan of correction completion date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Interviewed regarding service plan updates and nurse review deficiencies. | |
| Health and Wellness Director | Responsible party for corrective actions related to service plans and nurse reviews. | |
| Divisional Director of Health and Wellness | Responsible for re-educating Health and Wellness Director and conducting audits. |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 0
Feb 13, 2025
Visit Reason
The inspection was conducted as an investigation of multiple incidents and complaints, specifically Incident #126369-I, Incident #126391-I, Complaint #124898-C, and #125638-C.
Findings
No regulatory insufficiencies were cited during the investigation of the incidents and complaints.
Complaint Details
Investigation of Incident #126369-I, Incident #126391-I, Complaint #124898-C, and #125638-C with no regulatory insufficiencies cited.
Report Facts
Number of tenants without cognitive impairment: 22
Number of tenants with cognitive impairment: 8
Total census: 30
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 4
Dec 11, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to incident #1722582-1 and complaint #172233-0 concerning tenant C1 and tenant C2.
Findings
The investigation found multiple issues including falls risk evaluation deficiencies, failure to provide adequate tenant care and assistance, and inadequate staff training and supervision related to tenant C2. Several incidents of neglect and failure to follow care plans were documented.
Complaint Details
The complaint investigation was substantiated with findings of neglect and failure to provide adequate care to tenant C2, including failure to prevent falls and failure to follow care plans.
Severity Breakdown
Level 3: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to complete falls risk evaluation forms consistently and accurately for tenant C1 and tenant C2. | Level 3 |
| Failure to provide adequate care and assistance to tenant C2, including failure to assist with transfers and ambulation. | Level 3 |
| Failure to follow tenant care plans and provide required assistance with daily living activities for tenant C2. | Level 3 |
| Failure to maintain proper staff training and supervision related to tenant care and fall prevention. | Level 3 |
Report Facts
Number of tenants with cognitive impairment: 17
Total census: 28
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
Jun 19, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to the facility's failure to report a tenant elopement within the required 24-hour or next business day timeframe.
Findings
The investigation found that the facility failed to report an elopement incident involving one tenant within the required timeframe. The tenant eloped on 10/20/23 but the facility reported the incident to the Department on 11/3/23, which was beyond the required notification period.
Complaint Details
The complaint investigation was substantiated as the facility failed to notify the Department of an elopement incident involving Tenant #1 within the required 24-hour or next business day period.
Deficiencies (1)
| Description |
|---|
| Failure to report tenant elopement within 24 hours or next business day as required by state regulations. |
Report Facts
Total census: 27
Number of tenants without cognitive impairment: 19
Number of tenants with cognitive impairment: 8
Tenant age: 83
Global Deterioration Scale (GDS) score: 5
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 0
Nov 1, 2023
Visit Reason
Investigation of Incident #112776-I and Incident #115959-I at the Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the investigation of the two incidents.
Complaint Details
Investigation of Incident #112776-I and Incident #115959-I with no regulatory insufficiencies found.
Report Facts
Number of tenants without cognitive disorder: 16
Number of tenants with cognitive disorder: 10
Total census: 26
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 4
May 18, 2023
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program and included an investigation of complaints #112027-C and #112440-C.
Findings
No regulatory insufficiencies were cited during the recertification visit; however, regulatory insufficiencies were found during the complaint investigation related to tenant abuse, failure to respond reasonably to tenant requests, inadequate nurse delegation and staff training, and failure to perform required criminal history evaluations prior to employment.
Complaint Details
The complaint investigation involved allegations of abuse and other regulatory concerns. The investigation substantiated that Tenant #1 was subjected to physical harm when Tenant #2's son slammed a door on Tenant #1's finger. Additional complaints included billing errors and staff training deficiencies.
Deficiencies (4)
| Description |
|---|
| The program failed to consistently ensure tenants are free from mental and physical abuse, as evidenced by an incident involving Tenant #1 and Tenant #2's son. |
| The program failed to consistently ensure reasonable response regarding a billing error affecting Tenant #2. |
| The program's registered nurse failed to ensure staff were sufficiently trained and competent to meet individual tenant needs, affecting Staff A and potentially all tenants. |
| The program failed to consistently perform evaluations of criminal history prior to employment for Staff A. |
Report Facts
Number of tenants without cognitive impairment: 16
Number of tenants with cognitive impairment: 8
Total census: 24
Staff reviewed: 3
Tenants affected by staff training deficiency: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Staff member whose training and criminal history evaluation were found deficient. | |
| Divisional Director of Health and Wellness | Confirmed findings related to billing error and staff training deficiencies during exit interviews. | |
| Divisional Director of Operations | Confirmed failure to complete required criminal history evaluation prior to employment of Staff A. | |
| Executive Director | Responsible for corrective actions including staff training and audits. | |
| Delegating Nurse | Failed to ensure staff competency and confirmed findings during exit interview. |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 3
Sep 13, 2022
Visit Reason
The inspection was conducted following the investigation of Incident #107408-I concerning allegations of mistreatment by a staff person (Staff G) towards tenants. The visit also reviewed complaints #102970-C and #102219-C, during which no regulatory insufficiencies were cited.
Findings
The program failed to ensure tenants received adequate and appropriate treatment and services, affecting 4 of 5 sampled tenants (#1, #3, #4, and #5). Multiple incidents of physical and verbal mistreatment by Staff G were reported, including forceful redirection, use of restraints, spraying water, and inappropriate physical contact. These incidents were not immediately reported or documented as required by policy. The Administrator confirmed these findings.
Complaint Details
The investigation was triggered by a complaint alleging mistreatment by Staff G reported on 9/01/22. The allegations included physical and verbal abuse affecting tenants #1, #3, #4, and #5. Staff G was suspended on 8/31/22. Staff M and Staff N provided statements detailing multiple incidents. The incidents were not immediately reported or documented, and the Administrator confirmed the findings on 9/13/22.
Deficiencies (3)
| Description |
|---|
| Failure to ensure tenants received adequate and appropriate treatment and services, including allegations of physical and verbal mistreatment by Staff G affecting multiple tenants. |
| Failure to immediately report and document incidents of abuse or neglect as required by program policies. |
| Failure to treat tenants with consideration, respect, and full recognition of personal dignity and autonomy. |
Report Facts
Number of tenants without cognitive disorder: 24
Number of tenants with cognitive disorder: 9
Total population of program: 33
Sample tenants affected: 4
Sample tenants reviewed: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Named in multiple allegations of physical and verbal mistreatment of tenants | |
| Staff M | Reported incidents and provided written statements regarding Staff G's mistreatment | |
| Staff N | Provided statements regarding incidents involving Staff G and Staff M | |
| Staff H | Interviewed regarding knowledge of mistreatment allegations | |
| Administrator | Administrator | Confirmed findings and conducted interviews related to the investigation |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Feb 3, 2022
Visit Reason
Investigation of multiple complaints (#99950-C, #99048-C, #98313-C, #98343-C, and #98353-C) and an onsite infection control visit.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints or the onsite infection control visit.
Complaint Details
Investigation of Complaints #99950-C, #99048-C, #98313-C, #98343-C, and #98353-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 30
Number of tenants with cognitive disorder: 3
Total census: 33
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 0
Feb 20, 2019
Visit Reason
Investigation of Complaint #81087-C at the Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Investigation of Complaint #81087-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 24
Number of tenants with cognitive disorder: 5
Total census: 29
Inspection Report
Renewal
Census: 28
Deficiencies: 0
Mar 27, 2018
Visit Reason
Recertification visit conducted to determine compliance with certification for an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the recertification visit for the Assisted Living Program for People with Dementia.
Report Facts
Number of tenants without cognitive disorder: 21
Number of tenants with cognitive disorder: 7
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Aug 17, 2017
Visit Reason
The inspection was conducted as part of an investigation of Complaint #67075-C and incidents #64734-I and #67005-I at Bickford Cottage Fort Dodge, an assisted living program.
Findings
The program failed to complete a timely nurse review of a tenant after significant changes in condition, resulting in delayed assessment and medical intervention following two falls and injuries sustained by Tenant #2, including a large subdural hematoma.
Complaint Details
The visit was complaint-related, investigating Complaint #67075-C. The complaint was substantiated as the program failed to ensure timely nurse review after significant change in condition for Tenant #2.
Deficiencies (1)
| Description |
|---|
| Failure to complete timely nurse review of a tenant after significant change in condition. |
Report Facts
Number of tenants without cognitive disorder: 24
Number of tenants with cognitive disorder: 4
Total population of program at time of on-site: 28
Falls experienced by Tenant #2: 2
Time delay for nurse review: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Ratcliff | Director | Signed letter responding to complaint and plan of correction |
Inspection Report
Monitoring
Census: 32
Deficiencies: 0
Apr 7, 2016
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to determine compliance with certification requirements for an Assisted Living Program.
Findings
No regulatory insufficiencies were found during the evaluation. The review included recertification documents, a State Fire Marshal inspection report, and Facility Engineer approval of evacuation plans.
Report Facts
Number of tenants without cognitive disorder: 24
Number of tenants with cognitive disorder: 8
Total census of Assisted Living Program: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Ratcliffe | Director | Facility Director addressed in the report |
| Rose Boccella | Program Coordinator | Author of the report and contact person |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Dec 17, 2015
Visit Reason
The inspection was conducted as a complaint investigation following a family concern that a tenant was not treated appropriately at Bickford Cottage Fort Dodge.
Findings
The investigation found that the allegation of inappropriate treatment of a tenant was not substantiated. No regulatory insufficiencies were identified during the investigation.
Complaint Details
Allegation: Tenant Rights - a family concern was reported that a tenant was not treated appropriately. Findings: Not Substantiated. After notification, an internal investigation was conducted including interviews and tenant file review. Inappropriate treatment was not substantiated.
Report Facts
Number of tenants without cognitive disorder: 26
Number of tenants with cognitive disorder: 6
Total Population of Program at time of on-site: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Contact person for the report |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Aug 17, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation following a report that a tenant was missing one narcotic pill.
Findings
The investigation found no substantiation of tenant rights violation related to the missing narcotic pill. No regulatory insufficiencies were identified during the investigation.
Complaint Details
Allegation involved tenant rights regarding a missing narcotic pill. Findings were not substantiated after review of tenant files, staff and tenant interviews, and internal investigation.
Report Facts
Total census: 34
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 6
Tablets missing: 1
Tablets counted: 83
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 2
Dec 8, 2014
Visit Reason
The inspection was conducted as a Final Recertification & Complaint/Incident Investigation following a complaint intake #50916-C regarding regulatory insufficiencies related to program policies, procedures, and program notification to the department.
Findings
The investigation found that staff did not consistently follow policies and procedures, including medication administration and response to an unwitnessed door alarm. A tenant was found outside in cold weather without proper monitoring, and the program failed to report an elopement to the department.
Complaint Details
Complaint investigation #50916-C was substantiated with findings that staff failed to follow medication administration policies and failed to report an elopement of Tenant #7, who was found outside in cold weather with hypothermia risk.
Deficiencies (2)
| Description |
|---|
| Staff did not follow policies and procedures established by the program, including inconsistent handwashing during medication passes and failure to follow the policy for an unwitnessed door alarm. |
| Program failed to report an elopement to the Department within required timeframes. |
Report Facts
Civil penalty amount: 3000
Reduced civil penalty amount: 1950
Census: 42
Tenants without cognitive disorder: 36
Tenants with cognitive disorder: 6
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 3
Oct 9, 2013
Visit Reason
The inspection was conducted as a final complaint/incident investigation regarding allegations of tenant injuries and physical altercations at Bickford Cottage of Fort Dodge, Iowa.
Findings
The investigation found multiple incidents of tenant altercations involving physical aggression and injury, including one tenant with bruising and blackened eyes. The program had regulatory insufficiencies related to tenant rights and criteria for admission and retention. Tenant #5 exhibited repeated exit-seeking and aggressive behaviors requiring psychiatric intervention and increased supervision.
Complaint Details
Complaint/Incident Allegation 45276-C and 45289-I involved tenant injuries from physical altercations, including tenants hitting and punching each other resulting in bruises and blackened eyes. The complaint was substantiated with multiple tenant interviews and incident reports confirming altercations and inadequate program response.
Deficiencies (3)
| Description |
|---|
| Regulatory Insufficiency: Violations related to tenant rights including treatment with consideration, respect, dignity, and autonomy. |
| Regulatory Insufficiency: Failure to provide reasonable response to tenant requests from program staff and management. |
| Regulatory Insufficiency: Program knowingly admitting or retaining tenants who are dangerous to self or others, or medically unstable. |
Report Facts
Number of tenants without cognitive disorder: 30
Number of tenants with cognitive disorder: 8
Total census: 38
Tenant #5 GDS score: 5
Tenant #4 GDS score: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Signed cover letter for the Final Complaint/Incident Investigation Report |
| Maribeth Freland | RN | Monitor for the complaint/incident investigation |
| Lori Miner | RN BSN | Monitor for the complaint/incident investigation |
| Staff #1 | Licensed Practical Nurse (LPN) | Reported observations related to Tenant #5's behaviors and care |
| Staff #2 | Certified Nursing Assistant (CNA) | Reported observations related to Tenant #5's behaviors and care |
| Staff #3 | Certified Medication Aide (CMA) | Reported observations related to Tenant #5's behaviors and care |
Inspection Report
Renewal
Census: 38
Deficiencies: 0
Feb 14, 2012
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation for Bickford Cottage Assisted Living to review recertification documents and ensure compliance with Iowa Code and Administrative Code.
Findings
No regulatory insufficiencies were found during the evaluation. The program was found to be in compliance with all applicable regulations, and the State Fire Marshal's inspection and evacuation plans were approved.
Report Facts
Number of tenants without cognitive disorder: 35
Number of tenants with cognitive disorder: 3
Total census: 38
Tenant meeting attendance: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cindy Egdorf | Director | Director of Bickford Assisted Living |
| Lori Miner | RN BSN | Monitor conducting the evaluation |
| Jim Berkley | Program Coordinator | Signed the final report letter |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Sep 26, 2011
Visit Reason
The inspection was conducted as a final complaint/incident investigation following reports of tenant falls and a possible stolen narcotic medication at Bickford Cottage Assisted Living.
Findings
The investigation found no regulatory insufficiencies related to the reported incidents. Tenant #2 had multiple falls resulting in a hip fracture, and Tenant #1's medication administration was independent with no evidence of theft.
Complaint Details
Two incident allegations were investigated: #34839-I concerning Tenant #2's history of falls and resulting hip fracture, and #35941-I regarding a family member's suspicion of stolen narcotic medication. Both allegations resulted in no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder: 32
Number of tenants with cognitive disorder: 4
Total Population of Program at time of on-site visit: 36
Tenant #1 cognitive exam score: 30
Tenant #2 cognitive evaluation stage: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor for the complaint/incident investigation |
| Joyce Kix | RN | Monitor for the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Aug 3, 2010
Visit Reason
The inspection was conducted as a final incident investigation at Bickford Cottage Assisted Living following incidents involving tenant safety and care concerns.
Findings
The investigation found a regulatory insufficiency related to the admission and retention of a tenant requiring routine two-person assistance for transfers. Another tenant suffered a fall resulting in a femoral neck fracture, with monitoring system issues noted. A $500 civil penalty was assessed.
Complaint Details
The complaint involved incidents where Tenant #1 required two-person transfers but was admitted as a routine two-person transfer, and Tenant #2 was found on the floor with a right femoral neck fracture. The investigation substantiated regulatory insufficiencies in medication and staffing.
Deficiencies (1)
| Description |
|---|
| A program shall not knowingly admit or retain a tenant who requires routine, two-person assistance with standing, transfer or evacuation. |
Report Facts
Civil penalty amount: 500
Tenant count in Dementia Specific Program with dementia: 8
Tenant count in Dementia Specific Program without cognitive disorder: 28
Total population: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tamara Halvorson | Certification Coordinator | Contact person for civil penalty and appeals. |
| Hal L. Chase | RN BSN MPH Monitor | Monitor who conducted the incident investigation. |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter regarding the civil penalty. |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 6
Nov 4, 2004
Visit Reason
A complaint investigation on-site visit was conducted at Bickford Cottage in Fort Dodge to investigate allegations related to tenant care and program compliance.
Findings
The investigation found multiple regulatory insufficiencies including failure to complete tenant assessments prior to admission, failure to update assessments and service plans as needed, failure to transfer a tenant who was a danger to self due to chronic elopement, and failure to obtain required multidisciplinary team signatures on service plans.
Complaint Details
Complaint investigation was triggered by allegations that the program retained a tenant who had multiple incidents of eloping from the building. The complaint was not substantiated in prior certification periods.
Deficiencies (6)
| Description |
|---|
| The program did not complete an assessment of each tenant’s cognitive ability, functional ability and health status prior to admission. |
| The program did not complete an assessment as needed when a change occurred in the tenant(s) cognitive, functional or health status. |
| Program did not transfer a tenant that is a danger to self and despite intervention chronically wanders out of the building. |
| The program did not complete a preliminary service plan prior to tenant taking occupancy. |
| The program did not update the service plan as needed to meet the needs of the tenant in consultation with the tenant or with the tenant’s legal representative. |
| The program did not obtain signatures of the multidisciplinary team involved in the development of the tenant’s service plan. |
Report Facts
Current number of tenants with dementia or cognitive disorder: 8
Current number of tenants without cognitive disorder: 28
Total Population: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the complaint investigation |
| Laura Moen | Administrator | Program Administrator involved in leadership interviews and findings |
Loading inspection reports...
