Inspection Reports for Bickford of Iowa City

The inspection was a routine on-site visit to assess compliance with regulatory requirements for an assisted living program serving people with dementia.

The inspection identified multiple regulatory insufficiencies related to program policies on sexual relationships between tenants with cognitive impairment, criteria for admission and retention of tenants with aggressive behaviors, and nursing review for tenants with significant ongoing pain. Plans of correction were provided for each deficiency.

The inspection was conducted following a complaint investigation related to an incident involving the elopement of a tenant (Tenant #1) at the assisted living program.

The program failed to produce a detailed incident report regarding the elopement of Tenant #1, failed to have the staff in charge complete the incident report, and did not follow the policy on unwitnessed door alarms. Staff delayed responding to the door alarm and failed to account for all tenants promptly.

The visit was triggered by a complaint investigation of Incident #129102-I involving the elopement of Tenant #1. The investigation found failures in incident reporting and policy adherence related to the elopement.

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

Two regulatory insufficiencies were cited: failure to maintain documentation of routine personal or health-related care task sheets for one tenant, and failure to conduct nurse reviews every 90 days for one tenant receiving personal or health-related care.

No regulatory insufficiencies were cited during the investigation of Complaint #124099-C.

The inspection was conducted as an investigation of complaint #119834-M regarding an allegation of abuse at the assisted living program.

The program failed to ensure implementation of its established abuse and neglect policy concerning one tenant. Staff witnesses did not immediately report the alleged abuse incident as required, and the program did not complete the required investigation documentation.

The complaint investigation revealed that Staff A allegedly abused Tenant #1 on 3/27/24. Four staff witnesses confirmed witnessing the incident but did not immediately report it to management as required by policy. Staff A was suspended on 3/28/24 after the allegation was reported by Staff E. The program failed to complete an Investigation Report form related to the allegation.

The inspection was conducted following investigations of incidents #114814-I, #114815-I and Complaint #116350-C, focusing on regulatory compliance related to staffing, tenant safety, and alarm system functionality.

The facility failed to have sufficient staff to meet tenant needs, retained tenants dangerous to themselves or others, failed to supervise tenants according to service plans resulting in elopement and injury, and had a malfunctioning door alarm system affecting tenant safety.

The visit was complaint-related, investigating incidents and a complaint involving tenant safety, staffing adequacy, and alarm system failures. Specific incidents included tenant elopements, verbal aggression, and inadequate supervision.

The visit was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program serving people with dementia.

No regulatory insufficiencies were cited during the complaint investigation. However, deficiencies were cited during the recertification visit related to failure to ensure all personnel received the required eight hours of dementia-specific training within 30 days of employment for 2 of 3 staff members.

No regulatory insufficiencies were cited during the investigation of Complaint #108743-C.

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

The program failed to develop individualized service plans reflecting tenant needs and preferences and failed to ensure staff serving food had orientation on safe food handling prior to serving food. Deficiencies were cited related to service plans and food service training.

The inspection was conducted as an investigation of Complaint #77875-C at the assisted living facility.

No regulatory insufficiencies were cited during the investigation of the complaint.

Investigation of Complaint #77875-C found no regulatory insufficiencies.

The visit was conducted to investigate complaint #71893-C and to perform a regulatory inspection of the Assisted Living Program at Bickford Cottage Iowa City.

The program failed to ensure training for non-certified staff regarding the provision of activities of daily living, affecting 2 of 3 staff reviewed. A regulatory insufficiency was identified during the complaint investigation.

Complaint #71893-C was investigated during this visit and a regulatory insufficiency was identified.

The investigation was triggered by complaint #69217-I regarding the care and safety of tenants in the assisted living program, specifically focusing on service plans and life safety related to a tenant's wandering and falls.

The program failed to develop individualized service plans reflecting tenants' needs, particularly for Tenant #1 who had multiple falls and wandering incidents. Additionally, the program failed to ensure an operational door alarm system for the dementia-specific program, resulting in Tenant #1's elopement without staff being alerted.

Investigation #69217-I was conducted due to concerns about Tenant #1's safety related to wandering and falls. The complaint was substantiated as the program failed to develop adequate service plans and maintain functional safety monitoring systems.

Investigation of Complaint #66622-C at Bickford Cottage Iowa City Assisted Living Program.

No regulatory insufficiencies were cited during the complaint investigation.

Complaint #66622-C was investigated and found to have no regulatory insufficiencies.

A recertification visit was conducted to determine compliance with certification for an Assisted Living Program, including investigation of Incident #64695-I.

The program failed to complete criminal history background checks prior to employment for 3 of 7 staff files and failed to ensure staff completed required dementia-specific education and training within 30 days of employment for 2 of 7 staff files. Additionally, the program failed to provide hands-on dementia-specific training for 4 of 7 staff files reviewed.

The inspection was conducted as a complaint/incident investigation following allegations related to tenant documents and structural requirements at Bickford Cottage Iowa City.

The investigation found regulatory insufficiencies in maintaining tenant incident reports for two of four tenant files reviewed and in building and grounds maintenance, specifically a safety concern with a door lock that could prevent egress.

Complaint/Incident Intake #54823-I was investigated with findings related to tenant documents and structural requirements. The complaint was substantiated with regulatory insufficiencies noted.

The inspection was conducted as a Final Complaint Investigation and Recertification Monitoring Evaluation following complaints #51262-C and #51263-C regarding tenant rights and staffing at Bickford Cottage Iowa City.

The investigation found all allegations unsubstantiated with no regulatory insufficiencies related to the complaints. However, regulatory insufficiencies were cited related to record checks and dementia-specific education for program personnel during the recertification visit.

Two complaints (#51262-C and #51263-C) alleging tenant rights violations and staffing issues were investigated and found unsubstantiated. Tenant interviews, staff interviews, and document reviews revealed no concerns meeting regulatory insufficiency standards.

The inspection was conducted as a final complaint/incident investigation following complaints regarding service plans, mail handling, medication storage, staffing, food service, life safety, and other regulatory concerns at Bickford Cottage Iowa City.

The investigation identified a regulatory insufficiency related to service plans, specifically that service plans did not reflect tenants' identified needs and preferences. Other areas such as mail handling, medication storage, staffing, food service, life safety, and nurse review showed no regulatory insufficiencies. Multiple tenant files and staff interviews were reviewed with no concerns noted in many areas.

The complaint investigation was substantiated with a regulatory insufficiency noted in the area of service plans. Other complaints related to mail handling, medication storage, staffing, food service, life safety, nurse review, and other areas were investigated and found to have no regulatory insufficiencies.

The inspection was conducted as a final complaint/incident investigation following allegations related to tenant safety and program compliance at Bickford Cottage Iowa City.

The investigation found no regulatory insufficiency related to the wandering incident involving Tenant #1. However, a regulatory insufficiency was noted for failure to report a fire incident involving Tenant #2 within the required timeframe. Additional deficiencies were found in service plans and nurse reviews, including incomplete reflection of nutritional supplements, treatments, and care needs in tenant service plans.

The complaint involved a tenant (Tenant #1) following a visitor out of the program without signing out, raising concerns about tenant safety and wandering. The investigation included monitoring observations of Tenant #1 and Tenant #2, review of incident reports, and evaluation of service plans and nurse reviews. The complaint was substantiated in part due to regulatory insufficiency related to failure to report a fire incident timely.

The visit was a Final Recertification Monitoring Evaluation conducted by the Iowa Department of Inspections and Appeals to review recertification documents and evaluate compliance with assisted living program regulations.

No regulatory insufficiencies were found during this evaluation. The program met requirements for staffing and dementia-specific education, with no deficiencies noted.

The inspection was conducted as a complaint/incident investigation following a complaint intake #39755-IR, focusing on regulatory insufficiencies in evaluation, service plans, and managed risk at Bickford Cottage Assisted Living in Iowa City.

The investigation found regulatory insufficiencies related to staffing, evaluation, service plans, and managed risk. Specific issues included insufficient trained staff during incidents, incomplete functional and health evaluations, inadequate service plans, and lack of a managed risk policy. Tenant #4 experienced multiple falls and injuries, with insufficient interventions documented.

Complaint/Incident Intake #39755-IR. The investigation was a revisit following a complaint and incident reports involving tenant falls and care concerns. The complaint was substantiated with findings of regulatory insufficiencies in staffing, evaluation, service plans, and managed risk.

The inspection was conducted as a final complaint/incident investigation following a complaint intake regarding incidents involving tenant safety and staff response at Bickford Cottage Assisted Living.

The investigation found multiple incidents involving tenant injuries and aggressive behavior between tenants, with staff responses including monitoring and medication administration. Regulatory insufficiency was cited related to staffing and meeting tenants' identified needs.

The complaint involved incidents where Tenant #1 was pushed and injured by another tenant, Tenant #2 exhibited aggressive behavior including physical and verbal aggression towards other tenants and staff, and staff responses were documented. The complaint was substantiated with findings of regulatory insufficiency.

The inspection was conducted as a complaint/incident investigation following a report that a tenant was found outside on the front porch, triggering concerns about the electronic monitoring system and tenant safety.

The investigation found that the electronic monitoring wristwatch did not function at the time of the incident, the alarm did not register when the tenant left the building, and the tenant was outside for approximately 5 to 10 minutes without sustaining injury. The tenant's service plan did not reflect the identified needs related to the electronic monitoring system or behavior. Additional tenants' service plans also did not reflect their identified needs. Regulatory insufficiency was cited regarding individualized service plans.

The complaint investigation was substantiated based on findings that the electronic monitoring system failed to function properly during the tenant's elopement incident, and service plans did not adequately reflect tenant needs.

The inspection was conducted as a complaint and incident investigation at Bickford Senior Living following allegations of abuse and regulatory insufficiencies related to tenant care and program compliance.

The investigation found regulatory insufficiencies in tenant documentation, service plans, nurse review, and dementia-specific education for program personnel. An allegation of abuse involving staff and a tenant was investigated and determined not to have occurred. Several regulatory insufficiencies were cited related to care, documentation, and staff training.

The complaint involved an allegation that a tenant was not treated appropriately when refusing assistance with personal cares. The incident allegation involved an alleged abuse on 7-22-11 by four staff members and the RN Coordinator. The investigation concluded that abuse did not occur, but regulatory insufficiencies were found in care and documentation.

A complaint investigation on-site visit was conducted at Bickford Cottage on May 25 & 26, 2011, to investigate allegations including tenant aggression and issues with whirlpool and bathing services.

The investigation found regulatory insufficiencies related to tenant evaluations, service plans, nurse reviews, and maintenance of incident reports. Specific tenant files showed incomplete evaluations and service plans, and the whirlpool was broken and not functioning at the time of investigation.

The complaint alleged tenant aggression towards other tenants and that tenants were supposed to receive whirlpools and bathing services which were not provided due to a broken whirlpool. The investigation reviewed tenant files and incident reports related to aggression and found multiple regulatory insufficiencies.

A complaint investigation on-site visit was conducted at Bickford Cottage on May 25 & 26, 2011, triggered by allegations including tenant aggression and issues with whirlpool bathing services.

The investigation found regulatory insufficiencies related to tenant evaluations, service plans, nurse reviews, and maintenance of tenant documents. Specific incidents of tenant aggression were documented, and the whirlpool bathing service was found to be non-functional during the investigation.

The complaint alleged tenant aggression towards other tenants and that tenants did not receive appropriate bathing services due to a broken whirlpool. The investigation substantiated these issues with detailed tenant incident reports and maintenance logs confirming the whirlpool was non-functional.

A complaint investigation on-site visit was conducted at Bickford Cottage of Iowa City on January 3 and 4, 2011, to investigate regulatory insufficiencies in areas including Evaluation of Tenant, Service Plan, Nurse Review, and Medication Disposal.

The investigation found multiple regulatory insufficiencies related to tenant evaluations, service plans, nurse reviews, and medication disposal procedures. Some service plans were not updated or signed appropriately, nurse reviews were incomplete, and medication disposal policies were inconsistently followed. No deficiencies were noted regarding the front door latch and alarm compliance.

The complaint investigation was substantiated with findings of regulatory insufficiencies in tenant evaluation, service plans, nurse review, and medication disposal. The program was assessed a $1,000 civil penalty pursuant to Iowa Code section 231C.14 and 481 IAC 67.12(3)(a).

A complaint investigation on-site visit was conducted at Bickford Cottage Assisted Living on October 11 & 12, 2010, to evaluate regulatory insufficiencies related to tenant care, service plan, food service, staffing, and record checks.

The report identified multiple regulatory insufficiencies including evaluation of tenants, service plans, medications, staffing, and record checks. Several complaint allegations were investigated with some substantiated, and a $4,000 civil penalty was assessed. The program submitted a Plan of Correction which was accepted by the Department of Inspections and Appeals.

The complaint investigation included allegations of heavy lifts risking staff injury, shredding of tenant documents, insufficient nursing oversight, failure to return medications, lack of nurse delegation, and incomplete criminal background checks. Some allegations were substantiated, resulting in regulatory insufficiencies and civil penalties.

The inspection was conducted as a Final Incident & Complaint Investigation at Bickford Cottage Assisted Living following complaints and incidents related to medications, staffing, and tenant care.

The investigation found regulatory insufficiencies in medications and staffing, including medication administration errors and inadequate supervision of tenants. A $500 civil penalty was assessed, and a Plan of Correction was submitted and reviewed.

The complaint investigation included allegations of lost dentures without family notification, medication errors, tenant elopement with failure of alarm system, and inadequate housekeeping. Some allegations were substantiated, resulting in regulatory insufficiencies and a civil penalty.

A complaint investigation and on-site visit was conducted at Bickford Cottage on August 3, 4 & 5, 2010, in response to allegations including altered tenant records, medication room door security, tenant assessment, staffing concerns, and tenant rights violations.

The investigation found no regulatory insufficiencies related to tenant documents, medications, nurse review, or communication book records. However, a regulatory insufficiency was noted regarding staffing and tenant access to a 24-hour personal emergency response system. Tenant rights were found not upheld due to staff behavior. No substantiated regulatory insufficiencies were found related to the Director's nursing license.

Complaint Allegation #29630-C included allegations of altered tenant records, medication room door security issues, inadequate tenant assessment, Director's nursing license concerns, tenant rights violations, and destroyed communication book records. The complaint investigation found no regulatory insufficiencies for most allegations except for staffing and tenant emergency response system access. The program reported a tenant elopement incident which was investigated.

A complaint investigation on-site visit was conducted at Bickford Cottage in Iowa City on May 12, 13, and 17, 2010, to investigate multiple complaint intakes regarding tenant care, staffing, safety, and facility conditions.

The investigation found no regulatory insufficiencies related to tenant evaluation, service plans, staffing, nurse follow-up, life safety, or other allegations. Several complaints were reviewed including falls, wound care, door locking system, fire alarms, and tenant health concerns. No deficiencies or regulatory insufficiencies were noted in the final report.

Complaint investigation involved allegations that tenants did not receive required services, insufficient nurse follow-up on wound care, staffing concerns including the Director working as third staff member, tenant falls and injuries, malfunctioning door locking system, fire alarms going off without evacuation, and a tenant with pink eye. All allegations were reviewed and no regulatory insufficiencies were found.

An incident and complaint investigation on-site visit was conducted at Bickford Cottage Assisted Living on February 16, 17 and 18, 2010, related to allegations of medication errors, staffing, dementia-specific education, and record checks.

The investigation found regulatory insufficiencies in medications, staffing, dementia-specific education for program personnel, and record checks. A medication error involving incorrect administration of morphine sulfate was documented, and staff training deficiencies were noted. The program was assessed a $1,000 civil penalty and the Plan of Correction was accepted.

Complaint allegations included medication errors involving morphine sulfate given to the wrong tenant, failure to notify family of the incident, and inadequate staff training. The complaint investigator made observations confirming these issues. The complaint was substantiated with regulatory insufficiencies and a civil penalty assessed.

The inspection was conducted as a Final Incident Investigation Report related to allegations of theft and failure to report suspected dependent adult abuse within the required timeframe at Bickford Cottage of Iowa City.

The investigation found a regulatory insufficiency due to the program's failure to report suspected dependent adult abuse to the Department within twenty-four hours, resulting in a one thousand dollar civil penalty. The Plan of Correction submitted on November 25, 2009, was reviewed and approved.

The complaint involved allegations of theft of tenants' medications and failure to report suspected dependent adult abuse within 24 hours. The theft allegation was not reported timely, and the program was cited for regulatory insufficiency for not reporting suspected abuse within the required timeframe.

A complaint investigation on-site visit was conducted at Bickford Cottage of Iowa City on August 5 & 6, 2009, to investigate allegations related to tenant care, staffing, tenant documents, service plans, and structural issues.

The investigation found regulatory insufficiencies in evaluation of tenants, tenant documentation, service plans, and notification of incidents. Specific complaints included inadequate evaluation of tenant functional status, incorrect Do Not Resuscitate status documentation, lack of nursing coverage, and failure to notify the Department of Inspections and Appeals of incidents causing substantial injury.

Complaint allegations included unmanageable incontinence requiring three people for transfers, incorrect Do Not Resuscitate (DNR) code status documentation, lack of nursing coverage on 8-4-09, a tenant left unattended resulting in a fall and laceration requiring 14 stitches, unlocked utility closet, and mold in air conditioning vents and tenant apartments. Some allegations were substantiated with observations and incident reports.

The visit was a recertification monitoring evaluation conducted by the Iowa Department of Inspections and Appeals to assess compliance with assisted living program regulations at Bickford Cottage Assisted Living.

No regulatory insufficiencies were found during the monitoring visit. Tenant satisfaction was generally positive, and there were no substantiated regulatory insufficiencies during the certification period.

A complaint investigation on-site visit was conducted at Bickford Cottage Assisted Living on July 21 & 22, 2008, to investigate complaints related to regulatory insufficiencies in various areas including occupancy agreement, tenant evaluations, service plans, medications, nurse review, staffing, and managed risk.

The program was found to be in full compliance with no regulatory insufficiencies noted in the final report. Previous complaints had resulted in fines and sanctions, but the current investigation found no deficiencies. The program was issued a full certificate effective July 30, 2008 through November 30, 2008, and sanctions were discontinued.

The complaint investigation was substantiated with multiple regulatory insufficiencies identified in tenant evaluations, service plans, medication administration, nurse review, staffing, and compliance with the Plan of Correction. Previous investigations resulted in fines of $3,000, $6,000, and $10,000 civil penalties and sanctions including conditional certificates and restrictions on admissions.

A complaint investigation revisit was conducted at Bickford Cottage Assisted Living in Iowa City on May 12, 13, and 14, 2008, to evaluate regulatory insufficiencies related to tenant care, service plans, medications, nurse review, staffing, and other areas.

The program failed to comprehensively follow regulations, resulting in regulatory insufficiencies in multiple areas including occupancy agreements, tenant evaluations, service plans, medication administration, nurse review, staffing, life safety, and exit door alarm systems. Sanctions included conditional operation, restrictions on admissions, and a civil penalty of $10,000.

The complaint investigation was substantiated with findings of regulatory insufficiencies in tenant care, service plans, staffing, medication administration, and safety. Sanctions included conditional operation, restriction on admissions, and a $10,000 civil penalty.

A complaint investigation and revisit were conducted at Bickford Cottage Assisted Living on January 8, 9, 10 & 11, 2008, to investigate regulatory insufficiencies and complaints regarding occupancy agreement, evaluation of tenants, service plans, medications, nurse review, staffing, life safety, exit door alarm system, and other areas.

The program failed to comprehensively follow regulations, resulting in regulatory insufficiencies in multiple areas including occupancy agreements, tenant evaluations, service plans, medication protocols, staffing, life safety, and exit door alarm systems. Immediate sanctions were imposed, including conditional operation and civil penalties. The Plan of Correction was accepted by the Department of Inspections and Appeals.

The complaint investigation was substantiated with findings of regulatory insufficiencies in occupancy agreements, tenant evaluations, service plans, medications, nurse review, staffing, life safety, exit door alarm system, and other areas. Specific allegations included insufficient staffing, medication errors, elopement incidents, and improper handling of alarms and tenant dignity.

A complaint investigation was conducted at Bickford Cottage regarding allegations that a tenant was restricted from using the program’s telephone to receive telephone calls.

The investigation found that the program did not support the tenant’s autonomy by restricting telephone calls and visits by family and friends. The tenant was admitted with a note restricting contact, which was later removed, but the tenant left the program without approval and required hospitalization. The tenant is currently in protective custody.

The complaint was substantiated with findings related to tenant evaluation, occupancy and transfer, medications, and general requirements during the certification period.

A complaint investigation was conducted at Bickford Cottage to address allegations regarding staffing adequacy and other concerns.

The investigation found that the program had terminated its RN but was actively seeking a replacement. Staff and tenants reported no concerns with RN coverage, which included on-call regional RNs and periodic onsite visits. No regulatory insufficiencies were noted related to staffing.

The complaint alleged the program did not have appropriate staffing. The complaint was investigated and found no regulatory insufficiency related to staffing.

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

The monitor found no regulatory insufficiencies during this evaluation. Tenant feedback indicated some concerns about food quality and activity planning, but overall the program was clean, well maintained, and staff were pleasant and helpful.

There were substantiated complaints in the areas of Occupancy and Transfer Criteria and Service Plans.