Inspection Reports for Bickford of Iowa City
3500 Lower West Branch Rd, Iowa City, IA 52245, United States, IA, 52245
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 22, 2025, identified deficiencies related to program policies on tenant sexual relationships, discharge notices for tenants with aggressive behaviors, and nursing assessments for pain management. Earlier inspections showed a pattern of regulatory issues involving tenant safety, staffing adequacy, individualized service plans, nurse reviews, and documentation. Several complaint investigations substantiated deficiencies in incident reporting, supervision, and staff training, with some enforcement actions including civil penalties ranging from $500 to $10,000 in past years. No license suspensions or revocations were listed in the available reports. While deficiencies have persisted over time, recent inspections continue to identify similar themes, indicating ongoing challenges in fully meeting regulatory requirements.
Deficiencies (last 15 years)
Deficiencies (over 15 years)
7.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
70% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
26 residents
Based on a October 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Routine
Census: 26
Deficiencies: 3
Date: Oct 22, 2025
Visit Reason
The inspection was a routine on-site visit to assess compliance with regulatory requirements for an assisted living program serving people with dementia.
Findings
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.
Deficiencies (3)
Program failed to follow established policy and procedures regarding sexual relationships between tenants with cognitive impairment for 1 tenant.
Program failed to give notice of discharge for exceeding criteria for retention for 1 tenant with ongoing physically aggressive behaviors.
Program failed to ensure adequate nursing assessment and documentation for 1 tenant with significant ongoing pain.
Report Facts
Census - tenants without cognitive impairment: 13
Census - tenants with cognitive impairment: 13
Total census: 26
Deficiencies cited: 3
Date survey completed: Oct 22, 2025
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 3
Date: Jul 21, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
The program failed to produce a detailed incident report regarding the elopement of 1 of 1 tenants reviewed (Tenant #1).
The program staff in charge at the time of an elopement involving 1 of 1 tenants reviewed (Tenant #1) did not complete the incident report.
The program failed to follow the policy on unwitnessed door alarms involving 1 of 1 tenants reviewed who eloped (Tenant #1).
Report Facts
Number of tenants without cognitive impairment: 18
Number of tenants with cognitive impairment: 12
Total census: 30
Door alarm response time (minutes): 8
Distance tenant was found from building (miles): 1.3
Date of incident: Jun 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Staff present during the incident who failed to produce a detailed incident report and delayed responding to the door alarm | |
| Staff B | Staff present during the incident who failed to produce a detailed incident report and delayed responding to the door alarm | |
| Staff C | Staff who observed Tenant #1 off premises and reported the tenant missing | |
| Divisional Director | Completed the incident report after the fact and confirmed deficiencies in reporting | |
| Executive Director | Notified by staff about the missing tenant and involved in follow-up |
Inspection Report
Renewal
Census: 28
Deficiencies: 2
Date: Mar 26, 2025
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #124099-C.
Findings
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.
Deficiencies (2)
Failed to maintain documentation for 1 of 1 tenants reviewed who required task sheets (Tenant #3).
Failed to conduct nurse reviews every 90 days for 1 of 3 tenants reviewed who received personal or health-related care (Tenant #1).
Report Facts
Number of tenants without cognitive impairment: 8
Number of tenants with cognitive impairment: 20
Total census: 28
Days task sheets retained: 7
Nurse review interval: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Confirmed task sheet retention policy and nurse review findings | |
| Executive Director | Confirmed task sheet retention policy and nurse review findings |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Date: Aug 14, 2024
Visit Reason
The inspection was conducted as an investigation of complaint #119834-M regarding an allegation of abuse at the assisted living program.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure implementation of the established abuse and neglect policy regarding one tenant, including failure to immediately report alleged abuse and incomplete investigation documentation.
Report Facts
Number of tenants without cognitive impairment: 7
Number of tenants with cognitive impairment: 22
Total census: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Alleged abuser in the abuse incident | |
| Staff B | Witness to the incident who did not immediately report it | |
| Staff C | Witness to the incident who did not immediately report it | |
| Staff D | Witness to the incident who did not immediately report it | |
| Staff E | Reported the allegation on 3/28/24; no longer employed at the program | |
| Executive Director | Executive Director | Signed note regarding investigation and provided statements about the incident |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 4
Date: Feb 28, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
The program failed to have sufficient staff available to fully meet the needs of tenants.
The program retained tenants who were dangerous to themselves or others.
The program failed to supervise current tenants according to their service plans resulting in elopement and/or injury.
The program failed to ensure the building's alarm system worked properly, potentially affecting tenants with cognitive impairment.
Report Facts
Number of tenants without cognitive disorder: 19
Number of tenants with cognitive disorder: 16
Total census: 35
Global Deterioration Scale score: 6
Number of tenants reviewed for danger to self or others: 4
Number of tenants reviewed for supervision: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reported on tenant toileting and skin issues, and door alarm problems | |
| Staff B | Reported on tenant verbal aggression and door alarm issues | |
| Staff C | Reported on tenant wounds and elopement attempts | |
| Director of Health and Wellness | Director of Health and Wellness | Provided assessments, updated service plans, and confirmed findings |
| Executive Director | Executive Director | Confirmed findings and reported on alarm system issues |
| Licensed Practical Nurse | Licensed Practical Nurse | Documented tenant elopement and alarm failures |
Inspection Report
Renewal
Census: 35
Deficiencies: 1
Date: Nov 8, 2022
Visit Reason
The visit was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program serving people with dementia.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #108743-C.
Findings
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.
Deficiencies (1)
Failure to consistently ensure all personnel received eight hours of dementia-specific training within 30 days of employment, pertaining to 2 of 3 staff members.
Report Facts
Number of tenants without cognitive impairment: 22
Number of tenants with cognitive impairment: 13
Total census: 35
Hours of dementia-specific training completed by Staff B within 30 days: 5.5
Inspection Report
Renewal
Census: 35
Deficiencies: 2
Date: Feb 28, 2019
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for a Dementia Specific Assisted Living Program.
Findings
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.
Deficiencies (2)
Program failed to develop service plans to reflect the identified needs of tenants.
Program failed to ensure staff who served food had an orientation on safe food handling prior to serving food.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 7
Total Census of Assisted Living Program: 35
Staff reviewed for food service training: 7
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Date: Oct 17, 2018
Visit Reason
The inspection was conducted as an investigation of Complaint #77875-C at the assisted living facility.
Complaint Details
Investigation of Complaint #77875-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint.
Report Facts
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 9
Total census: 38
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Date: Jan 8, 2018
Visit Reason
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.
Complaint Details
Complaint #71893-C was investigated during this visit and a regulatory insufficiency was identified.
Findings
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.
Deficiencies (1)
The Program failed to ensure training for non-certified staff regarding the provision of activities of daily living (ADLs).
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 8
Total Census of Assisted Living Program: 35
Staff reviewed: 3
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
Date: Oct 5, 2017
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Program failed to develop service plans to reflect the identified needs of tenants, including failure to address wandering behavior and falls for Tenant #1.
Program failed to consistently ensure an operational door alarm system as required for a dementia-specific program, leading to failure to alert staff when Tenant #1 eloped.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 7
Total population of program at time of on-site: 34
Number of tenants reviewed: 2
Number of falls Tenant #1 had in past 90 days: 4
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Date: Apr 5, 2017
Visit Reason
Investigation of Complaint #66622-C at Bickford Cottage Iowa City Assisted Living Program.
Complaint Details
Complaint #66622-C was investigated and found to have no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 25
Number of tenants with cognitive disorder: 12
Total population of Program at time of on-site: 37
Total census of Assisted Living Program: 37
Inspection Report
Renewal
Census: 34
Deficiencies: 3
Date: Feb 23, 2017
Visit Reason
A recertification visit was conducted to determine compliance with certification for an Assisted Living Program, including investigation of Incident #64695-I.
Findings
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.
Deficiencies (3)
Failed to complete a criminal history background check and dependent adult abuse registries check prior to employment for 3 of 7 staff files.
Failed to ensure staff completed eight hours of dementia-specific education and training within 30 days of employment for 2 of 7 staff files.
Failed to provide dementia-specific training, including hands-on training, for 4 of 7 staff files reviewed.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 7
Total Population of Program: 34
Staff files reviewed: 7
Staff files with incomplete background checks: 3
Staff files with incomplete dementia-specific education within 30 days: 2
Staff files missing hands-on dementia-specific training: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in findings related to incomplete background checks and dementia-specific education | |
| Staff B | Named in findings related to incomplete background checks and dementia-specific education | |
| Staff D | Named in findings related to incomplete background checks and dementia-specific education | |
| Staff C | Named in findings related to missing hands-on dementia-specific training | |
| Staff E | Named in findings related to missing hands-on dementia-specific training |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Date: Oct 5, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations related to tenant documents and structural requirements at Bickford Cottage Iowa City.
Complaint Details
Complaint/Incident Intake #54823-I was investigated with findings related to tenant documents and structural requirements. The complaint was substantiated with regulatory insufficiencies noted.
Findings
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.
Deficiencies (2)
The Program failed to maintain documentation for tenants regarding incident reports for two of the four tenant files reviewed.
The Program failed to have buildings and grounds that were well-maintained, clean, safe and sanitary. A door lock was installed with the lock on the corridor side, creating a safety concern as it could prevent a path of egress from the area.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 3
Total Population of Program at time of on-site: 31
Total census of Assisted Living Program: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed the cover letter and is contact for questions regarding the report |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Date: Jan 5, 2015
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to complete criminal history background checks and abuse history background checks for two of seven staff members.
Failure to provide eight hours of dementia-specific training within 30 days of employment for six out of seven staff files.
Report Facts
Number of tenants without cognitive disorder: 25
Number of tenants with cognitive disorder: 6
Total Population of Program at time of on-site: 31
Staff files missing dementia training: 6
Staff files reviewed: 7
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Aug 18, 2014
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Service plans did not reflect the identified needs and preferences for assistance for tenants.
Report Facts
Census: 37
Tenants without cognitive disorder: 34
Tenants with cognitive disorder: 3
Dates of Complaint/Incident Investigation: August 18, 19, 20 and 25, 2014
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator, Adult Services Bureau | Author of the cover letter for the Final Complaint/Incident Investigation Report |
| Stephanie Cummins | Monitor | Investigator for the Complaint/Incident Investigation |
| Stephanie Radabaugh | Monitor | Investigator for the Complaint/Incident Investigation |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 7
Date: Oct 17, 2013
Visit Reason
The inspection was conducted as a final complaint/incident investigation following allegations related to tenant safety and program compliance at Bickford Cottage Iowa City.
Complaint Details
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.
Findings
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.
Deficiencies (7)
Incident reports for 8-19-13 and 9-29-13 lacked vital signs as required by program policy.
Failure to report the fire incident involving Tenant #2 to the Department within 24 hours as required.
Tenant #1's service plan did not reflect weight loss and nutritional supplement needs.
Service plans did not reflect the identified needs of Tenant #3 and other tenants.
Treatment Administration Record (TAR) for Tenant #3 did not reflect completion of ordered treatments.
Orders for Exuderm RCD 4 x 4 for Tenant #4 were unclear and needed clarification regarding time and frequency.
Review of tenant files indicated treatments were not completed per order and treatment orders needed clarification.
Report Facts
Number of tenants without cognitive disorder: 35
Number of tenants with cognitive disorder: 4
Total population of program at time of on-site: 39
Weight loss in pounds: 10
Date of complaint/incident investigation: October 17 and 21, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | MA | Monitor for the complaint/incident investigation |
| Rose Boccella | Program Coordinator, Adult Services Bureau | Reviewer and contact person for the report |
Inspection Report
Monitoring
Census: 34
Deficiencies: 0
Date: Oct 22, 2012
Visit Reason
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.
Findings
No regulatory insufficiencies were found during this evaluation. The program met requirements for staffing and dementia-specific education, with no deficiencies noted.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 7
Total Population of Program at time of on-site: 34
Community meeting attendance: 13
Hours of dementia training completed by Staff #1: 10
Hours of dementia training completed by Staff #3: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maribeth Freland | RN | Monitor for the evaluation visit |
| Joyce Kix | RN | Monitor for the evaluation visit |
| Emily Elmendorf | Director | Director of Bickford Cottage of Iowa City, named in report |
| Staff #4 | Registered Nurse (RN) | Identified as delegating nurse and involved in delegation documentation |
| Staff #1 | Certified Medication Assistant (CMA) | Performed personal care and medication administration tasks |
| Staff #2 | Certified Nursing Assistant (CNA) | Performed personal care tasks |
| Staff #3 | Assistant Cook | Completed dementia training documentation |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 4
Date: Aug 29, 2012
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Regulatory insufficiency related to insufficient number of trained staff to meet tenant needs during an incident.
Regulatory insufficiency for failure to evaluate each tenant's functional, cognitive, and health status within required timeframes and as needed.
Regulatory insufficiency for failure to establish service plans that direct staff to assist tenants appropriately and update plans timely.
Regulatory insufficiency for failure to have a managed risk policy including a consensus-based process and documentation.
Report Facts
Census: 32
Number of tenants without cognitive disorder: 25
Number of tenants with cognitive disorder: 7
Civil penalty amount: 3000
Date of complaint/incident investigation: Aug 29, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor for the complaint/incident investigation |
| Emily Elmendorf | Administrator | Administrator of Bickford Cottage Assisted Living named in report |
| Rose Boccella | Program Coordinator mentioned in relation to civil penalty and contact for appeal |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Jul 11, 2012
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Regulatory Insufficiency: A sufficient number of trained staff shall be available at all times to fully meet tenants' identified needs.
Report Facts
Total census: 33
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 6
Civil penalties: 5000
Civil penalties: 4000
Civil penalties: 1000
Civil penalties: 4000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor for the Complaint/Incident Investigation |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Date: Nov 9, 2011
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
The service plan did not reflect the tenant's identified needs and preferences for assistance, including the failure of the electronic monitoring wristwatch and alarm system.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 9
Total population of program at time of on-site: 36
Tenant age: 95
Tenant age: 69
Tenant age: 78
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 5
Date: Aug 2, 2011
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Documentation for each tenant was not adequately maintained, including incident reports related to medication errors, accidents, falls, and elopements.
The service plan was not individualized and did not reflect refusal of care, combative behavior, or specify who provided assistance with the tenant's catheter.
A nurse review was not completed related to the allegation of abuse or to assess the tenant for injuries or changes in health status.
Staff did not receive the required eight hours of dementia-specific education within 30 days of employment.
All tenants did not receive care, treatment, and services that were adequate and appropriate.
Report Facts
Civil penalty: 5000
Tenant census: 38
Tenants with dementia: 9
Tenants without cognitive disorder: 29
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the complaint investigation and on-site visit. |
| Rose Boccella | Program Coordinator | Contact person for the program regarding the demand letter and appeal process. |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter related to the civil penalty and investigation. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 6
Date: May 25, 2011
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (6)
Regulatory insufficiency in evaluating tenant functional, cognitive, and health status within required timeframes.
Regulatory insufficiency in maintaining incident reports involving tenants, including medication errors and accidents.
Regulatory insufficiency in developing and updating tenant service plans within required timeframes.
Regulatory insufficiency in completing nurse reviews every 90 days and after significant changes.
Regulatory insufficiency related to whirlpool maintenance and bathing services.
Regulatory insufficiency in ensuring tenant rights to adequate and appropriate care and services.
Report Facts
Civil penalty amount: 4000
Tenant population: 35
Tenants with dementia: 8
Tenants without cognitive disorder: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Elmendorf | Director | Facility Director named in the report. |
| Stephanie Cummins | Monitor | Monitor for the complaint investigation. |
| Rose Boccella | Program Coordinator | Contact person for the demand letter and civil penalty. |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 5
Date: May 25, 2011
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (5)
Failure to complete cognitive and health evaluations within 30 days of occupancy for multiple tenants.
Incident reports involving tenant aggression and physical/verbal abuse were not properly documented or monitored.
Service plans were not developed or updated within required timeframes and did not indicate tenant needs and preferences for assistance.
Nurse reviews were not completed as required every 90 days or after significant changes in tenant condition.
Whirlpool bathing service was broken and not functioning, impacting tenant care.
Report Facts
Civil penalty amount: 4000
Complaint intake number: 33881
Tenant census: 35
DSP tenants with dementia: 8
DSP tenants without cognitive disorder: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Elmendorf | Director | Facility Director named in report |
| Stephanie Cummins | Monitor | Investigator for the complaint |
| Rose Boccella | Program Coordinator | Named in demand letter and contact for appeal |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed conclusion letter |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 4
Date: Jan 3, 2011
Visit Reason
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.
Complaint Details
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).
Findings
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.
Deficiencies (4)
Failure to evaluate each tenant's functional, cognitive, and health status within 30 days of occupancy and as needed thereafter.
Service plans were not updated as needed, individualized, or signed appropriately by tenants or legal representatives.
Incomplete nurse reviews and failure to assess and document tenant health status regularly.
Medication disposal procedures were not consistently followed and documented as required by policy.
Report Facts
Civil penalty amount: 1000
Complaint intake number: 32072
Tenant census: 36
Tenants with dementia: 8
Tenants without cognitive disorder: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the complaint investigation. |
| Rose Boccella | Program Coordinator | Contact person for appeal and civil penalty payment. |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter and report conclusion. |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 8
Date: Oct 11, 2010
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (8)
Failure to evaluate each tenant's functional, cognitive, and health status within 30 days of occupancy and as needed thereafter.
Lack of policy regarding destruction of tenant documents; shredded papers were limited to communication pages but no tenant records were shredded.
Service plan for a tenant was not updated as needed with significant changes.
Failure to return medications to pharmacy for tenants discharged from the program.
Food service staff lacked orientation on sanitation and safe food handling prior to handling food.
Insufficient nursing oversight and no director or registered nurse to monitor tenants and direct staff.
Lack of appropriate nurse delegation training for staff.
Failure to complete criminal background checks appropriately for prospective employees.
Report Facts
Civil penalty amount: 4000
Current number of tenants in Dementia Specific Program: 9
Current number of tenants without cognitive disorder: 25
Total population: 34
Dates of investigation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor for the complaint investigation. |
| Stephanie Cummins | MA | Monitor for the complaint investigation. |
| Ann Martin | RN | Monitor for the complaint investigation and Bureau Chief who signed the demand letter. |
| Lori Miner | RN BSN | Monitor for the complaint investigation. |
| Rose Boccella | Certification Coordinator | Contact person for questions regarding the report and penalty. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 4
Date: Aug 12, 2010
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Medication administration errors including delayed administration and failure to document contacting physician.
Inadequate supervision of a tenant who eloped and failure of the call system to alarm.
Failure to notify tenant's family about lost dentures and poor oral hygiene.
Failure to provide 24-hour personal emergency response system that identifies tenant in distress.
Report Facts
Civil penalty amount: 500
Current number of tenants in Dementia Specific Program: 7
Current number of tenants without cognitive disorder: 25
Total population: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Patricia McNichol | Administrator | Named in relation to medication administration errors and overall facility management. |
| Hal L. Chase | RN BSN MPH | Monitor conducting the investigation. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 2
Date: Aug 3, 2010
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Each tenant shall have access to a 24-hour personal emergency response system that automatically identifies the tenant in distress and can be activated by one touch.
Tenant rights were not upheld due to staff roughness and failure to treat tenants with consideration, respect, and full recognition of personal dignity and autonomy.
Report Facts
Complaint Intake Number: 29630
Incident Intake Number: 29629
Census - Dementia Specific Program tenants with dementia: 8
Census - Dementia Specific Program tenants without cognitive disorder: 24
Total Population Census: 32
Civil Penalty: 1000
Civil Penalty: 1000
Civil Penalty: 500
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the complaint investigation |
| Patricia McNichol | Director | Named in complaint and monitoring observations regarding nursing license and tenant records |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Date: May 12, 2010
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Complaint Intake Numbers: 3
Tenant Census: 36
Dementia Specific Program Tenants with Dementia: 11
Tenants without Cognitive Disorder: 25
Community Meeting Tenants: 15
Family Members Interviewed: 3
Civil Penalties: 1000
Civil Penalties: 1000
Civil Penalties: 500
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 4
Date: Feb 16, 2010
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Medication administration error where Tenant #1 was given medications prescribed for Tenant #2.
Insufficient number of trained staff available at all times to meet tenants' identified needs.
Lack of required dementia-specific education and training for program personnel within 30 days of employment.
Failure to ensure criminal background checks were completed prior to employment of staff.
Report Facts
Civil penalty amount: 1000
Census: 32
Tenants with dementia: 7
Tenants without cognitive disorder: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor for the investigation. |
| Staff #1 | Registered Nurse (RN) | Involved in medication error and training deficiencies. |
| Staff #2 | Registered Nurse (RN) | Provided orientation and medication administration training to Staff #1. |
| Staff #4 | Certified Medication Aide | Contacted regarding medication error. |
| Staff #5 | On-call RN | Directed medication administration after error. |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter assessing civil penalty. |
| Chris Nothaft | Certification Coordinator | Contact person for questions regarding the letter and report. |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: Oct 6, 2009
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
The program did not report suspected dependent adult abuse to the Department within twenty-four hours.
Report Facts
Civil penalty amount: 1000
Reduced penalty amount: 650
Number of tenants with dementia or cognitive disorder: 8
Number of tenants without cognitive disorder: 26
Total population: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | MA | Monitor during the incident investigation. |
| Joyce Kix | RN | Monitor during the incident investigation. |
| Patricia McNichol | Director | Facility director named in the report. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 5
Date: Aug 5, 2009
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (5)
The program did not consistently evaluate each tenant’s functional, cognitive and health status as needed.
The program did not consistently maintain a file for each tenant that contains advance directives as applicable.
The program did not consistently update each tenant’s service plan as needed, when a tenant needs personal or health related care.
The program did not consistently develop service plans that were individualized and indicate at a minimum the tenant’s identified needs and requests for assistance and expected outcomes.
The program did not notify the Department of Inspections and Appeals within twenty-four hours of any accident causing substantial injury or death.
Report Facts
Complaint Intake Number: 24460
Complaint Intake Number: 24717
Tenant Count: 24
Tenant Count: 11
Total Population: 35
Civil Penalty: 500
Stitches: 14
Penalty Reduction Percentage: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter and report conclusion |
| Kathy Dye | Divisional Operations Specialist | Addressee of the complaint investigation report |
| Hal Chase | RN BSN MPH | Monitor for the complaint investigation |
| Stephanie Cummins | MA | Monitor for the complaint investigation |
| Chris Nothaft | Certification Coordinator | Contact person for questions regarding the letter and report |
Inspection Report
Monitoring
Census: 29
Deficiencies: 0
Date: Nov 4, 2008
Visit Reason
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.
Findings
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.
Report Facts
Tenants with dementia or cognitive disorder: 8
Tenants without cognitive disorder: 21
Total Population: 29
Tenant meeting attendance: 12
Inspection Report
Complaint Investigation
Census: 21
Deficiencies: 7
Date: Jul 21, 2008
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (7)
Regulatory insufficiency related to not consistently completing functional, cognitive and health evaluations for tenants #5, #10, #13 and #19.
Regulatory insufficiency related to retaining a tenant (#18) who required two-person assistance with standing, evacuation and transfer.
Regulatory insufficiency related to not consistently developing service plans for tenants #5, #10, #13 and #18.
Regulatory insufficiency related to medication administration errors and documentation issues noted during May 2008 visit.
Regulatory insufficiency related to not consistently assessing and documenting tenants' health related activities for tenants #5, #10 and #13.
Regulatory insufficiency related to not consistently providing sufficiently trained staff to meet tenants' needs.
Regulatory insufficiency related to not consistently following the Plan of Correction submitted to DIA in response to a previous complaint investigation.
Report Facts
Total Population: 21
Tenants with dementia or cognitive disorder: 6
Tenants without cognitive disorder: 15
Fines: 3000
Fines: 6000
Civil penalty: 10000
Civil penalty: 10000
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 10
Date: May 12, 2008
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (10)
Failure to consistently obtain signed occupancy agreements prior to tenant admission.
Failure to consistently evaluate tenants' functional and cognitive abilities and health status within required timeframes.
Failure to exclude tenants requiring a higher level of care without written exception.
Failure to consistently develop and update individualized service plans reflecting tenants' current needs.
Failure to consistently follow acceptable medication administration protocols and documentation.
Failure to complete nurse reviews as required and assess tenants' health-related activities.
Failure to provide sufficiently trained staff at all times to meet tenants' needs.
Failure to follow written emergency policies and procedures related to life safety.
Failure to maintain a free and unobstructed exit door alarm system in the dementia-specific program.
Failure to consistently follow the Plan of Correction submitted in response to previous complaints.
Report Facts
Civil penalty amount: 10000
Complaint investigation dates: May 12, 13 & 14, 2008
Current number of tenants in dementia specific program: 7
Current number of tenants without cognitive disorder: 16
Total population: 23
Previous fines: 3000
Previous fines: 6000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Bricker | Director | Named as Director of Bickford Cottage Assisted Living, recipient of the report. |
| Hal Chase | RN BSN MPH | Monitor involved in the complaint investigation. |
| Stephanie Cummins | SW MA | Monitor involved in the complaint investigation. |
| Ann Martin | RN, Bureau Chief Adult Services Bureau | Signed the report and involved in monitoring. |
| Ted Hose | Direct care staff mentioned in relation to nurse delegation training. |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 10
Date: Jan 8, 2008
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (10)
The program does not consistently obtain signed occupancy agreements for all tenants prior to taking occupancy.
The program did not consistently complete cognitive, health and functional evaluations within 30 days and as needed.
The program did not consistently update service plans for tenants with a change in condition.
The program did not consistently follow an acceptable medication/treatment protocol.
The program did not complete nurse reviews as needed with changes in condition.
The program did not consistently provide sufficient trained staff at all times to meet tenants' needs.
The program did not consistently provide sufficient trained staff available at all times to fully meet tenants' identified needs.
The program did not consistently follow written emergency policies and procedures.
The program did not have a functioning exit door alarm system connected to each exit door in the dementia-specific program.
The program did not assure that the dignity of the tenant was maintained.
Report Facts
Complaint Intake Numbers: 4
Census: 30
Civil Penalty Amount: 10000
Dates of Investigation: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the Final Complaint Investigation & Revisit Report letter |
| Stephanie Cummins | SW MA | Monitor during the complaint investigation |
| Ann Martin | RN | Monitor during the complaint investigation |
| Christina Bricker | Divisional Director of Operations | Named in relation to Plan of Correction and facility operations |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 1
Date: Dec 22, 2004
Visit Reason
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.
Complaint Details
The complaint was substantiated with findings related to tenant evaluation, occupancy and transfer, medications, and general requirements during the certification period.
Findings
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.
Deficiencies (1)
The program did not support the tenant’s autonomy by allowing the tenant to receive telephone calls and visits by family and friends.
Report Facts
Current number of tenants in Dementia Specific Program: 5
Current number of tenants without cognitive disorder: 22
Total Population: 27
Mini Mental Status Exam score: 19
Hospitalization duration: 5
Date of emergency guardianship: Dec 14, 2004
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 0
Date: Dec 22, 2004
Visit Reason
A complaint investigation was conducted at Bickford Cottage to address allegations regarding staffing adequacy and other concerns.
Complaint Details
The complaint alleged the program did not have appropriate staffing. The complaint was investigated and found no regulatory insufficiency related to staffing.
Findings
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.
Report Facts
Current tenants: 27
Tenants with dementia or cognitive disorder: 5
Tenants without cognitive disorder: 22
RN termination date: Nov 5, 2004
RN interviews conducted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Social Worker | Monitor conducting the complaint investigation |
Inspection Report
Monitoring
Census: 26
Deficiencies: 0
Date: Sep 21, 2004
Visit Reason
The visit was a re-certification monitoring evaluation conducted to assess compliance with assisted living program regulations at Bickford Cottage.
Complaint Details
There were substantiated complaints in the areas of Occupancy and Transfer Criteria and Service Plans.
Findings
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.
Report Facts
Current number of tenants in Dementia Specific Program: 26
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