Inspection Reports for Bickford of Sioux City
4020 Indian Hills Dr, Sioux City, IA 51108, United States, IA, 51108
Back to Facility ProfileInspection Report Summary
The most recent inspection on August 7, 2025, found no deficiencies during the recertification visit and complaint investigation. Earlier inspections showed a mixed pattern, with some citations related primarily to service plan updates, transportation supervision, pest control, and staff training in dementia care. Complaint investigations occasionally substantiated issues such as failure to update service plans after health changes and lapses in transportation policy adherence, but no fines, immediate jeopardy findings, or license actions were listed in the available reports. Most complaints were unsubstantiated, and enforcement actions were limited to a single $500 fine in 2010 for delayed background checks. The facility’s record shows improvement over time, with recent inspections free of deficiencies following earlier citations in care planning and staff education.
Deficiencies (last 12 years)
Deficiencies (over 12 years)
1.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
64% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
20 residents
Based on a August 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Recertification
Census: 20
Deficiencies: 0
Date: Aug 7, 2025
Visit Reason
The visit was conducted to investigate Incident #128254-I, Complaint #128809-C, and to perform the recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Complaint #128809-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation and recertification visit.
Report Facts
Number of tenants without cognitive impairment: 0
Number of tenants with cognitive impairment: 20
Total census: 20
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 1
Date: Feb 25, 2025
Visit Reason
The inspection was conducted to investigate complaints #124657-C, #126350-I, and #125646-C related to the assisted living program for people with dementia.
Complaint Details
Complaint #125646-C was substantiated with a finding that the service plan for Tenant #3 was not updated to reflect physician-ordered changes for pressure ulcers and related care.
Findings
No regulatory insufficiencies were found for complaints #124657-C and #126350-I. However, a regulatory insufficiency was cited for complaint #125646-C due to failure to update the service plan for Tenant #3 following significant changes in health condition.
Deficiencies (1)
Program failed to update service plans with significant change for Tenant #3, including pressure sore and blister care instructions.
Report Facts
Number of tenants without cognitive impairment: 25
Number of tenants with cognitive impairment: 25
Total census: 25
Pressure sore size: 3
Blister size: 2
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 3
Date: Nov 1, 2023
Visit Reason
The inspection was conducted to investigate complaints related to tenant safety during transportation and tenant rights regarding pest control and staff training.
Complaint Details
The investigation was triggered by complaints #115919-C and 116546-C. No regulatory insufficiencies were found during investigations of incidents #115785-I and 116547-I. The complaint investigation substantiated failures in transportation supervision, pest control response, and staff training compliance.
Findings
The program failed to consistently follow its transportation policy, resulting in a tenant being left unattended on a bus for approximately one hour and 40 minutes in high heat conditions. Additionally, the program did not timely address reported bed bug infestations affecting a tenant and failed to ensure all staff received the required eight hours of dementia-specific education annually.
Deficiencies (3)
Failed to consistently follow the program's transportation policy, leaving Tenant #4 unattended on the bus.
Failed to consistently ensure reported bed bugs were addressed in a timely manner and did not provide alternative sleeping arrangements for Tenant #1.
Failed to consistently ensure all staff received eight hours of dementia-specific education annually.
Report Facts
Tenant census: 30
Duration tenant left unattended: 100
Temperature: 86
Dementia-specific training hours: 3.5
Required dementia-specific training hours: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Admitted to leaving Tenant #4 unattended on the bus | |
| Staff C | Did not complete required eight hours of dementia-specific training | |
| Director | Program Director | Confirmed failures in transportation supervision and pest control response |
Inspection Report
Renewal
Census: 35
Deficiencies: 0
Date: Aug 16, 2023
Visit Reason
Recertification visit conducted to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the recertification visit or during investigations #114013-I and 11604-I.
Report Facts
Number of tenants without cognitive impairment: 0
Number of tenants with cognitive impairment: 35
Total census: 35
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 4
Date: Mar 16, 2022
Visit Reason
The inspection was conducted following the investigation of Incident #102863-I involving a tenant elopement and failure to follow resident monitoring policies.
Complaint Details
The visit was complaint-related, investigating Incident #102863-I involving a tenant elopement on 2/28/22. The complaint was substantiated based on findings of policy noncompliance and system failures.
Findings
The facility failed to follow its resident monitoring system policy, resulting in a tenant with dementia eloping without triggering alarms due to a missing watch battery and unauthorized access to door codes. The service plan was not updated to reflect increased supervision needs, and alarm system checks were not properly documented. The alarm system was not fully effective, and staff failed to detect the elopement in a timely manner.
Deficiencies (4)
Failure to follow resident monitoring system policy for Tenant #1 leading to elopement.
Failure to provide adequate and appropriate care, treatment, and services for Tenant #1 with dementia and exit-seeking behavior.
Failure to update service plans to reflect increased supervision needs for Tenant #1.
Failure to ensure an operating alarm system was connected to each exit door in the dementia unit.
Report Facts
Number of tenants: 34
Number of tenants with cognitive disorder: 33
Number of tenants without cognitive disorder: 1
Global Deterioration Score: 5
Number of tenants wearing Watch alarm system: 26
Exit door inspections frequency: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse | Reported Tenant #1's watch was missing its battery on the evening of 2/28/22 and confirmed failure of alarm system | |
| Staff C | Former Maintenance Man | Confirmed failure to use HomeFree System Testing Procedure and failure to document alarm system checks |
| Administrator | Confirmed no completed HomeFree System Testing Procedure Checklist was found | |
| Nurse | Confirmed findings related to failure to update service plan and alarm system issues |
Inspection Report
Renewal
Census: 34
Deficiencies: 4
Date: Sep 30, 2021
Visit Reason
The inspection was a recertification visit to determine compliance with certification of an Assisted Living Program for people with Dementia.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaints #92962-C and #93151-C.
Findings
The inspection identified regulatory insufficiencies related to dependent adult abuse training, background checks prior to employment, retention criteria for tenants requiring two-person assistance, and dementia-specific education for personnel. No deficiencies were found during complaint investigations or infection control survey.
Deficiencies (4)
Failed to provide required two hours of dependent adult abuse training within 6 months of employment for 3 of 7 staff reviewed.
Failed to complete criminal, child, and dependent adult abuse background checks prior to employment for 2 of 7 staff reviewed.
Retained tenants who routinely required the assistance of at least two staff with standing, transfer, or evacuation, contrary to retention criteria.
Failed to provide eight hours of dementia-specific education and training within 30 days of employment for 2 of 7 staff reviewed.
Report Facts
Census: 34
Staff reviewed: 7
Tenants reviewed: 4
Discharged tenants reviewed: 4
Dependent adult abuse training deficiency: 3
Background check deficiency: 2
Dementia training deficiency: 2
Inspection Report
Renewal
Census: 26
Deficiencies: 2
Date: Nov 6, 2019
Visit Reason
The inspection was conducted as a recertification to determine compliance with certification for an Assisted Living Program - Dementia Specific.
Findings
The program failed to consistently discharge tenants who exceeded admission/discharge criteria and did not ensure all personnel received required dementia-specific education within 30 days of employment.
Deficiencies (2)
The Program failed to consistently discharge tenants who exceed admission/discharge criteria.
All personnel employed by or contracting with a dementia-specific program did not receive a minimum of eight hours of dementia-specific education and training within 30 days of employment for 1 of 3 staff reviewed.
Report Facts
Census: 26
Staff reviewed: 3
Staff not compliant: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Did not complete dementia training within 30 days of employment | |
| Staff A | Director | Confirmed Staff B had not completed training within required time period |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 0
Date: Jul 2, 2018
Visit Reason
The inspection was conducted as an investigation of Incident #75820-I at the Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Incident #75820-I; no deficiencies were found.
Findings
No regulatory insufficiencies were cited during the investigation of the incident.
Report Facts
Number of tenants with cognitive disorder: 23
Number of tenants without cognitive disorder: 0
Total census: 23
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 0
Date: Mar 6, 2018
Visit Reason
Investigation of Incident #73803-I at an Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Incident #73803-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Number of tenants with cognitive disorder: 22
Number of tenants without cognitive disorder: 0
Inspection Report
Annual Inspection
Census: 22
Deficiencies: 0
Date: Dec 5, 2017
Visit Reason
The inspection was conducted as a recertification visit for the Assisted Living Program, including an investigation of complaint #72331-I.
Complaint Details
Investigation of complaint #72331-I was conducted during the recertification visit and resulted in no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the recertification visit, and the complaint investigation resulted in no regulatory insufficiencies.
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 0
Date: Aug 23, 2017
Visit Reason
Investigation of Incident #68450-I at Bickford Cottage II Sioux City, an assisted living program with a dementia-specific program by dedication.
Complaint Details
Investigation of Incident #68450-I found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the incident.
Report Facts
Number of tenants with cognitive disorder: 23
Number of tenants without cognitive disorder: 0
Total census of Assisted Living Program: 23
Inspection Report
Renewal
Census: 28
Deficiencies: 0
Date: Dec 21, 2015
Visit Reason
A recertification visit and incident investigation were conducted at the Assisted Living Program from 12/21/15 to 12/23/15 to evaluate compliance and investigate an incident.
Complaint Details
The incident investigation related to a tenant's fall was unsubstantiated.
Findings
No regulatory insufficiencies were found during the evaluation. The incident investigation found the tenant's fall was responded to appropriately and the complaint was unsubstantiated.
Report Facts
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 27
Total Population of Program at time of on-site: 28
Total census of Assisted Living Program: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Signed letter regarding certification and recertification monitoring evaluation |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 0
Date: Sep 2, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding staffing and an incident involving a tenant's elopement at Bickford Cottage II Sioux City.
Complaint Details
Allegation: Staffing. Findings: Not substantiated. Comments indicated that the tenant had no history of elopement behavior, and the window securing methods had been in place for 16 years without incident.
Findings
No regulatory insufficiencies were identified. The allegation of staffing issues was not substantiated based on observations, staff interviews, and review of incident reports and program policies.
Report Facts
Staff working the floor: 8
Tenant census: 26
Number of tenants with cognitive disorder: 26
Number of tenants without cognitive disorder: 0
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 0
Date: May 21, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding tenant rights allegations at Bickford Cottage II, Sioux City, IA, following an on-site monitoring visit from May 19-21, 2015.
Complaint Details
Allegation: Tenant Rights. Findings: Unsubstantiated. Based on tenant file review, staff interviews, policy reviews, incident report review, and other investigative steps, it could not be determined that tenants had been mistreated. Staff failed to report suspected dependent adult abuse immediately and failed to document allegations properly, resulting in reprimands, but no regulatory insufficiencies were cited.
Findings
The allegation of tenant rights mistreatment was unsubstantiated due to lack of immediate reporting, no eyewitnesses, and tenants' inability to contribute to the investigation. No regulatory insufficiencies were identified during the investigation.
Report Facts
Number of tenants without cognitive disorder: 8
Number of tenants with cognitive disorder: 15
Total census: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Author of the report and contact person for questions |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 3
Date: Mar 11, 2014
Visit Reason
The inspection was conducted as a Final Recertification Monitoring Evaluation and Incident Investigation following a complaint/incident intake #47202-I, focusing on regulatory insufficiencies related to dementia-specific education, mandatory dependent adult abuse training, and policies and procedures.
Complaint Details
The complaint/incident involved an incident where Staff #1 was observed grabbing and spinning Tenant #1 around in a bear-hug manner. The incident was reported and investigated, with no harm found to the tenant. Staff #1 was described as loud and interventions were put in place to address the behavior. The program reported the incident timely.
Findings
The program received regulatory insufficiencies in the areas of dementia-specific education for program personnel, mandatory reporter training for dependent adult abuse, and policies and procedures. An incident involving staff and a tenant was investigated, with no regulatory insufficiency noted related to tenant rights. The program was required to submit a Plan of Correction within 10 working days.
Deficiencies (3)
Training files lacked documentation of the completion of any dementia training for certain staff.
Mandatory reporter training for dependent adult abuse was not completed within required timeframes for some staff.
The program's policies and procedures did not meet minimum standards, including failure to follow handwashing and glove use procedures during medication pass and meal service.
Report Facts
Number of tenants with cognitive disorder: 26
Total Population of Program at time of on-site: 26
Hours of dementia training received by Staff #1: 8
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 0
Date: Oct 15, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation based on allegations regarding tenant apartment cleanliness, incontinence care, staffing sufficiency, care provision, and odor issues at Bickford Cottage II Memory Care Assisted Living.
Complaint Details
The complaint alleged dirty tenant apartments, unattended incontinence, insufficient staff to prevent falls, inadequate care provision, and strong odors. The investigation found no preponderance of evidence to support these allegations and no regulatory insufficiencies were noted.
Findings
The investigation found no regulatory insufficiencies or violations. Observations and interviews indicated that apartments were generally clean, tenants were assisted appropriately with toileting and hygiene, staffing levels were adequate, and no evidence supported the allegations. Some odors of urine were noted but did not meet criteria for regulatory insufficiency.
Report Facts
Number of tenants with cognitive disorder: 21
Total population of program at time of on-site: 23
Number of tenants without cognitive disorder: 2
Number of staff members available: 3
Number of staff members available: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Author of cover letter and contact for report questions |
| Lori Miner | RN BSN | Monitor conducting the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 22
Deficiencies: 0
Date: Jul 22, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation based on allegations regarding activities, nurse care, tenant rights, staffing, service plans, and food service at Bickford Cottage II of Sioux City.
Complaint Details
The complaint investigation addressed allegations that the program did not provide activities for all tenants, tenants had untreated cuts, staff made fun of tenants, tenants were put to bed early, food was shoved into tenants' mouths, a staff person pulled a tenant by the arms during transfer, a tenant was dropped on the floor, incontinence care was neglected, tenants were not provided a ground meat diet when needed, and food was undercooked and unpalatable. None of these allegations were substantiated.
Findings
The investigation found no regulatory insufficiencies in any of the complaint areas including activities, nurse review, tenant rights, staffing, service plans, and food service. Observations and interviews confirmed appropriate care and services were provided.
Report Facts
Number of tenants without cognitive disorder: 3
Number of tenants with cognitive disorder: 19
Total census: 22
Tenant age: 87
Tenant age: 99
Tenant age: 93
Tenant age: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor conducting the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 1
Date: Jun 5, 2013
Visit Reason
The inspection was conducted as a Final Complaint/Incident Investigation for Bickford Cottage II of Sioux City, Iowa, based on complaints regarding tenant elopement, staffing issues, medication overuse, lack of planned activities, nurse review concerns, and structural requirements.
Complaint Details
The complaint investigation involved three complaint/incident intake numbers (43751-I, 43741-C, 44166-C). Allegations included tenant elopement, lack of staff presence in the memory care unit during weekends, increased tenant falls due to lack of supervision, medication overuse, lack of planned activities, failure to identify changes in tenant condition, and a community cat residing in the program. Some allegations were substantiated with findings of regulatory insufficiency, particularly regarding tenant admission/retention criteria and staffing.
Findings
The investigation found multiple issues including tenant elopement incidents, inadequate supervision during weekends in the memory care unit, medication management concerns, and lack of planned activities. Several tenants exhibited exit seeking and wandering behaviors, with some receiving medications to manage agitation. The program had no regulatory insufficiencies noted in some areas but did have substantiated complaints related to staffing and tenant safety.
Deficiencies (1)
A program shall not knowingly admit or retain a tenant who is bed-bound, requires routine two-person assistance, is dangerous to self or others, or has other specified conditions (IAC r. 481-69.23(1))
Report Facts
Number of tenants with cognitive disorder: 22
Total population of program at time of onsite visit: 24
Number of apartments: 36
Incident reports documented: 51
Falls: 47
Elopements: 3
Staff scheduled on day shift: 3
Staff scheduled on evening shift: 3
Staff scheduled on night shift: 2
Medication administration days for Lorazepam in March 2013: 15
Weight loss for Tenant #2: 19
Weight loss for Tenant #5: 15
Weight loss for Tenant #6: 8
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 0
Date: Dec 14, 2011
Visit Reason
The inspection was conducted as a complaint/incident investigation following an allegation that the program did not adequately assess tenants for change of condition or physical needs.
Complaint Details
The complaint alleged inadequate assessment of tenants for changes in condition or physical needs. The investigation found no regulatory insufficiencies and determined that care was appropriately provided.
Findings
The investigation reviewed four tenant files, all admitted to hospice, and found no regulatory insufficiencies. Observations and interviews indicated that care needs were met, tenants appeared neat and clean, and no deficiencies were noted.
Report Facts
Number of tenants with cognitive disorder: 25
Total census of Assisted Living Program: 25
Number of tenant files reviewed: 4
Number of tenants observed in dining room: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the complaint/incident investigation |
Inspection Report
Monitoring
Census: 24
Deficiencies: 0
Date: Nov 9, 2011
Visit Reason
The visit was a Final Recertification Monitoring Evaluation to assess compliance with Iowa Administrative Code chapters related to assisted living programs and to review recertification documents.
Findings
No regulatory insufficiencies were found during the evaluation. The program was clean, well-maintained, and staff treated tenants kindly. The program did not receive any regulatory insufficiencies during the certification period.
Report Facts
Number of tenants with cognitive disorder: 24
Total census of Assisted Living Program: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN BSN | Monitor conducting the evaluation |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 1
Date: Jun 1, 2010
Visit Reason
A complaint investigation on-site visit was conducted at Bickford Cottage II on June 1 and 2, 2010, to investigate regulatory insufficiency related to record checks.
Complaint Details
Complaint Intake #: 28713-M. The complaint investigation found regulatory insufficiency in record checks. No substantiated regulatory insufficiencies were found during the certification period prior to this complaint.
Findings
The investigation found a regulatory insufficiency regarding incomplete dependent adult abuse and criminal background checks for a staff member, resulting in a $500 civil penalty being assessed to the facility.
Deficiencies (1)
Personnel record for Staff #1 documented a hire date of 1-29-09, but the dependent adult abuse and criminal background check was not completed until 3-13-09, with a positive history not approved by the Department of Human Services until 3-17-09.
Report Facts
Civil penalty amount: 500
Reduced penalty amount: 325
Total Population of Dementia Specific Program: 31
Total Census of Assisted Living Program: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joyce Kix | RN | Monitor of the complaint investigation |
| Tamara Halvorson | Certification Coordinator referenced for civil penalty payment and appeals | |
| Carol Johnson | Director | Facility Director named in the report |
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