Inspection Reports for Bickford of Urbandale
5915 Sutton Pl, Urbandale, IA 50322, United States, IA, 50322
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Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Oct 16, 2025
Visit Reason
The inspection was conducted as an investigation of Incident #130330-I and Complaint 129623-C at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigation of the incident and complaint.
Complaint Details
Investigation of Incident #130330-I and Complaint 129623-C found no regulatory insufficiencies.
Report Facts
Tenants without cognitive impairment: 28
Tenants with cognitive impairment: 11
Total census: 39
Inspection Report
Complaint Investigation
Census: 42
Deficiencies: 0
Jun 10, 2025
Visit Reason
Investigation of Complaints 127813-C and 127814-C at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Complaint Details
Complaints 127813-C and 127814-C were investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 28
Number of tenants with cognitive impairment: 14
Total census: 42
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 3
Mar 19, 2025
Visit Reason
The inspection was conducted during the investigation of Complaint #127207-C and the recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
The Program failed to ensure medications and treatments were administered as prescribed, failed to maintain required tenant documentation including durable power of attorney documents, and failed to consistently maintain accurate documentation of personal and health-related care for a sample tenant.
Complaint Details
The visit was complaint-related, investigating Complaint #127207-C. The deficiencies pertained to Tenant #1 and were substantiated by record review and interviews.
Deficiencies (3)
| Description |
|---|
| Failed to ensure treatments were administered as prescribed for Tenant #1, including failure to administer calmoseptine ointment as ordered on multiple dates. |
| Failed to ensure tenant records included copies of durable power of attorney documentation for Tenant #1. |
| Failed to consistently maintain accurate documentation of personal and/or health-related care (task sheets) for Tenant #1. |
Report Facts
Number of tenants without cognitive impairment: 34
Number of tenants with cognitive impairment: 14
Total census: 48
Missed medication administrations: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director | Interviewed during exit on 3/19/25; confirmed Program responsibilities and lack of documentation. |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Oct 14, 2024
Visit Reason
The inspection was conducted as an investigation of incidents #123518-I and 123901-I at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigation of the reported incidents.
Complaint Details
Investigation of incidents #123518-I and 123901-I found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 31
Number of tenants with cognitive impairment: 14
Total census: 45
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 2
Apr 24, 2024
Visit Reason
The inspection was conducted as part of an investigation of Complaint #120221-C regarding the retention of tenants who did not meet admission or retention criteria for the assisted living program.
Findings
The program failed to discharge tenants who were bed bound or required maximal assistance with activities of daily living, contrary to retention criteria. Specifically, three tenants were identified as not meeting retention criteria due to their care needs and physical conditions.
Complaint Details
The investigation was triggered by Complaint #120221-C. The complaint was substantiated as the program failed to meet retention criteria for tenants requiring significant assistance or who were bed bound.
Deficiencies (2)
| Description |
|---|
| Failed to discharge a bed bound tenant who required two-person assistance with transfers and had worsening stage 2 wounds. |
| Failed to consistently discharge tenants requiring maximal assistance with activities of daily living, including assistance with bathing, grooming, dressing, toileting, transferring, and feeding. |
Report Facts
Number of tenants without cognitive impairment: 24
Number of tenants with cognitive impairment: 24
Total census: 48
Number of tenants reviewed for retention criteria: 5
Number of tenants failing retention criteria: 3
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 20
Feb 19, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to regulatory insufficiencies identified in complaints #115146-C, #115562-I, and #113317-M.
Findings
The Program failed to consistently follow policies and procedures including incident reporting, response to door alarms, tenant dignity and respect, staffing sufficiency and training, record checks, tenant evaluations, admission/retention criteria, documentation accuracy, service plan updates and signatures, inclusion of service providers in plans, and dementia-specific education for personnel.
Complaint Details
Investigation of complaints #115146-C, #115562-I, and #113317-M revealed multiple regulatory insufficiencies including failure to follow incident reporting policies, door alarm procedures, tenant dignity, staffing and training requirements, record checks, tenant evaluations, admission/retention criteria, documentation, service plans, and dementia-specific education.
Deficiencies (20)
| Description |
|---|
| Failed to consistently follow established policy regarding completion of incident reports. |
| Failed to consistently follow procedures regarding response to door alarms. |
| Failed to consistently treat tenants with consideration and personal dignity. |
| Failed to ensure availability of sufficient trained staff to meet tenant needs. |
| Delegating nurse failed to ensure staff were sufficiently trained within 60 days of employment. |
| Delegating nurse failed to ensure staff were sufficiently trained within 30 days of employment. |
| Failed to ensure staff received dependent adult abuse training as required. |
| Failed to consistently perform criminal history and background checks prior to employment. |
| Failed to ensure record check evaluations met criteria for 60-day evaluation period. |
| Failed to complete tenant evaluations as needed following significant change in condition. |
| Failed to discharge tenants who exceeded admission/retention criteria, specifically those requiring maximal assistance with activities of daily living. |
| Failed to maintain accurate documentation on task sheets for routine personal and/or health related care. |
| Failed to consistently update service plans to meet tenants' needs. |
| Failed to ensure service plans were signed and dated by all parties. |
| Failed to ensure service plans included tenant's identified needs and assistance needed. |
| Failed to ensure tenant service plans included additional service providers such as hospice. |
| Failed to ensure all personnel including contract/agency staff were appropriately trained to meet tenant needs. |
| Failed to ensure the Director completed required management training within six months of hire. |
| Failed to ensure staff received eight hours of dementia-specific training within 30 days of employment. |
| Failed to ensure all staff received eight hours of dementia-specific continuing education annually. |
Report Facts
Total census: 45
Tenants without cognitive impairment: 28
Tenants with cognitive impairment: 17
Number of tenants affected by dignity issue: 4
Number of tenants potentially affected by dignity issue: 5
Number of tenants dependent on staff for ADLs: 3
Number of tenants with missing task sheet documentation: 9
Number of staff lacking dementia training within 30 days: 4
Number of staff lacking dementia continuing education annually: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff K | Medication Aide (former) | Named in incident report deficiency and staffing insufficiency |
| Staff B | Medication Aide | Named in staffing and training deficiencies |
| Staff F | Staff | Named in door alarm response deficiency and training |
| Agency Staff J | Agency Staff | Named in staffing and training deficiency |
| Executive Director | Executive Director | Named in multiple deficiencies and responsible for corrective actions |
| Health and Wellness Director | Health and Wellness Director | Named in multiple deficiencies and responsible for corrective actions |
| Staff A | Director of Nursing or similar | Named in staffing and training deficiencies |
| Staff C | Staff | Named in training deficiencies |
| Staff D | Staff | Named in training deficiencies |
| Staff E | Former Staff | Named in dementia training deficiency |
| Staff G | Former Staff | Named in dementia training deficiency |
| Staff H | Former Staff | Named in record check deficiency |
| Staff I | Former Staff | Named in record check deficiency |
Inspection Report
Plan of Correction
Census: 51
Deficiencies: 0
Jul 7, 2021
Visit Reason
The document is a plan of correction related to an assisted living program for people with dementia, following an investigation identified as 96132-C.
Findings
There were no regulatory insufficiencies cited during the investigation of 96132-C.
Report Facts
Number of tenants without cognitive disorder: 25
Number of tenants with cognitive disorder: 26
Total Census of Program: 51
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 0
Jan 28, 2021
Visit Reason
The inspection was conducted during the investigation of complaints 94921-C and 95150-C, as well as an on-site infection control survey.
Findings
No regulatory insufficiencies were cited during the complaint investigations and infection control survey.
Complaint Details
Investigation of complaints 94921-C and 95150-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder in general population: 20
Number of tenants with cognitive disorder in general population: 14
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 10
Total census of assisted living program for people with dementia: 44
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 0
Feb 19, 2020
Visit Reason
Investigation of Complaint #87937-C at Bickford Cottage Urbandale Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Complaint Details
Complaint #87937-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder in General Population: 25
Number of tenants with cognitive disorder in General Population: 12
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 13
Total Census: 50
Inspection Report
Renewal
Census: 32
Deficiencies: 2
ScannedReport 1743 2024 02 05 121911
Visit Reason
The visit was a recertification visit conducted to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
Two regulatory insufficiencies were cited: failure to discharge tenants requiring maximal assistance with activities of daily living, and failure to provide eight hours of dementia-specific training within 30 days of employment for staff.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaints #101792-C and #109276-C.
Deficiencies (2)
| Description |
|---|
| The program failed to discharge a tenant requiring maximal assistance with activities of daily living, thus exceeding level of care. |
| The program failed to provide eight hours of dementia-specific training within 30 days of employment. |
Report Facts
Number of tenants without cognitive disorder in General Population Program: 12
Number of tenants with cognitive disorder in General Population Program: 11
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 9
Total census of Assisted Living Program for People with Dementia: 32
Number of tenants reviewed for maximal assistance deficiency: 5
Number of staff reviewed for dementia training deficiency: 7
Hours of dementia training completed by Staff A within first 30 days: 2.5
Hours of dementia training completed by Staff B within first 30 days: 1.5
Hours of dementia training completed by Staff C within first 30 days: 2.25
Hours of dementia training completed by Staff D within first 30 days: 0.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Named in dementia training deficiency with 2.5 hours completed within first 30 days | |
| Staff B | Named in dementia training deficiency with 1.5 hours completed within first 30 days | |
| Staff C | Named in dementia training deficiency with 2.25 hours completed within first 30 days | |
| Staff D | Named in dementia training deficiency with 0.25 hours completed within first 30 days |
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