Inspection Reports for Bickford of West Des Moines
5050 Hawthorne Dr, West Des Moines, IA 50265, United States, IA, 50265
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 15, 2025, found no deficiencies during complaint investigations. Earlier inspections showed a pattern of occasional deficiencies related mainly to tenant retention criteria—specifically retaining tenants requiring two-person assistance—and staff training, including background checks and dementia-specific education. Complaint investigations were mostly unsubstantiated, with no enforcement actions or fines listed in the available reports. Prior reports noted issues with alarm systems and individualized service plans, but these were addressed over time. The overall trend suggests improvement, with recent inspections showing fewer and less frequent deficiencies.
Deficiencies (last 17 years)
Deficiencies (over 17 years)
2.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
35 residents
Based on a October 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Oct 15, 2025
Visit Reason
The inspection was conducted to investigate complaints numbered 129980-C and 130554-C at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Complaint Details
Investigation of Complaints 129980-C and 130554-C found no regulatory insufficiencies.
Report Facts
Tenants without cognitive impairment: 31
Tenants with cognitive impairment: 4
Total census: 35
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 0
Jul 9, 2025
Visit Reason
Investigation of complaints numbered 127855-C, 128455-C, and 128653-C at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigation of the complaints.
Complaint Details
Investigation of Complaints 127855-C, 128455-C, and 128653-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 29
Number of tenants with cognitive impairment: 2
Total census: 31
Inspection Report
Renewal
Census: 33
Deficiencies: 1
Apr 1, 2025
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during complaint investigations, but one regulatory insufficiency was cited during the recertification visit related to the program retaining a tenant who routinely required two staff to assist with transfers.
Complaint Details
No regulatory insufficiencies were cited during the investigations of Complaints #121111-C and #121112-C.
Deficiencies (1)
| Description |
|---|
| Program retained 1 of 4 tenants reviewed who routinely required two staff to assist with transfers, which is against admission/retention criteria. |
Report Facts
Number of tenants without cognitive impairment: 31
Number of tenants with cognitive impairment: 2
Total census: 33
Residents reviewed requiring two staff assistance: 1
Date deficiencies corrected by: May 7, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed and observed regarding Tenant #3's care needs and transfer assistance. | |
| Staff B | Interviewed and agreed Tenant #3 required two staff assistance. | |
| Staff C | Observed assisting Tenant #3 and commented on transfer difficulties. | |
| Staff D | Observed assisting Tenant #3 and involved in transfer attempts. | |
| Staff E | Interviewed about Tenant #3's assistance needs and concerns about staff safety. | |
| Staff F | Agreed with Staff C about transfer difficulties. | |
| Staff G | Staff on duty who responded to Tenant #3's call for assistance. | |
| Staff H | Staff on duty who responded to Tenant #3's call for assistance. | |
| Director of Health and Wellness | Director of Health and Wellness (DHW) | Interviewed and confirmed findings regarding Tenant #3's care and transfer assistance. |
| Physician Assistant-Certified | Physician Assistant-Certified (PA-C) | Reviewed Tenant #3 and ordered therapy services. |
| Divisional Director of Health and Wellness | Provided re-education and will monitor compliance as part of the plan of correction. |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 0
Sep 12, 2023
Visit Reason
The inspection was conducted to investigate Incident 110612-I and Complaints #113474-C, 111027-C, and 110601-C at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigation of the incident and complaints.
Complaint Details
Investigation of Incident 110612-I and Complaints #113474-C, 111027-C, 110601-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive impairment: 22
Number of tenants with cognitive impairment: 5
Total census: 27
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 3
Jan 23, 2023
Visit Reason
The inspection was conducted to investigate Complaints #105218-C and 107992-C and to conduct a recertification visit to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
The Program failed to consistently perform criminal history and background checks prior to employment, failed to ensure all personnel including contract/agency staff were appropriately trained, and failed to ensure staff received eight hours of dementia-specific training annually. These deficiencies potentially affected all 20 tenants.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #108093-C. Deficiencies were cited during the investigation of Complaints #105218-C and 107992-C.
Deficiencies (3)
| Description |
|---|
| Failed to consistently perform criminal history and background checks prior to employment. |
| Failed to consistently ensure all personnel including contract/agency staff were appropriately trained to meet tenant needs. |
| Failed to consistently ensure staff received eight hours of dementia-specific training annually. |
Report Facts
Number of tenants without cognitive impairment: 12
Number of tenants with cognitive impairment: 8
Total census: 20
Tenants potentially affected: 20
Tenants potentially affected: 20
Tenants potentially affected: 20
Agency/contract staff reviewed: 2
Inspection Report
Plan of Correction
Census: 27
Deficiencies: 0
Jun 8, 2022
Visit Reason
The document is a plan of correction related to investigations of incidents and complaints at the assisted living facility.
Findings
No regulatory insufficiencies were cited during the investigations of Incident #98855-I or Complaints #98402-C, #98848-C, #101334-C, and #103167-C.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 19
Number of tenants with cognitive disorder in General Population Program: 3
Number of tenants without cognitive disorder in Memory Care Unit: 0
Number of tenants with cognitive disorder in Memory Care Unit: 5
Total census: 27
Inspection Report
Renewal
Census: 30
Deficiencies: 4
Apr 26, 2021
Visit Reason
Recertification visit conducted to determine compliance with certification of an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the recertification visit, infection control survey, or investigation of incidents. However, deficiencies were found related to dependent adult abuse training, record checks, criteria for admission/retention of tenants, and dementia-specific education for personnel.
Deficiencies (4)
| Description |
|---|
| Program failed to provide staff the required two hours of dependent adult abuse training within six months of employment for 3 of 8 staff reviewed (Staff B, Staff C, and Staff E). |
| Program failed to complete criminal, child, and dependent adult abuse background checks prior to employment for 2 of 8 staff reviewed (Staff C and Staff D). |
| Program failed to ensure tenants continued to meet criteria for retention of an assisted living program for people with dementia, specifically for 2 of 4 tenants reviewed who required routine two-person assistance with standing, transfer, or evacuation. |
| Program failed to provide the required eight hours of dementia-specific education and training within 30 days of employment for 3 of 8 staff reviewed (Staff B, Staff D, and Staff E). |
Report Facts
Number of tenants without cognitive disorder: 19
Number of tenants with cognitive disorder: 5
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 6
Total census: 30
Staff reviewed: 8
Tenants reviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Named in deficiencies related to dependent adult abuse training and dementia-specific education | |
| Staff C | Named in deficiencies related to dependent adult abuse training and record checks | |
| Staff D | Named in deficiencies related to record checks and dementia-specific education | |
| Staff E | Named in deficiencies related to dependent adult abuse training and dementia-specific education | |
| Registered Nurse Coordinator | Registered Nurse Coordinator | Confirmed findings related to tenant care needs and transfers |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Oct 15, 2020
Visit Reason
The inspection was conducted as an investigation of Complaint #93587-C regarding regulatory insufficiencies in the Assisted Living Program for People with Dementia.
Findings
The program failed to follow policies and procedures related to communicable disease preparedness, screening of tenants and staff, and enforcement of mask-wearing and social distancing. Several staff failed to properly screen for COVID-19 symptoms, and tenant screenings were not consistently documented.
Complaint Details
Complaint #93587-C was investigated and regulatory insufficiencies were cited related to program policies and procedures for incident reports and communicable disease preparedness.
Deficiencies (1)
| Description |
|---|
| Program failed to follow policies and procedures for communicable and contagious disease preparedness and lifting of restricted access, affecting all 32 tenants. |
Report Facts
Number of tenants without cognitive disorder in general population: 27
Number of tenants with cognitive disorder in general population: 3
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 4
Total census of Assisted Living Program for People with Dementia: 34
Number of tenants potentially affected by failure to follow policies: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Swartzel | RN | Led infection control team for return to work procedures after positive COVID-19 tests |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 1
Sep 23, 2020
Visit Reason
The inspection was conducted as part of an investigation of Complaint 89775-C regarding the retention of tenants who exceeded the level of care.
Findings
The program failed to ensure tenants who exceeded the level of care were discharged, specifically Tenant #1 who required routine two-person assistance with transfers and toileting but was retained. Observations and interviews confirmed staff did not routinely transfer Tenant #1 during meals and that the tenant required maximal assistance with all transfers and daily activities.
Complaint Details
Investigation of Complaint 89775-C found the program retained a tenant (Tenant #1) who required routine two-person assistance with transfers and toileting, exceeding the level of care allowed.
Deficiencies (1)
| Description |
|---|
| Failed to ensure tenants who exceeded level of care were discharged, specifically Tenant #1 requiring routine two-person assistance with standing, transfer, or evacuation. |
Report Facts
Total Census: 45
Number of tenants without cognitive disorder: 35
Number of tenants with cognitive disorder: 3
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Coordinator | Registered Nurse Coordinator (RNC) | Interviewed regarding Tenant #1's transfer status and care needs |
| Program Director | Program Director | Acknowledged Tenant #1's responsiveness and ability to assist |
Inspection Report
Life Safety
Deficiencies: 1
Jan 27, 2020
Visit Reason
The inspection was conducted to evaluate compliance with life safety-emergency policies and structural safety requirements, specifically focusing on the operating alarm system connected to each exit door in a dementia-specific program.
Findings
The facility failed to consistently ensure operating alarm systems were attached and functional on each exit door, resulting in a tenant exiting the building without staff knowledge. The door alarm system was found to be malfunctioning due to a pager system error and lack of maintenance after the responsible maintenance man quit.
Deficiencies (1)
| Description |
|---|
| Failure to consistently ensure operating alarm systems attached to each exit door in a dementia-specific program, allowing a tenant to exit without staff knowledge. |
Report Facts
Date survey completed: Jan 27, 2020
Date of incident report: Jan 19, 2020
Date of last door alarm check: Nov 21, 2019
Temperature at time of incident: 4
Wind chill: -13
Tenant body temperature: 97.8
Tenant cognitive assessment score: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Reported tenant found outside, assisted tenant, and provided vital signs information | |
| Staff B | Reported hearing someone calling for help and assisted in locating tenant | |
| Staff C | Notified about pager system malfunction and tenant location | |
| Director | Confirmed no assessment was done immediately after incident and investigated pager system malfunction | |
| Certified Medication Aide (CMA) | Confirmed no physical assessment was completed on night of incident |
Inspection Report
Renewal
Census: 37
Deficiencies: 0
Apr 30, 2019
Visit Reason
The inspection was conducted as a recertification to determine compliance with certification for an Assisted Living Program for People with Dementia (ALP/D).
Findings
No regulatory insufficiencies were cited during the recertification inspection for the Assisted Living Program for People with Dementia.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 3
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 7
Total Census: 37
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Feb 6, 2019
Visit Reason
Investigation of Incident #80585-I at the assisted living program for people with dementia.
Findings
No regulatory insufficiencies were cited during the investigation.
Complaint Details
Investigation of Incident #80585-I; no regulatory insufficiencies found.
Report Facts
Number of tenants without cognitive disorder in general population: 27
Number of tenants with cognitive disorder in general population: 3
Number of tenants with cognitive disorder in memory care unit: 6
Total census: 36
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Jul 12, 2018
Visit Reason
Investigation of Complaint #76682-C regarding the Assisted Living Program for People with Dementia at Bickford Cottage West Des Moines.
Findings
No regulatory insufficiencies were cited during the complaint investigation. The census included 28 tenants without cognitive disorder and 2 with cognitive disorder in the general population, and 7 tenants with cognitive disorder in the memory care unit.
Complaint Details
Complaint #76682-C was investigated and found to have no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder in general population: 28
Number of tenants with cognitive disorder in general population: 2
Number of tenants without cognitive disorder in memory care unit: 0
Number of tenants with cognitive disorder in memory care unit: 7
Total census of Assisted Living Program for People with Dementia: 37
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Jan 8, 2018
Visit Reason
The revisit of investigations #71462-I and #72020-I was conducted to verify correction of previously cited regulatory insufficiencies. Additionally, an investigation of Complaint #73076-C was conducted.
Findings
Previously cited regulatory insufficiencies were found to be corrected. No regulatory insufficiencies were cited during the investigation of Complaint #73076-C.
Complaint Details
Complaint #73076-C was investigated and no regulatory insufficiencies were found.
Report Facts
Number of tenants without cognitive disorder in General Population program: 3
Number of tenants with cognitive disorder in General Population program: 2
Total population of General Population program: 33
Number of tenants without cognitive disorder in Dementia-Specific program: 0
Number of tenants with cognitive disorder in Dementia-Specific program: 6
Total population of Dementia-Specific program: 6
Total census of Assisted Living Program: 39
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Nov 15, 2017
Visit Reason
The inspection was conducted as an investigation of complaints/incidents #71462-I and #72020-I related to tenant rights and elopement behavior at Bickford Cottage West Des Moines.
Findings
The program failed to consistently provide adequate and appropriate care to prevent elopement behavior, affecting one tenant. The tenant left the facility unnoticed due to malfunctioning or improperly monitored HomeFree watch and door alarm systems.
Complaint Details
The complaint investigation was substantiated, involving incidents where Tenant #1, a 75-year-old with cognitive decline, left the facility without proper alarm activation or staff awareness. The HomeFree watch and door alarm system were found to be malfunctioning or inadequately monitored.
Deficiencies (1)
| Description |
|---|
| Program failed to consistently provide adequate and appropriate care to prevent elopement behavior. |
Report Facts
Number of tenants without cognitive disorder: 10
Number of tenants with cognitive disorder: 4
Total population of General Population program: 34
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 6
Total population of Dementia-Specific Program: 6
Total census of Assisted Living Program: 40
Civil penalty amount: 2000
Inspection Report
Renewal
Census: 48
Deficiencies: 2
May 2, 2017
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program.
Findings
Two regulatory insufficiencies were cited: failure to ensure completion of appropriate background checks prior to employment for 1 employee, and failure to provide eight hours of dementia-specific training within 30 days of employment for 2 out of 6 employees reviewed.
Complaint Details
No regulatory insufficiencies were cited during the investigation of Complaint #67401-C.
Deficiencies (2)
| Description |
|---|
| The Program failed to ensure completion of appropriate background check prior to employment for 1 out of 1 employee files reviewed. |
| The Program failed to provide eight hours of dementia specific training within 30 days of employment for 2 out of 6 employee files reviewed. |
Report Facts
Number of tenants without cognitive disorder: 39
Number of tenants with cognitive disorder: 2
Total Population of General Population Program: 41
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 7
Total Population of Dementia-Specific Program: 7
TOTAL census of Assisted Living Program: 48
Employee files reviewed for dementia training: 6
Employee files not provided dementia training within 30 days: 2
Employee files reviewed for background check: 1
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 0
Nov 17, 2016
Visit Reason
Investigation of Incident #63019-I and Complaint #64100-C at Bickford Cottage West Des Moines Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the investigation of the incident and complaint.
Complaint Details
Investigation of Incident #63019-I and Complaint #64100-C found no regulatory insufficiencies.
Report Facts
Number of tenants without cognitive disorder in General Population Program: 37
Number of tenants with cognitive disorder in General Population Program: 3
Total Population of General Population Program: 40
Number of tenants without cognitive disorder in Dementia-Specific Program: 0
Number of tenants with cognitive disorder in Dementia-Specific Program: 7
Total Population of Dementia-Specific Program: 7
Total census of Assisted Living Program: 47
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 2
Mar 24, 2016
Visit Reason
The inspection was conducted as a complaint/incident investigation following a complaint identified as Incident #58882-I, focusing on tenant documents and service plans.
Findings
The investigation found regulatory insufficiencies related to tenant documents and service plans, specifically the program's failure to maintain documentation of routine personal care tasks for a tenant unable to advocate for themselves and the service plan not meeting the identified needs of that tenant.
Complaint Details
The complaint investigation was substantiated with findings of regulatory insufficiencies in tenant documents and service plans related to Tenant #1, an 85-year-old resident with dementia who experienced multiple falls and a fractured hip, ultimately passing away during the investigation period.
Deficiencies (2)
| Description |
|---|
| The program did not maintain documentation of the completion of routine personal cares on task sheets for a tenant who was unable to advocate for self. |
| The service plan did not meet the identified needs of Tenant #1, including failure to identify fall risk and provide direction to staff for fall prevention. |
Report Facts
Number of tenants without cognitive disorder: 38
Number of tenants with cognitive disorder: 3
Total Population of General Population Program: 41
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 6
Total Population of Dementia-Specific Program: 6
Total census of Assisted Living Program: 47
Age of Tenant #1: 85
Date Tenant #1 admitted: Oct 11, 2014
Date deficiencies corrected by: Apr 26, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Miner | RN, BSN | Provided education to RN Coordinator on 3/24/2016 regarding fall risk details |
Inspection Report
Monitoring
Census: 51
Deficiencies: 0
May 27, 2015
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were found during this evaluation. The review of recertification documents was completed and accepted, including the State Fire Marshal's inspection and Facility Engineer's approval of evacuation plans.
Report Facts
Number of tenants: 41
Number of tenants: 2
Total Population: 43
Number of tenants: 0
Number of tenants: 7
Total Population: 7
TOTAL census: 51
Inspection Report
Monitoring
Census: 51
Deficiencies: 2
Mar 26, 2013
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction and assess compliance with regulatory requirements for the Assisted Living Program at Bickford Cottage West Des Moines.
Findings
The report found regulatory insufficiencies related to tenant care, including failure to exclude tenants requiring maximal assistance with activities of daily living and failure to develop individualized service plans reflecting tenant needs. The Plan of Correction was accepted by the Department of Inspections and Appeals.
Deficiencies (2)
| Description |
|---|
| A program shall not knowingly admit or retain a tenant who requires maximal assistance with activities of daily living. |
| A service plan shall be developed for each tenant based on evaluations and updated at least annually and whenever changes are needed; the service plan did not reflect Tenant #1's individualized needs after changes. |
Report Facts
Number of tenants without cognitive disorder: 35
Number of tenants with cognitive disorder: 9
Total Population of Program at time of on-site: 44
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 7
Total Population of Program at time of on-site: 7
TOTAL census of Assisted Living Program: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Fristo | Director | Named as facility director in report header |
| Maribeth Freland | RN Monitor | Named as monitor conducting the evaluation |
| Rose Boccella | Program Coordinator, Adult Services Bureau | Signed letter transmitting report |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Oct 3, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation following an allegation that the program moved a tenant out of his/her apartment and the tenant was sleeping in the lobby all day.
Findings
The investigation found no regulatory insufficiencies. Tenant #3, who had dementia and other health issues, was moved to a different apartment to better meet care needs, with staff and family involvement. No violations were noted.
Complaint Details
The complaint alleged that a tenant was moved out of his/her apartment and was sleeping in the lobby all day. The investigation found this was not substantiated and no regulatory insufficiencies were identified.
Report Facts
Number of tenants without cognitive disorder: 33
Number of tenants with cognitive disorder: 17
Total Population of Program at time of on-site: 50
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 7
Total Population of Program at time of on-site: 7
TOTAL census of Assisted Living Program: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor of the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 0
Aug 29, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation following a report of a cognitively impaired tenant who fell, resulting in major injury.
Findings
The investigation found no regulatory insufficiencies. The program had incidents of multiple falls among tenants with cognitive impairments, but no violations were identified that met the criteria for regulatory insufficiency.
Complaint Details
The complaint alleged a cognitively impaired tenant fell resulting in major injury. The investigation reviewed incident reports and clinical records of tenants with multiple falls. Although some deviations from requirements were noted, no regulatory insufficiencies were substantiated.
Report Facts
Total census: 50
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 14
Total population of Dementia-Specific Program by Definition: 43
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 7
Total population of Dementia-Specific Program by Dedication: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Fristo | Administrator | Administrator of Bickford Cottage West Des Moines, named in report header |
| Maribeth Freland | RN | Monitor who conducted the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 0
Jun 20, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation following reports of tenant falls resulting in fractures and hospitalizations at Bickford Cottage WDM.
Findings
The investigation found that Tenant #1 and Tenant #2 each fell on separate occasions resulting in fractures requiring hospitalization. The program adequately addressed the falls and implemented appropriate interventions to decrease fall risk. No regulatory insufficiencies were identified.
Complaint Details
Complaint/Incident Allegation involved Tenant #1 and Tenant #2 falling on separate occasions resulting in fractures requiring hospitalization. The program addressed the falls and interventions were in place to reduce fall risk. No regulatory insufficiencies were noted.
Report Facts
Tenant count: 50
Tenants without cognitive disorder: 32
Tenants with cognitive disorder: 11
Tenants without cognitive disorder: 0
Tenants with cognitive disorder: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Maribeth Freland | RN | Monitor involved in complaint/incident investigation |
| Joyce Kix | RN | Monitor involved in complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Nov 28, 2011
Visit Reason
The inspection was conducted as a complaint/incident investigation following allegations that a tenant routinely refused personal care, touched staff inappropriately, made sexual comments to staff, and made suicidal statements.
Findings
The investigation reviewed tenant service plans and staff interviews, finding that the program did not establish interventions related to the tenant's refusal of care or sexual inappropriate behavior. A regulatory insufficiency was cited for failure to individualize the service plan to address tenant needs and preferences for assistance.
Complaint Details
The complaint alleged a tenant routinely refused personal care, touched staff inappropriately, made sexual comments to staff, and made suicidal statements. Staff interviews confirmed suicidal ideation and refusal of care. The tenant was also identified as sexually inappropriate toward staff. The program failed to establish interventions related to these behaviors.
Deficiencies (1)
| Description |
|---|
| The service plan shall be individualized and indicate at a minimum the tenant's identified needs and preferences for assistance, including tenants with dementia, planned and spontaneous activities based on tenant abilities and interests. |
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 22
Total Population of Program at time of on-site: 50
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor for the complaint/incident investigation |
Inspection Report
Monitoring
Census: 45
Deficiencies: 5
Apr 19, 2011
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction and ensure compliance with Iowa Code and Administrative Code for the assisted living program at Bickford Cottage.
Findings
The program did not receive any Regulatory Insufficiencies during the certification period; however, monitoring observations identified several regulatory insufficiencies related to occupancy agreements, medication administration, food service training, staffing documentation, and staff training. The Plan of Correction was accepted by the Department of Inspections and Appeals.
Deficiencies (5)
| Description |
|---|
| Occupancy agreements were not dated, making it unclear if signed prior to tenant admission. |
| Medications were observed unattended on a tenant's table and stored in an unlocked cupboard. |
| Staff personnel files lacked documentation of completion of food safety and sanitation orientation or training. |
| Staff files lacked documentation of RN delegation for colostomy care and training appropriate to assigned tasks. |
| Discrepancies in tenant weight records were not addressed with retraining of staff on weighing procedures. |
Report Facts
Current number of tenants in Dementia Specific Program with dementia: 8
Current number of tenants without cognitive disorder: 30
Total Population of Dementia Specific Program: 7
Total Population: 45
Weight discrepancies: 7
Weight difference range: 83
Weight difference range: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Heidi Fristo | Administrator | Named as administrator of Bickford Cottage in the report |
| Joyce Kix | RN | Monitor conducting the evaluation |
| Maribeth Freland | RN | Monitor conducting the evaluation |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Feb 9, 2010
Visit Reason
The inspection was conducted as a final incident investigation following complaints regarding incidents involving tenant falls and injuries at Bickford Cottage Assisted Living.
Findings
The investigation found regulatory insufficiencies in life safety related to the operation of alarm systems in the dementia-specific program. Two incidents involving tenant falls resulting in fractures were documented, and a civil penalty of $1,000 was assessed.
Complaint Details
The complaint investigation substantiated incidents where tenants fell and sustained fractures. Tenant #1 fell while being assisted to the bathroom and fractured his/her left hip. Tenant #2 stepped out into the courtyard, fell, and fractured his/her left humerus. The alarm system connected to the courtyard door was not functioning properly on the day of the incident.
Deficiencies (1)
| Description |
|---|
| An operating alarm system shall be connected to each exit door in a dementia-specific program; the program failed to have appropriate alarm systems and staff response procedures. |
Report Facts
Civil penalty amount: 1000
Reduced penalty amount: 650
Current number of tenants without cognitive disorder: 33
Current number of tenants with cognitive disorder: 0
Total Population of General Population Program: 33
Total Population of Dementia Specific Program: 7
Total Census of Assisted Living Program: 40
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Hal L. Chase | RN BSN MPH | Monitor conducting the investigation |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Jul 27, 2009
Visit Reason
The inspection was conducted as a complaint investigation triggered by Complaint #23985-C regarding concerns about the quality and quantity of food at Bickford Cottage Assisted Living.
Findings
The investigation found that all eleven tenants interviewed agreed they received enough food to eat, with meals observed on July 27, 2009, being adequate and well received. No regulatory insufficiencies were identified related to the complaint.
Complaint Details
Complaint Allegation #23985-C alleged inadequate quality and quantity of food, tenant dissatisfaction with meals, and a tenant not receiving enough food. The complaint was not substantiated as no regulatory insufficiencies were noted.
Report Facts
Current number of tenants without cognitive disorder: 24
Current number of tenants with cognitive disorder: 2
Total Population of GPP: 26
Total Population of DSP: 6
Total Census of ALP: 32
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vickie Clingan | RN, MA | Monitor who conducted the complaint investigation |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 7
Jun 9, 2009
Visit Reason
A complaint investigation on-site visit was conducted at Bickford Cottage Assisted Living on June 9, 2009, to investigate allegations related to tenant care and facility conditions.
Findings
The investigation found multiple regulatory insufficiencies related to tenant care, medication administration, staffing, and facility maintenance. Several complaint allegations were substantiated, including issues with bed alarms, apartment cleanliness, medication errors, unexplained bruising, and safety hazards in the dementia unit.
Complaint Details
Complaint investigation #23677-C involved allegations including bed alarm use, apartment cleanliness, medication errors, unexplained bruising, staffing inadequacies, safety hazards, and inappropriate staff behavior. Several allegations were substantiated with observations and record reviews.
Deficiencies (7)
| Description |
|---|
| Tenant #1's bed alarm may not have been on every night. |
| Tenant #1's apartment was filthy with urine and phlegm stains; carpet and mattress soiled and not replaced. |
| Medication administration errors including giving medication despite family objection and failure to follow physician orders. |
| Unexplained bruises on Tenant #1 and other tenants in the Dementia Unit. |
| New staff in the Dementia Unit lacked training and the program used 'pool' staff with inadequate coverage. |
| Safety hazard: toaster plugged in and left unattended in the Dementia Unit kitchen. |
| The program did not provide a well-maintained, clean, and safe building and grounds. |
Report Facts
Current number of tenants without cognitive disorder: 25
Current number of tenants with cognitive disorder: 2
Total Population of General Population Program: 27
Total Population of Dementia Specific Program: 7
Total Census of Assisted Living Program: 34
Incident reports of falls: 5
Medication administration refusals: 15
Medication administration refusals: 10
Medication administration refusals: 18
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 4
Feb 4, 2008
Visit Reason
A complaint investigation on-site visit was conducted at Bickford Cottage Assisted Living to revisit previously substantiated complaints regarding evaluation of tenants, criteria for exclusion of tenants, service plans, staffing, and record checks.
Findings
The investigation found that the program completed required functional, cognitive, and health evaluations for tenants with changes in condition and updated service plans accordingly. No regulatory insufficiencies were noted during the revisit for evaluation, service plans, or staffing, although prior complaints had been substantiated. The program had received a 30-day waiver related to exceeding occupancy and transfer criteria for one tenant.
Complaint Details
The complaint investigation was a revisit related to substantiated complaints in the areas of evaluation of tenants, criteria for exclusion of tenants, service plans, staffing, and record checks. The revisit confirmed that the program addressed prior regulatory insufficiencies.
Deficiencies (4)
| Description |
|---|
| Prior regulatory insufficiency related to not completing functional, cognitive, and health evaluations when a change in condition existed for Tenants #1, #2, and #3. |
| Prior regulatory insufficiency related to not excluding Tenant #2 who exceeded occupancy and retention criteria. |
| Prior regulatory insufficiency related to not consistently updating service plans to reflect identified needs of Tenants #1, #2, and #3. |
| Prior regulatory insufficiency related to not having sufficiently trained staff available at all times and not having an activated 24-hour personal emergency response system that automatically identifies a tenant in distress. |
Report Facts
Current number of tenants without cognitive disorder: 20
Current number of tenants with cognitive disorder: 8
Current number of tenants in Dementia Specific Program: 3
Total Population: 31
30-day waiver period: 30
Antibiotic treatment duration: 10
Inspection Report
Monitoring
Census: 36
Deficiencies: 3
Mar 3, 2005
Visit Reason
An on-site monitoring evaluation was conducted at Bickford Cottage Assisted Living in West Des Moines to assess compliance with assisted living program regulations and to evaluate tenant satisfaction and program operations.
Findings
The evaluation identified three regulatory insufficiencies: failure to complete cognitive evaluations within 30 days of admission, failure to consult tenants when service plans were updated, and lack of a licensed dietician to approve therapeutic menus and review food service procedures. Tenant satisfaction was generally positive, though some concerns about staff shortages during meals and variety of activities were noted.
Complaint Details
There was a substantiated complaint in the area of Service Plan.
Deficiencies (3)
| Description |
|---|
| The program did not complete a cognitive evaluation within 30 days of admission as required. |
| The program did not consult with the tenant when an update or change was made to service plans. |
| The program did not have a licensed dietician write and approve the therapeutic menu and review procedures for preparation and service of food for therapeutic diets. |
Report Facts
Current number of tenants with dementia or cognitive disorder: 8
Current number of tenants without cognitive disorder: 28
Total Population: 36
Tenants present at community meeting: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kris Lang | Director | Director of Bickford Cottage, mentioned in relation to service plan consultation and plan of correction |
| Hal Chase | RN BSN MPH | Monitor conducting the evaluation |
| Mary Oliver | LISW | Monitor conducting the evaluation |
| Ollie Peterson | RD/LD Consultant Dietician | Consultant Dietician involved in plan of correction for therapeutic diet deficiency |
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