Inspection Reports for Bickford of Clinton
1150 13th Ave N, Clinton, IA 52732, United States, IA, 52732
Back to Facility ProfileInspection Report Summary
The most recent inspection on October 30, 2025, found no deficiencies during a complaint investigation. Earlier inspections showed a pattern of deficiencies related mainly to service plan updates and incident reporting, with some issues involving tenant safety measures such as door alarm policies and retention of tenants with challenging behaviors. A substantiated complaint in October 2024 cited delayed staff response to a tenant elopement and inadequate service plans, while prior investigations noted failures in timely incident documentation and care plan updates. Enforcement actions included a $500 civil penalty in 2012 for multiple regulatory insufficiencies, but no license suspensions or immediate jeopardy findings were listed in the available reports. The facility’s inspection history indicates some recurring challenges with documentation and individualized care planning, though recent reports suggest improvements in compliance.
Deficiencies (last 13 years)
Deficiencies (over 13 years)
1.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
57% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
32 residents
Based on a October 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Date: Oct 30, 2025
Visit Reason
Investigation of Incident #130295-I at an Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Incident #130295-I; no deficiencies found.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Tenants without cognitive impairment: 22
Tenants with cognitive impairment: 10
Total census: 32
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 2
Date: Oct 29, 2024
Visit Reason
The inspection was conducted as a recertification visit combined with an investigation into Incident #122918-I regarding tenant elopement and compliance with certification rules for an Assisted Living Program for People with Dementia.
Complaint Details
The visit was triggered by a complaint investigation into Incident #122918-I involving the elopement of Tenant #1 on 8/17/24. The complaint was substantiated based on findings of delayed staff response and inadequate service plans.
Findings
The program failed to follow the door alarm policy resulting in a delayed staff response to a tenant elopement. Additionally, service plans for 3 of 4 tenants reviewed did not adequately address their individual needs, including failure to update plans after significant incidents or changes in condition.
Deficiencies (2)
Failed to follow the door alarm policy resulting in delayed staff response following the elopement of Tenant #1.
Failed to ensure service plans addressed the needs of 3 of 4 tenants reviewed (Tenant #1, Tenant #2, and Tenant #4).
Report Facts
Total census: 35
Response time: 141
Date of incident: Aug 17, 2024
Date of survey completion: Oct 29, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Schaffer | Executive Director | Named in the Plan of Correction letter and confirmed findings during interview. |
| Staff A | Staff involved in delayed response to door alarm and tenant elopement incident. | |
| Staff B | Staff involved in tenant elopement incident and follow-up. | |
| Staff C | Staff who reported on Tenant #4's wound care and assistance needs. | |
| Staff D | Staff who reported on Tenant #4's transfer assistance needs. |
Inspection Report
Renewal
Census: 37
Deficiencies: 1
Date: Sep 1, 2022
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for an Assisted Living Program for People with Dementia.
Findings
No regulatory insufficiencies were cited during the investigation into Incident #103591-I. However, a regulatory insufficiency was cited for retaining a tenant who displayed unmanageable verbal abuse and physical aggression despite interventions.
Deficiencies (1)
The program retained 1 of 4 tenants reviewed who displayed unmanageable verbal abuse and physical aggression despite interventions.
Report Facts
Number of tenants without cognitive disorder: 31
Number of tenants with cognitive disorder: 6
Total census: 37
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 2
Date: Sep 12, 2019
Visit Reason
The inspection was conducted as an investigation of complaint #83996-I related to regulatory insufficiencies in incident reporting and service plan updates for tenants at Bickford Cottage Clinton.
Complaint Details
The investigation was triggered by complaint #83996-I. The complaint was substantiated as the program failed to document incidents immediately and failed to update the service plan timely after significant behavioral changes in Tenant #1.
Findings
The program failed to immediately record incidents for Tenant #1 and failed to update the service plan with significant changes in tenant behavior. Multiple incident reports documented Tenant #1's aggressive and combative behavior towards staff, and the service plan was not updated timely to reflect these changes.
Deficiencies (2)
Program failed to immediately record incidents for Tenant #1.
Program failed to update a service plan with a significant change for Tenant #1.
Report Facts
Number of tenants without cognitive disorder: 33
Number of tenants with cognitive disorder: 5
Total number of tenants in ALP/D: 38
Date deficiencies corrected by: Nov 13, 2019
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 0
Date: Dec 20, 2018
Visit Reason
Investigation of Complaint #79860-C at an Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Complaint #79860-C found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the complaint investigation.
Report Facts
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 4
Total census: 33
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 7
Date: Oct 17, 2018
Visit Reason
The investigation of Complaint #77764-C was completed, resulting in regulatory insufficiencies. A recertification visit was conducted to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program, which also resulted in regulatory insufficiencies.
Complaint Details
Investigation of Complaint #77764-C was completed resulting in regulatory insufficiencies.
Findings
The program failed to follow policies and procedures regarding incident reports and failed to consistently provide adequate and appropriate services to tenants. Multiple tenants had issues including inadequate incident reporting, insufficient care, incomplete evaluations, failure to follow admission and retention criteria, and failure to notify regarding involuntary transfers. Service plans were not updated as needed to reflect tenant needs.
Deficiencies (7)
Program failed to follow policy and procedure regarding completion of incident reports.
Program failed to consistently provide adequate and appropriate services.
Program failed to complete evaluations as needed with significant change.
Program failed to follow the criteria for admission and retention of tenants by retaining a tenant with unmanageable incontinence.
Program failed to notify the tenant or tenant's legal representative of the reason for involuntary transfer.
Program failed to immediately notify the Office of the Long-Term Care Ombudsman and the tenant's treating physician of involuntary transfer via certified mail.
Program failed to update service plans as needed with significant change and failed to ensure service plans reflected identified needs of tenants.
Report Facts
Number of tenants without cognitive disorder: 32
Number of tenants with cognitive disorder: 6
Total Census of Assisted Living Program for People with Dementia: 38
Number of current tenants reviewed: 6
Number of tenants with unmanageable incontinence retained: 1
Number of tenants with 30 day notice for transfer: 1
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Date: Dec 13, 2017
Visit Reason
Investigation of Incident #70775-I at an Assisted Living Program for People with Dementia.
Complaint Details
Investigation of Incident #70775-I; no regulatory insufficiencies were found.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Number of tenants without cognitive disorder: 31
Number of tenants with cognitive disorder: 4
Total Population of Program at time of on-site: 35
Total Census of Assisted Living Program for People with Dementia: 35
Inspection Report
Renewal
Census: 34
Deficiencies: 0
Date: Nov 16, 2016
Visit Reason
The inspection was conducted as a recertification to determine compliance with certification for an Assisted Living Program.
Findings
No regulatory insufficiencies were cited during the recertification inspection of the Assisted Living Program.
Report Facts
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 6
Total Population of Program at time of on-site: 34
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Date: Aug 26, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation following an allegation related to service plans at Bickford Cottage Clinton.
Complaint Details
Allegation: Service Plans. Findings: Not substantiated. Comments indicated appropriate care was provided and no concerns were found regarding service plans.
Findings
The investigation found that the allegation regarding service plans was not substantiated. Review of tenant files, incident reports, and staff interviews indicated appropriate care was provided and no regulatory insufficiencies were identified.
Report Facts
Number of tenants without cognitive disorder: 32
Number of tenants with cognitive disorder: 2
Total Population of Program at time of on-site: 34
TOTAL census of Assisted Living Program: 34
Inspection Report
Monitoring
Census: 33
Deficiencies: 0
Date: Nov 19, 2014
Visit Reason
The visit was 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, and the State Fire Marshal's inspection report and Facility Engineer's approval of evacuation plans were received.
Report Facts
Number of tenants without cognitive disorder: 26
Number of tenants with cognitive disorder: 7
Total Population of Program at time of on-site: 33
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator, Adult Services Bureau | Author of the Final Recertification Monitoring Evaluation Report |
Inspection Report
Monitoring
Census: 36
Deficiencies: 1
Date: Jul 24, 2012
Visit Reason
The visit was conducted as a Final Recertification Monitoring Evaluation to review the Plan of Correction and ensure compliance with regulatory requirements for the Assisted Living Program.
Findings
The program had no regulatory insufficiencies during this certification period. However, deficiencies were noted related to staff orientation on food sanitation and safe food handling, with three staff members serving meals prior to completing required training.
Deficiencies (1)
Personnel responsible for food preparation or service had not completed orientation on sanitation and safe food handling prior to handling food.
Report Facts
Number of tenants without cognitive disorder: 29
Number of tenants with cognitive disorder: 7
Total Population of Program at time of on-site: 36
TOTAL census of Assisted Living Program: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Signed letter regarding certification |
| Maribeth Freland | RN | Monitor conducting the evaluation |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 8
Date: Feb 14, 2012
Visit Reason
The inspection was conducted as a Final Complaint/Incident Investigation for Bickford Cottage of Clinton related to allegations of regulatory insufficiencies in policies and procedures, tenant rights, program reporting, staffing, tenant documents, and service plans.
Complaint Details
The complaint investigation was substantiated with findings of regulatory insufficiencies including failure to document tenant condition changes, failure to respond to tenant complaints, forced medication administration, failure to report suspected abuse, and inadequate staff training and supervision.
Findings
The investigation found multiple regulatory insufficiencies including failure to document tenant condition changes timely, staff allegedly falsifying documentation, failure to respond appropriately to tenant complaints and symptoms, improper medication administration, and failure to report suspected dependent adult abuse. A $500 civil penalty was assessed.
Deficiencies (8)
Failure to document pertinent tenant information related to changes in condition in a timely manner and falsification of documentation by staff.
Failure to call RN or assist tenant experiencing stroke symptoms, resulting in tenant death.
Staff holding tenant's head back and forcing medication administration against tenant's verbal refusal.
Staff allegedly restraining tenants and forcing medication administration.
Failure of program registered nurse to respond to reports of changes in tenant condition.
Failure to report suspected dependent adult abuse and failure to maintain documentation of investigations.
Failure to maintain adequate staffing training and delegation documentation.
Failure to develop and maintain individualized service plans and meal plans for tenants.
Report Facts
Civil penalty amount: 500
Complaint/Incident Investigation dates: 7
Current census: 37
Tenants without cognitive disorder: 32
Tenants with cognitive disorder: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Schaffer | Director | Named as Director of Bickford Cottage of Clinton; involved in internal investigations and responses. |
| Jim Berkley | Program Coordinator | Contact person for questions regarding the report and civil penalty. |
Inspection Report
Monitoring
Census: 28
Deficiencies: 0
Date: Dec 14, 2010
Visit Reason
The visit was conducted as a Final Incident Investigation and Recertification Monitoring Evaluation at Bickford Cottage of Clinton to review an incident involving a tenant elopement and to evaluate compliance with regulatory requirements.
Findings
No regulatory insufficiencies were found during the on-site inspection and recertification monitoring evaluation. The tenant elopement incident was investigated thoroughly, and no injuries or harm were related to the incident. The program was found to have sufficient staff and appropriate policies in place.
Report Facts
Current number of tenants with dementia: 5
Current number of tenants without cognitive disorder: 23
Total Population: 28
Tenant meeting attendance: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Schaffer | Director | Named as Director of Bickford Cottage of Clinton and involved in the tenant elopement incident investigation |
| Stephanie Cummins | Monitor | Conducted the incident investigation and monitoring visit |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Date: Mar 23, 2010
Visit Reason
The visit was conducted as a final incident investigation following a report that a tenant was missing $200.00. The investigation was triggered by an incident allegation of missing money reported by the program.
Complaint Details
The complaint involved a missing $200.00 from a tenant's envelope during a three-hour timeframe on 11-27-09. Multiple interviews were conducted with the tenant, family member, and staff. No perpetrator was identified and no regulatory insufficiencies were noted.
Findings
The investigation found that the tenant and family reported the money missing after shopping, but no perpetrator could be identified. Staff interviews and tenant file audits did not reveal any regulatory insufficiencies related to the incident.
Report Facts
Current number of tenants with dementia: 8
Current number of tenants without cognitive disorder: 27
Total Population: 35
Missing money amount: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kim Schaffer | Director | Named as Director of Bickford Cottage, involved in incident report |
| Stephanie Cummins | Monitor | Conducted the incident investigation |
| Chris Nothaft | Certification Coordinator – Eastern Iowa | Signed the cover letter transmitting the final incident investigation report |
Inspection Report
Monitoring
Census: 36
Deficiencies: 2
Date: Sep 24, 2008
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted by the Iowa Department of Inspections and Appeals to monitor regulatory compliance in assisted living programs, specifically addressing regulatory insufficiencies in transportation and record checks.
Findings
The report found regulatory insufficiencies related to transportation services and employee record checks, including a driver without the required license and incomplete criminal and abuse background checks prior to hire. The Plan of Correction was accepted and a civil penalty of $500 was assessed.
Deficiencies (2)
The program did not consistently have a driver with a valid and appropriate Iowa driver's license or commercial driver's license as required for transportation services.
The program did not consistently complete required Department of Public Safety criminal history checks and Department of Human Services dependent adult abuse checks of potential employees prior to hire.
Report Facts
Civil penalty amount: 500
Number of tenants with dementia or cognitive disorder: 9
Number of tenants without cognitive disorder: 27
Total population: 36
Number of employee files reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hal Chase | RN BSN MPH | Monitor for the evaluation |
| Stephanie Cummins | SW MA | Monitor for the evaluation |
| Staff #1 | Employee file reviewed; hired on 2-10-98; involved in record check deficiency | |
| Staff #2 | Provided transportation; had a regular State of Iowa driver's license, not the required Class D license |
Inspection Report
Monitoring
Census: 40
Deficiencies: 2
Date: Jul 19, 2004
Visit Reason
The visit was a re-certification monitoring evaluation conducted to assess compliance with assisted living program regulations and to review tenant satisfaction and complaint history.
Complaint Details
During this certification period, there was a substantiated complaint in the areas of Evaluations, Occupancy and Transfer Criteria, and Transfer Planning.
Findings
The program had regulatory insufficiencies related to service plans, including failure to develop service plans prior to tenant occupancy and improper documentation from legal representatives. Tenant complaints included late meals and crowded dining rooms, but tenants felt safe and appreciated staff and activities.
Deficiencies (2)
The program did not develop a service plan for all tenants prior to taking occupancy.
The program did not obtain proper documentation from an appropriate legal representative to sign the service plan.
Report Facts
Current number of tenants without cognitive disorder: 28
Current number of tenants with cognitive disorder: 13
Current number of tenants in Dementia Specific Program: 9
Total General Population: 28
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