Inspection Reports for Bickford of Davenport
4040 E 55th St, Davenport, IA 52807, United States, IA, 52807
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 15, 2025, identified deficiencies related to incomplete tenant evaluations, retention of a bed-bound tenant without appropriate accommodations, and missed nurse reviews for tenants on prescription medications. Earlier inspections showed a pattern of similar issues, including retention of tenants beyond admission criteria, incomplete or outdated health and functional assessments, and gaps in staff training and incident reporting. Complaint investigations substantiated concerns about tenant evaluations, care planning, and retention practices, with no fines or enforcement actions listed in the available reports. Most complaints were substantiated, focusing on tenant care, safety, and documentation, while some investigations found no deficiencies. The inspection history indicates ongoing challenges with compliance in tenant evaluations and retention, with no clear trend of sustained improvement or worsening.
Deficiencies (last 12 years)
Deficiencies (over 12 years)
5.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
24 residents
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 3
Date: Sep 15, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to regulatory insufficiencies at Bickford Cottage Davenport, specifically Complaint #129204-C.
Complaint Details
The investigation was triggered by Complaint #129204-C. The complaint was substantiated as regulatory insufficiencies were cited regarding tenant evaluations, retention of a bed-bound tenant, and nurse review failures.
Findings
The program failed to complete required functional, cognitive, and health evaluations for 5 tenants, retained a bed-bound tenant contrary to admission criteria, and did not complete nurse reviews every 90 days for 2 tenants receiving prescription medications.
Deficiencies (3)
Failed to ensure all required evaluations (functional, cognitive, health) were completed for 5 tenants.
Retained a bed-bound tenant since January 2025 without appropriate accommodations or hospice waiver.
Failed to complete nurse reviews every 90 days for 2 tenants receiving program-administered prescription medications.
Report Facts
Total census: 24
Tenants without cognitive impairment: 11
Tenants with cognitive impairment: 13
Tenants reviewed for evaluations: 5
Tenants with missed nurse reviews: 2
Months bed bound tenant retained: 8
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 3
Date: Jan 22, 2025
Visit Reason
The inspection was conducted as an investigation into Complaint #125932-C and Complaint #125018-C regarding regulatory insufficiencies at the assisted living program.
Complaint Details
The investigation was triggered by complaints #125932-C and #125018-C. The findings included failure to follow incident reporting policies and retention of tenants with unsafe behaviors or conditions.
Findings
The program failed to follow established policies for incident reporting related to a tenant injury and retained tenants who were bed bound or displayed dangerous behaviors including verbal and physical aggression despite interventions.
Deficiencies (3)
Failed to follow established policy regarding incident reports for a tenant with an injury.
Retained a tenant who was bed bound without submitting a hospice waiver to the Department.
Retained tenants who displayed exit-seeking behavior, verbal or physical aggression despite interventions.
Report Facts
Number of tenants without cognitive impairment: 9
Number of tenants with cognitive impairment: 24
Total census: 33
Number of tenants reviewed for dangerous behavior: 7
Number of tenants retained with dangerous behavior: 3
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 0
Date: Sep 26, 2024
Visit Reason
The inspection was conducted as an investigation of Complaint #123497-C and Mandatory Report #122759-M.
Complaint Details
Investigation of Complaint #123497-C and Mandatory Report #122759-M found no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation of the complaint and mandatory report.
Report Facts
Number of tenants without cognitive impairment: 20
Number of tenants with cognitive impairment: 11
Total census: 31
Inspection Report
Renewal
Census: 25
Deficiencies: 5
Date: Jun 19, 2024
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification rules for an Assisted Living Program for People with Dementia.
Complaint Details
There were no regulatory insufficiencies cited during the investigation into Complaint #117601-C, Complaint #119817-C, and Complaint #120048-C.
Findings
The program was found to have multiple regulatory insufficiencies including failure to conduct health assessments prior to admission and within 30 days of occupancy for certain tenants, failure to evaluate tenant health status annually or with significant change, retention of tenants requiring two-person assistance for transfers, and retention of a tenant displaying unmanageable aggression.
Deficiencies (5)
Failed to conduct health assessments prior to admission for 2 of 2 tenants reviewed admitted since March 2024 (Tenant #2 and Tenant #3).
Failed to conduct health assessments within 30 days of occupancy for 2 of 2 tenants admitted since March 2024 (Tenant #2 and Tenant #3).
Failed to evaluate tenant health status annually or with significant change for 2 of 4 current tenants reviewed (Tenant #1 and Tenant #4).
Retained tenants routinely requiring the assistance of two staff for transfers (Tenant #4).
Retained a tenant who displayed unmanageable aggression (Tenant #3).
Report Facts
Number of tenants without cognitive impairment: 14
Number of tenants with cognitive impairment: 11
Total census: 25
Two-person assist frequency: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Health and Wellness Director | Confirmed findings related to health assessments and tenant evaluations; involved in assessments and evaluations of tenants. | |
| Staff A | Reported Tenant #3's exit-seeking and aggressive behaviors. | |
| Staff B | Reported Tenant #4 required two people to assist with transfers. | |
| Staff C | Reported ability to transfer Tenant #4 alone but noted preference for two-person assist due to tenant anxiety. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 5
Date: Mar 30, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to multiple complaints (#111838-C and #111846-C) concerning tenant care and safety issues at Bickford Cottage Davenport, an assisted living program for people with dementia.
Complaint Details
The investigation was triggered by complaints #111838-C and #111846-C. No regulatory insufficiencies were cited during the investigation of Complaint #111633-C. Tenant #1 exhibited multiple incidents of aggression, exit seeking, and wandering into other tenants' apartments uninvited, requiring multiple 911 calls and hospital transports.
Findings
The investigation found regulatory insufficiencies including failure to provide adequate and appropriate care for a tenant with exit seeking behaviors, failure to evaluate functional, cognitive, and health status after significant changes, failure to develop individualized service plans, and failure to ensure all personnel, including contract staff, received appropriate dementia-specific training.
Deficiencies (5)
Program failed to provide adequate and appropriate care, treatment, and services for 1 of 1 tenants observed with exit seeking behaviors (Tenant #1).
Program failed to evaluate the functional, cognitive, and health status as needed for a significant change in health status for 1 of 1 tenants observed with exit seeking behaviors.
Program failed to develop an individualized service plan to meet the identified needs of the tenants, specifically for Tenant #1 with exit seeking behaviors.
Program failed to consistently ensure all personnel including contract/agency staff were appropriately trained to meet tenant needs, including dementia-specific training.
Program failed to ensure contract staff completed the required eight hours of dementia-specific education and training within 30 days of employment or contract start.
Report Facts
Census of tenants: 35
Number of tenants without cognitive disorder: 21
Number of tenants with cognitive disorder: 14
Number of incidents of aggression in January 2023: 4
Number of 911 calls in January 2023: 1
Number of exit attempts in January 2023: 2
Number of incidents of aggression in February 2023: 9
Number of 911 calls in February 2023: 3
Number of exit attempts in February 2023: 3
Number of times Tenant #1 exited building on 3/22/23: 10
Number of times Tenant #1 exited building on 3/22/23 (range): 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Contract/Agency Staff | Reported lack of training, verbal aggression from Tenant #1, and failure to respond to door alarms during overnight shift. |
| Director | Program Director | Confirmed staff fears, lack of training for agency staff, and issues with door key access. |
| Assistant Director | Assistant Director of Home Health Agency | Confirmed agency staff did not receive dementia training and reported communication with Program Director. |
| Registered Nurse | Registered Nurse | Confirmed failure to evaluate tenant's functional, cognitive, and health status after significant changes. |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 3
Date: Dec 4, 2022
Visit Reason
The inspection was conducted as a complaint investigation into multiple complaints (#108383-C, #108255-C, #107202-C, #107132-C, and #105750-C) regarding the assisted living program.
Complaint Details
The complaint investigation involved multiple complaints (#108383-C, #108255-C, #107202-C, #107132-C, and #105750-C). No regulatory insufficiencies were found for complaints #108383-C, #108255-C, and #107202-C. Regulatory insufficiencies were cited for complaints #107132-C and #105750-C.
Findings
The investigation found regulatory insufficiencies related to tenant rights violations where tenants were not consistently treated with respect and dignity, and failures in documentation of routine personal or health-related care on task sheets for tenants receiving hospice care. Additionally, the program failed to retain tenant records for the required minimum of three years.
Deficiencies (3)
Failure to ensure tenants were consistently treated with respect and dignity, affecting 2 of 6 tenants reviewed.
Failure to document the completion of routine personal or health-related care on task sheets for 3 of 5 tenants receiving hospice care.
Failure to retain tenant program records for a minimum of three years after transfer or death.
Report Facts
Number of tenants without cognitive disorder: 22
Number of tenants with cognitive disorder: 11
Total census: 33
Number of tenants reviewed for respect and dignity deficiency: 6
Number of tenants affected by respect and dignity deficiency: 2
Number of tenants receiving hospice care reviewed for documentation deficiency: 5
Number of tenants affected by documentation deficiency: 3
Dates of retained task sheets: 8
Inspection Report
Recertification
Census: 38
Deficiencies: 5
Date: Jan 19, 2022
Visit Reason
The inspection was conducted as a recertification visit combined with complaint investigations for an Assisted Living Program for People with Dementia.
Complaint Details
The inspection included investigations of Complaint #101520-C and Complaint #97727-C.
Findings
The facility was found deficient in multiple areas including failure to provide required dependent adult abuse training within six months of hire, failure to maintain incident reports for discharged tenants, failure to have all parties sign service plans, failure to update service plans to reflect identified needs and preferences, and failure to provide eight hours of dementia-specific education within 30 days of employment.
Deficiencies (5)
Failed to provide the required 2 hours of dependent adult abuse training within six months of hire for 2 of 8 staff reviewed.
Failed to maintain incident reports as required for 2 of 3 discharged tenants reviewed.
Failed to have all parties sign the Service Plan for 3 of 3 discharged tenants reviewed.
Failed to update service plans to reflect the identified needs and preferences for 3 of 3 discharged tenants reviewed.
Failed to provide eight hours of dementia-specific education within 30 days of employment for 8 of 8 employees reviewed.
Report Facts
Census: 38
Staff reviewed: 8
Discharged tenants reviewed: 3
Dependent adult abuse training hours required: 2
Dementia-specific education hours required: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Failed to complete dependent adult abuse training within six months of hire. | |
| Staff C | Failed to complete dependent adult abuse training within six months of hire. | |
| Staff A | Failed to complete dementia-specific education within 30 days of employment. | |
| Staff D | Failed to complete dementia-specific education within 30 days of employment. | |
| Staff E | Failed to complete dementia-specific education within 30 days of employment. | |
| Staff F | Failed to complete dementia-specific education within 30 days of employment. | |
| Staff G | Failed to complete dementia-specific education within 30 days of employment. | |
| Staff H | Failed to complete dementia-specific education within 30 days of employment. |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 2
Date: Dec 1, 2020
Visit Reason
The investigation was conducted due to Incident #89498-M involving medication diversion from tenants, including medications for Tenant #1.
Complaint Details
The complaint investigation was substantiated based on findings of medication diversion and failure to follow policies regarding abuse and neglect reporting and medication disposal. The program self-reported the allegation and failed to provide requested investigative documentation.
Findings
The program failed to consistently follow established policies and procedures related to medication management and nurse delegation. Specifically, medication diversion was identified involving Tenant #1, with missing Tramadol tablets and inadequate documentation of medication destruction and nurse delegation.
Deficiencies (2)
Program failed to consistently follow established policies and procedures related to incident reports and medication management.
Program failed to maintain documentation of nurse delegated tasks.
Report Facts
Number of tenants without cognitive disorder: 25
Number of tenants with cognitive disorder: 4
Total census: 29
Tablets of Tramadol received: 120
Tablets missing: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Interviewed and admitted to taking medications from tenants including Tenant #1; involved in medication diversion investigation | |
| Staff B | Recalled receiving Tramadol bubble pack cards and involved in medication diversion investigation | |
| Staff C | Interviewed regarding missing PRN Tramadol bubble pack card and medication diversion | |
| Former RN Coordinator | Signed statements, questioned medication delivery, took pictures of medication cards, and coordinated interviews related to medication diversion | |
| Director | Confirmed lack of destruction records and nurse delegation documents; confirmed staff statements | |
| Staff A | Certified medication aide | Failed to maintain nurse delegation documentation; employed at another branch before transfer |
Inspection Report
Renewal
Census: 41
Deficiencies: 3
Date: Jan 15, 2020
Visit Reason
The inspection was a recertification visit to determine compliance with certification for an Assisted Living Program for People with Dementia.
Findings
The program was found deficient in nurse delegation procedures, specifically the newly hired registered nurse failed to delegate tasks to existing staff within 60 days of employment and failed to ensure newly hired staff received training within 30 days. Additionally, the program failed to update tenant service plans when changes were needed.
Deficiencies (3)
The program’s newly hired registered nurse failed to delegate to 4 of 6 existing staff members within 60 days of beginning employment.
The program’s registered nurse failed to ensure newly hired staff received training within 30 days of beginning employment.
The program failed to update 2 of 5 tenant service plans when changes were needed.
Report Facts
Number of tenants without cognitive disorder (General Population): 32
Number of tenants with cognitive disorder (General Population): 3
Number of tenants without cognitive disorder (Memory Care Unit): 1
Number of tenants with cognitive disorder (Memory Care Unit): 5
Total Census of Assisted Living Program for People with Dementia: 41
Inspection Report
Renewal
Census: 41
Deficiencies: 0
Date: Dec 20, 2017
Visit Reason
Recertification conducted to determine compliance with certification for an Assisted Living Program - Dementia Specific.
Findings
No regulatory insufficiencies were cited during the recertification inspection.
Report Facts
General Population Census: 34
Memory Care Unit Census: 7
Total Census: 41
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 4
Date: Dec 16, 2015
Visit Reason
A recertification visit was conducted to determine compliance with certification for an Assisted Living Program. Incident #55743-I was also investigated as part of the complaint/incident investigation.
Complaint Details
Complaint Intake #55743-I was investigated along with the recertification visit. The complaint involved regulatory insufficiencies related to Program policies and procedures, including medication administration and destruction.
Findings
The Program failed to comply with regulatory requirements related to Program policies and procedures, Criteria for Admission and Retention, Service Plans, and Nurse Review. Specific deficiencies included medication destruction and administration, admission and retention criteria, service plan maintenance, and nurse review documentation.
Deficiencies (4)
Program failed to follow policies and procedures regarding medication destruction and medication administration.
Program failed to follow admission and retention criteria; one tenant exceeded criteria for retention requiring maximal assistance with activities of daily living.
Program failed to maintain service plans that were developed for each tenant based on evaluations and update them at least annually or when changes were needed.
Program failed to assess and document the health status of each tenant, make recommendations and referrals as appropriate, and monitor progress relating to previous recommendations whenever there were changes in the tenant's health status.
Report Facts
Census: 39
Civil penalty amount: 500
Medication capsules counted: 120
Medication pass date: Dec 14, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Contact person for questions regarding the letter and report |
| Jim Friberg | Bureau Chief, Adult Services Bureau | Signed the demand letter |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
Date: Jan 29, 2015
Visit Reason
The inspection was conducted as a Final Complaint/Incident Investigation following complaints #51666-I and #50744-I regarding incidents involving tenants at Bickford Cottage Davenport.
Complaint Details
The investigation involved incidents #50744-I and #51666-I. Incident #50744-I pertained to Tenant #1 with no regulatory insufficiencies found. Incident #51666-I involved two tenants (#2 and #3) with regulatory insufficiencies identified for Tenant #3. The complaint investigation substantiated regulatory insufficiencies related to medication management, incident reporting, and staffing.
Findings
Regulatory insufficiencies were identified in the areas of Program Policies and Procedures and Staffing, including failure to follow policies on narcotic medication counts, incident reporting, nurse notification, and staff training documentation.
Deficiencies (2)
The Program failed to follow policies and procedures regarding narcotic medication count, completion of an incident report, and nurse notification of an incident.
The Program failed to document a review to ensure all staff was sufficiently trained and competent in tasks within 60 days of the Nurse's employment.
Report Facts
Number of tenants without cognitive disorder: 24
Number of tenants with cognitive disorder: 4
Total Population of General Program: 28
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 6
Total Population of Dementia Program: 6
Total census of Assisted Living Program: 34
Deficiencies cited: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator | Author of the cover letter and contact for questions regarding the report |
| Staff A | Involved in narcotic medication count and medication management findings | |
| Staff B | Involved in narcotic medication count and medication management findings | |
| Staff C | Provided statements regarding Tenant #3's fall and condition | |
| Staff D | Provided statements regarding Tenant #3's fall and condition; interviewed about nurse delegations | |
| Staff E | Mentioned in staffing training and nurse delegation documentation findings | |
| Staff F | Mentioned in staffing training and nurse delegation documentation findings | |
| Director | Interviewed regarding nurse delegations and staff training | |
| Nurse | Involved in narcotic medication count, incident reporting, and staff training |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 2
Date: Nov 18, 2013
Visit Reason
The inspection was conducted as a Final Complaint/Incident Investigation based on complaints regarding missing money and a fall with injury at Bickford Cottage Davenport, Iowa.
Complaint Details
Complaint/Incident Intake #45965-I involved Tenant #2 who fell and suffered a head injury. Complaint/Incident Intake #46113-I involved Tenant #1 reporting missing money. The complaints were investigated with interviews, file reviews, and observations. The missing money complaint was substantiated with findings of inadequate documentation and policy adherence. The fall incident was documented with appropriate emergency response and no regulatory insufficiency noted.
Findings
The investigation found that Tenant #1 reported missing money and the program failed to properly document the incident or follow policies. Tenant #2 suffered a fall resulting in a head injury and a non-stable cervical fracture, with appropriate emergency response and notification documented. Regulatory insufficiency was cited related to policies and procedures for reporting incidents.
Deficiencies (2)
The program did not complete an incident report regarding the missing money and did not document the incident in the Tenant Progress Notes, failing to follow established policies and procedures.
The program's policies and procedures did not meet minimum standards for reporting incidents including allegations of dependent adult abuse.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 10
Total census of Assisted Living Program: 37
Date of Complaint/Incident Investigation: November 18 & 19, 2013
Missing money amount: 19
Missing money amount: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Laura Brock | Director | Named as Director of Bickford Cottage Davenport, involved in investigation and incident reporting |
| Margaret Kaltefleiter | RN MS | Monitor for the complaint/incident investigation |
Inspection Report
Monitoring
Census: 39
Deficiencies: 4
Date: Sep 23, 2013
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction and ensure compliance with regulatory requirements for the Assisted Living Program at Bickford Cottage of Davenport.
Findings
The report found regulatory insufficiencies related to food safety and sanitation training, life safety alarm systems, structural requirements, and record checks. The program had deficiencies in staff training, alarm system operation, and documentation of required background checks.
Deficiencies (4)
Staff personnel files lacked documentation of food safety and sanitation training prior to nurse delegation and annual training.
The program did not have an operating alarm system connected to each exit door in the dementia-specific program as required by life safety code.
The courtyard gate was left unsecured for three days, allowing unsupervised cognitively impaired tenants to exit the secured dementia unit.
The program did not maintain documentation of required dependent adult abuse and child abuse history checks for staff prior to hire.
Report Facts
Total census: 39
Number of tenants without cognitive disorder: 28
Number of tenants with cognitive disorder: 11
Number of apartments in dementia unit: 10
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 5
Date: Jun 13, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation following reports that a tenant was found outside the program and taken to an emergency room by an unknown person. The investigation focused on regulatory insufficiencies in staffing, evaluation, service plans, nurse review, and policies and procedures.
Complaint Details
Complaint/Incident Intake #44173-I involved a tenant found outside the program and taken to an emergency room by an unknown person. The tenant was missing until the ER contacted the program. The tenant exited the building without staff knowledge on two occasions and was involved in multiple incidents including pulling fire alarms and elopement attempts.
Findings
The investigation found multiple regulatory insufficiencies including inadequate staffing to meet tenant needs, incomplete evaluations and service plans, lack of nurse reviews for significant changes, and failure to follow policies and procedures related to incident reporting and tenant supervision. Tenant #1 was found to have left the program unsupervised multiple times, resulting in safety risks.
Deficiencies (5)
A sufficient number of trained staff shall be available at all times to fully meet tenants' identified needs.
A program shall evaluate each tenant’s functional, cognitive and health status within 30 days of occupancy and as needed thereafter.
The service plan shall be individualized and indicate tenant needs and preferences, including services provided by other providers.
If a tenant does not receive personal or health-related care, but an observed significant change occurs, a nurse review shall be conducted.
A program’s policies and procedures must meet minimum standards and include reporting of incidents including allegations of dependent adult abuse.
Report Facts
Tenant census: 37
Complaint/Incident Investigation Dates: June 13 and 17, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Kaltefleiter | RN MS | Monitor of the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 27
Deficiencies: 3
Date: Apr 16, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding tenant safety and use of personal pad alarm systems at Bickford Cottage Davenport.
Complaint Details
Complaint/Incident Intake #38616-I involved investigation of tenant falls and staff response to personal pad alarms. The complaint was substantiated with findings of regulatory insufficiencies in tenant care and staff responsiveness.
Findings
The investigation found multiple incidents where tenants fell or were at risk of falling, with delayed or inadequate staff response to pad alarms. Several tenants were found to have experienced injuries due to falls, and staff did not consistently place or respond to pad alarms as required. Regulatory insufficiencies were identified related to tenant care, treatment, and staff response to requests.
Deficiencies (3)
Failure to ensure timely staff response to personal pad alarms for tenants, resulting in falls and injuries.
Staff did not consistently place personal pad alarms under tenants when required or respond promptly to call light requests.
Service plans did not accurately reflect individualized tenant needs regarding pad alarm use and fall prevention.
Report Facts
Total census: 27
Number of tenants without cognitive disorder: 15
Number of tenants with cognitive disorder: 12
Response times exceeding five minutes: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Signed cover letter for the report |
| Laura Brock | Manager | Manager of Bickford Cottage Davenport, named in findings related to pad alarm system and response times |
| Maribeth Freland | RN | Monitor during complaint/incident investigation |
| Joyce Kix | RN | Monitor during complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 26
Deficiencies: 0
Date: Feb 28, 2012
Visit Reason
The inspection was conducted as a complaint and incident investigation following allegations of inappropriate conduct involving Tenant #1 at Bickford Cottage Assisted Living.
Complaint Details
The complaint involved Tenant #1 alleging molestation by Staff #3. The investigation included interviews with tenants, staff, the tenant's guardian, and review of medical and personnel records. No regulatory insufficiencies were substantiated.
Findings
The investigation found no regulatory insufficiencies. Tenant #1 alleged being molested by a staff member, but after interviews, record reviews, and internal investigation, no evidence supported the incident. The program took steps to ensure tenant safety.
Report Facts
Total census: 26
General Population Program tenants: 20
Dementia-Specific Program tenants: 6
Date of complaint/incident investigation: Feb 28, 2012
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 0
Date: Oct 24, 2011
Visit Reason
The inspection was conducted as a complaint/incident investigation based on allegations regarding tenant requests for assistance, medication administration errors, staff training on catheter care, service plan compliance, and notification release policies.
Complaint Details
The complaint alleged delays or lack of response to tenant emergency calls, coercion of a tenant by corporate management, medication dose errors, inadequate staff training on urinary catheter care, failure to follow individualized service plans for lab testing, and refusal to allow release of notification requiring 30-day notice and payment. None of these allegations resulted in regulatory insufficiencies.
Findings
No regulatory insufficiencies were identified during the investigation. The monitor reviewed multiple tenant records and program policies and found no violations despite the allegations.
Report Facts
Total census: 23
General Population Program tenants without cognitive disorder: 16
General Population Program tenants with cognitive disorder: 2
Dementia-Specific Program tenants without cognitive disorder: 1
Dementia-Specific Program tenants with cognitive disorder: 4
Emergency call system uses: 500
Emergency call delayed responses: 2
Inspection Report
Monitoring
Census: 26
Deficiencies: 7
Date: Sep 21, 2011
Visit Reason
The visit was a Final Recertification Monitoring Evaluation conducted to review the Plan of Correction and ensure compliance with regulatory requirements for the Assisted Living Program at Bickford Cottage.
Findings
The evaluation found that the program had no regulatory insufficiencies during the certification period. However, deficiencies were noted related to dementia-specific education for program personnel, with some staff lacking required dementia education in 2011.
Deficiencies (7)
Staff #1, a certified medication aide, had not completed any dementia education in 2011 despite prior training.
Staff #2, a certified medication aide, had not completed any dementia education in 2011 despite prior training.
Staff #3, a certified medication aide, lacked documentation of dementia education hours completed in 2010 or 2011.
Staff #4, a certified nursing aide, lacked any documentation of dementia education completion.
Staff #5, a certified nursing aide who resigned on 9-3-11, lacked any documentation of dementia education completion.
Regulatory insufficiency: All personnel employed or contracted with a dementia-specific program must receive a minimum of eight hours of dementia-specific education and training within 30 days of employment or contract start.
Regulatory insufficiency: All personnel must receive a minimum of two hours of dementia-specific continuing education annually; direct-contact personnel must receive a minimum of eight hours annually.
Report Facts
Number of tenants without cognitive disorder: 20
Number of tenants with cognitive disorder: 6
Total census: 26
Number of tenants without cognitive disorder: 19
Number of tenants with cognitive disorder: 1
Number of tenants without cognitive disorder: 1
Number of tenants with cognitive disorder: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maribeth Freland | RN | Monitor for the evaluation visit |
Inspection Report
Complaint Investigation
Census: 23
Deficiencies: 5
Date: Apr 12, 2011
Visit Reason
A complaint/incident investigation was conducted at Bickford Cottage Assisted Living due to allegations of staff using profanity, verbal and physical abuse, and mistreatment of tenants.
Complaint Details
Complaint Intake #33160-M involved allegations that Staff #1, #2, and #3 used profanity, raised voices, frightened tenants, physically abused tenants by grabbing and pushing, and verbally humiliated tenants. Specific incidents involved tenants #1, #2, #3, and #4 with diagnoses including dementia and cognitive impairments. Staff actions were contrary to established service plans and interventions. Some staff were terminated following the investigation.
Findings
The investigation found multiple incidents where staff #1, #2, and #3 verbally and physically abused tenants, including yelling, humiliating, pushing tenants, and using profanity. Several tenants were negatively affected, and staff actions were contrary to established interventions. The program was assessed regulatory insufficiencies related to staffing and tenant rights violations.
Deficiencies (5)
Staff #1, #2, and #3 used profanity, raised voices, frightened tenants, and physically abused tenants including grabbing and pushing.
Staff did not treat tenants with consideration, respect, dignity and were mentally and physically abusive.
A sufficient number of trained staff shall be available at all times to fully meet tenants' identified needs.
All tenants have rights to be treated with consideration, respect, dignity, and to be free from mental and physical abuse.
A staff member or employee must report suspected dependent adult abuse to the department.
Report Facts
Current number of tenants without cognitive disorder: 13
Current number of tenants with cognitive disorder: 6
Total Population of General Population Program: 19
Total Population of Dementia Specific Program: 4
Total Census of Assisted Living Program: 23
Civil penalty amount: 3000
Reduced civil penalty amount: 1950
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jim Berkley | Program Coordinator | Contact for formal hearing and civil penalty payment |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter |
| Hal L. Chase | RN BSN MPH | Monitor for the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 0
Date: Jan 19, 2010
Visit Reason
The visit was conducted as a final incident investigation, complaint investigation, and recertification monitoring evaluation at Bickford Cottage, Davenport, IA, triggered by Incident #26595-I and Complaint #25297-C.
Complaint Details
Complaint #25297-C alleged a tenant had a pet that urinated and defecated in the apartment causing odor and skin tears to the tenant. Several staff were alleged to have refused to spend time in the apartment due to odor. The investigation found that cleaning, deodorizing, and repairs were scheduled and odor issues were addressed with the tenant's family. No regulatory insufficiencies were found related to the complaint.
Findings
No regulatory insufficiencies were identified during the recertification monitoring evaluation. The complaint investigation included allegations about a tenant fall and odor issues related to a pet. The investigation found no regulatory insufficiencies related to the fall or odor complaints.
Report Facts
Current number of tenants without cognitive disorder: 25
Current number of tenants with cognitive disorder: 3
Total Population of General Population Program: 28
Total Population of Dementia Specific Program: 6
Total Census of Assisted Living Program: 34
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the incident, complaint investigation, and monitoring visit |
Inspection Report
Monitoring
Census: 35
Deficiencies: 4
Date: Sep 6, 2007
Visit Reason
The visit was a final recertification monitoring evaluation conducted to assess compliance with Iowa assisted living program regulations and to evaluate tenant care and service plans.
Complaint Details
There were substantiated complaints during the certification period related to Evaluation of Tenant, Criteria for Exclusion of Tenant, and Service Plans.
Findings
The evaluation found multiple regulatory insufficiencies including failure to consistently update tenant evaluations and service plans as needed with changes in condition, and inadequate nurse delegated staff training. Tenant satisfaction was generally positive, but some concerns were noted regarding emergency response and food quality.
Deficiencies (4)
The program does not consistently evaluate tenants’ functional and cognitive abilities and health status, as needed, with a change in the tenant’s condition.
The program does not consistently update service plans, as needed, with a change in a tenant’s condition.
The program does not consistently update service plans signed by the health professional, two staff and the tenant or the tenants’ legal representative.
The program does not consistently provide appropriate nurse delegated staff training.
Report Facts
Current number of tenants without cognitive disorder: 23
Current number of tenants with cognitive disorder: 7
Total Population: 30
Current number of tenants in Dementia Specific Program: 5
Current number of tenants without cognitive disorder: 0
Total Population: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | SW MA | Monitor conducting the evaluation |
| Chris Nothaft | LBSW | Monitor conducting the evaluation |
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