Inspection Reports for Bickford of Marion
1100 Linden Dr, Marion, IA 52302, United States, IA, 52302
Back to Facility ProfileInspection Report Summary
The most recent inspection on January 7, 2025, identified deficiencies related to medication administration, tenant evaluations, documentation, service plan updates, dietitian review, and food temperature. Earlier inspections showed a consistent pattern of issues with tenant evaluations, updating service plans, medication administration, and tenant dignity, along with some concerns about staffing and building maintenance. Several complaint investigations substantiated deficiencies involving tenant rights, incident reporting, retention criteria, and infection control, with a civil penalty issued in 2013 for retaining a tenant who exceeded level of care criteria. Enforcement actions included staff suspensions and terminations related to tenant rights violations, as well as civil penalties totaling $6,000 in earlier years; no license suspensions or immediate jeopardy findings were listed in the available reports. The inspection history indicates ongoing challenges with compliance in key areas, with no clear trend of sustained improvement over time.
Deficiencies (last 19 years)
Deficiencies (over 19 years)
4.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
35 residents
Based on a January 2025 inspection.
Census over time
Inspection Report
Renewal
Census: 35
Deficiencies: 6
Date: Jan 7, 2025
Visit Reason
The inspection was a recertification visit conducted to determine compliance with certification rules for a Dedicated Dementia-Specific Assisted Living Program.
Findings
The program failed to administer medications and treatments as prescribed, failed to complete evaluations with significant change, failed to document routine cares on individualized task sheets, failed to update service plans as needed, and failed to have a licensed dietitian review procedures for therapeutic diets and to provide food at required temperatures.
Deficiencies (6)
The program failed to administer medications and treatments as prescribed.
The program failed to complete evaluations as needed with significant change.
The program failed to document routine cares on individualized task sheets.
The program failed to update service plans as needed to reflect the identified needs of the tenants.
The program failed to have a licensed dietitian review procedures for food preparation and service for therapeutic diets.
The program failed to provide food at required temperatures.
Report Facts
Number of tenants without cognitive impairment: 20
Number of tenants with cognitive impairment: 15
Total census: 35
Census in memory care unit: 7
Blood glucose readings: 8
Sliding scale insulin units: 13
Dates of blood glucose readings less than 60: 7
Dates of blood glucose readings less than 60: 4
Weight loss: 20
Weight loss: 12
Temperature readings: 46.9
Temperature readings: 126.7
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 7
Date: Jun 4, 2024
Visit Reason
Complaint #116237-C was investigated regarding regulatory insufficiencies related to incident reporting, tenant rights, evaluations, retention criteria, service plans, and building maintenance at Bickford Cottage Marion.
Complaint Details
Complaint #116237-C was investigated and multiple regulatory insufficiencies were identified related to incident reporting, tenant rights, evaluations, retention criteria, service plans, and building maintenance.
Findings
The investigation identified multiple deficiencies including incomplete incident report policies and procedures, failure to follow incident report policies, failure to treat a tenant with dignity and autonomy, incomplete tenant evaluations, failure to discharge a tenant exceeding retention criteria, outdated service plans, and poor building maintenance with stained and frayed carpeting posing safety risks.
Deficiencies (7)
The program failed to have a policy and procedure regarding incident reports that included statements from witnesses.
The program failed to follow their policy and procedure related to the completion of incident reports for Tenant #2.
The program failed to ensure Tenant #1 was treated with consideration, respect, and full recognition of personal dignity and autonomy.
The program failed to complete evaluations as needed with significant change for Tenants #1 and #2.
The program failed to discharge Tenant #2 who required routine two-person assistance with transfers, exceeding retention criteria.
The program failed to update service plans as needed for Tenants #1, #2, and #3.
The program failed to maintain a well-maintained, clean, and safe building; carpets were heavily stained, frayed, and posed a fall risk.
Report Facts
Total census: 35
Tenants without cognitive impairment: 22
Tenants with cognitive impairment: 13
Number of tenants reviewed: 3
Number of falls Tenant #2 had in past 180 days: 5
Frequency of carpet cleaning: 3
Inspection Report
Annual Inspection
Census: 38
Deficiencies: 6
Date: Oct 13, 2022
Visit Reason
The inspection was conducted as a recertification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program and to investigate Complaint #101953-C.
Complaint Details
The inspection included investigation of Complaint #101953-C related to tenant care and incident reporting.
Findings
The inspection identified multiple regulatory deficiencies including failure to follow incident reporting policies, failure to treat a tenant with dignity related to hospital discharge and return, failure to provide nurse delegation training within 30 days for some staff, failure to document nurse's notes by exception, failure to update tenant service plans as needed, and failure to ensure exit doors were alarmed at all times.
Deficiencies (6)
Failure to follow established policies and procedures regarding incident reporting for tenants.
Failure to ensure a tenant was treated with respect, consideration, and dignity related to an emergency room visit and return to the program.
Failure to ensure staff received nurse delegated training within 30 days of employment.
Failure to document nurse's notes by exception for multiple tenants.
Failure to update service plans as needed and ensure service plans reflected the identified needs of tenants.
Failure to ensure the exit doors were alarmed at all times in a dementia-specific program.
Report Facts
Total census: 38
Tenants without cognitive impairment: 27
Tenants with cognitive impairment: 11
Staff training delay days: 32
Staff training delay days: 124
30 day notice for discharge: 30
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 1
Date: Sep 2, 2021
Visit Reason
The inspection was conducted to investigate complaints #98918-C, #98977-I, and #99404-C, and included an onsite infection control survey.
Complaint Details
The investigation of Complaint #99404-C revealed regulatory insufficiencies related to infection control and communicable disease preparedness. Complaints #98918-C and #98977-I were investigated with no regulatory insufficiencies cited.
Findings
No regulatory insufficiencies were found for complaints #98918-C and #98977-I. However, during the investigation of complaint #99404-C and the infection control survey, the program failed to follow its communicable and contagious disease preparedness plan, specifically failing to consistently document daily temperature and symptom monitoring for tenants as required by policy.
Deficiencies (1)
Failure to follow policy and procedures for communicable and contagious disease preparedness plan, including inconsistent documentation of daily temperatures and symptoms for all tenants.
Report Facts
Number of tenants: 28
Date of health check screenings: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse Coordinator | Confirmed staff failed to consistently document tenants' temperatures and symptoms as required by policy |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 3
Date: Mar 4, 2021
Visit Reason
The inspection was conducted as an onsite infection control survey and investigation of Complaint #92042-C regarding regulatory insufficiencies in program policies and procedures, tenant evaluations, and service plans.
Complaint Details
The investigation was triggered by Complaint #92042-C. The complaint was substantiated with findings related to inadequate policies for head injuries, incomplete evaluations, and outdated service plans for tenants.
Findings
The program failed to establish an accident and emergency response policy that included provisions for head injuries, failed to complete tenant evaluations as needed with significant change, and failed to update service plans accordingly. Specific deficiencies were identified for four tenants, including inadequate response to falls and head injuries, incomplete evaluations after significant health changes, and outdated service plans.
Deficiencies (3)
Failed to establish an accident and emergency response policy that included provisions for head injuries.
Failed to complete tenant evaluations as needed with significant change for 4 tenants reviewed.
Failed to update service plans as needed with significant change for 4 tenants reviewed.
Report Facts
Tenant census: 31
Weight loss: 24
Number of tenants reviewed: 4
Staples received: 5
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 6
Date: Jan 23, 2020
Visit Reason
The inspection was conducted to investigate Complaint #87457-C, Incident #88018-I, and to perform a recertification visit to determine compliance with certification for a Dedicated Dementia Specific Assisted Living Program.
Complaint Details
The visit was triggered by Complaint #87457-C and Incident #88018-I. The complaint involved allegations of tenant mistreatment and failure to provide adequate care. The investigation included interviews, record reviews, and observations. Staff M and Staff N were suspended and Staff N was terminated due to tenant rights violations.
Findings
The program failed to ensure tenants were treated with consideration, respect, and full recognition of personal dignity and autonomy, failed to discharge a tenant requiring routine two-person assistance with transfers, failed to update service plans to reflect tenant needs, failed to ensure staff serving food had proper training, failed to ensure dementia-specific education for staff within 30 days of employment, and failed to administer medications as prescribed by the tenant's physician.
Deficiencies (6)
Program failed to ensure tenants were treated with consideration, respect, and full recognition of personal dignity and autonomy.
Program failed to discharge a tenant who required a routine two-person assist with transfers.
Program failed to update service plans as needed and failed to ensure service plans reflected the identified needs of the tenants.
Program failed to ensure staff who served food had an orientation on sanitation and safe food handling prior to handling food and an annual in-service training on food protection.
Program failed to ensure all staff employed by the program completed eight hours of dementia-specific education and training within 30 days of employment.
Program failed to administer medications as prescribed by the tenant's physician.
Report Facts
Total census: 38
Tenants without cognitive disorder: 31
Tenants with cognitive disorder: 7
Tenants with cognitive disorder: 6
Tenants affected by tenant rights deficiency: 8
Staff reviewed for food safety training: 8
Staff required dementia-specific education: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Named in tenant rights violation and abuse allegations; denied allegations but was suspended and terminated. | |
| Staff N | Named in tenant rights violation and abuse allegations; denied allegations but was suspended and terminated. | |
| Staff L | Conducted interviews and reported tenant concerns. | |
| Staff D | Reported concerns regarding Staff N's interactions with tenants. | |
| Staff G | Reported tenant transfer needs and interactions. | |
| Staff F | Reported on tenant shower and transfer incidents. | |
| Director | Interviewed regarding tenant concerns and staff suspensions. | |
| RN Coordinator | Registered Nurse Coordinator | Performed nursing assessments and service plans for tenants as part of plan of correction. |
| Staff B | Received training on food safety and sanitation. | |
| Staff E | Received training on food safety and sanitation. | |
| Staff A | Failed to complete dementia-specific education within 30 days; no longer employed. |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 6
Date: Jan 22, 2019
Visit Reason
The inspection was conducted as part of an investigation into Complaint #79520-C and self-reported incidents #80141-I and #80586-I at Bickford Cottage Marion.
Complaint Details
The investigation was triggered by Complaint #79520-C and self-reported incidents #80141-I and #80586-I. The complaint involved incidents of tenant injuries, inadequate incident reporting, and safety concerns related to tenant wandering and staffing.
Findings
The facility was found to have multiple regulatory insufficiencies including failure to follow incident reporting policies, insufficient staffing to meet tenant needs, failure to maintain written communication logs, failure to update service plans following significant changes, and failure to ensure a well-maintained building with a functioning secondary alarm system to monitor wandering activity.
Deficiencies (6)
Failure to follow policy on incident reporting for 3 of 7 tenant files reviewed.
Failure to provide sufficient number of trained staff to fully meet a tenant's identified needs.
Failure to maintain a written communication log for a period of not less than three years.
Failure to make changes to a service plan following a significant change for 1 of 7 tenant files reviewed.
Failure to develop service plans to reflect the identified needs of tenants for 3 of 7 tenants reviewed.
Failure to ensure a well-maintained building, evidenced by failure of a secondary alarm system to monitor wandering activity.
Report Facts
Census of tenants with cognitive disorder: 9
Total census: 38
Number of tenants reviewed: 7
Mini Mental Status Examination score: 28
Temperature: 97.4
Blood pressure: 136
Pulse: 86
Respirations: 20
Weight gain: 14
Medication dosage: 40
Mini Mental Status Examination score: 5
Distance traveled: 0.1
Temperature: 34
Wind speed: 14
Relative humidity: 64
Temperature: 16
Humidity: 92
Inspection Report
Renewal
Census: 35
Deficiencies: 4
Date: Jan 2, 2018
Visit Reason
The inspection was a recertification visit to determine compliance with certification for a Dementia Specific Assisted Living Program.
Findings
The program failed to ensure training for non-certified staff regarding activities of daily living, failed to hire staff within 30 calendar days of background check results, failed to develop service plans reflecting tenant needs, and failed to ensure staff completion of orientation on sanitation and safe food handling as well as annual in-service training on food protection.
Deficiencies (4)
Program failed to ensure training for non-certified staff regarding the provision of activities of daily living.
Program failed to hire staff within 30 calendar days from the date of the results of the background check.
Program failed to develop service plans to reflect the identified needs of tenants.
Program failed to ensure staff completion of orientation on sanitation and safe food handling, as well as annual in-service training on food protection.
Report Facts
Census: 35
Staff reviewed: 7
Staff requiring training: 3
Tenants reviewed: 4
Staff requiring food safety orientation: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Non-certified staff lacking nurse delegated training on ADLs | |
| Staff D | Non-certified staff lacking nurse delegated training on ADLs | |
| Staff F | Non-certified staff lacking nurse delegated training on ADLs and background check delay | |
| Staff A | Staff lacking orientation on sanitation and safe food handling | |
| Staff C | Staff lacking orientation on sanitation and safe food handling | |
| Staff G | Staff lacking orientation on sanitation and safe food handling | |
| Staff B | Staff lacking orientation on sanitation and safe food handling | |
| Staff D | Staff lacking orientation on sanitation and safe food handling |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Date: Aug 9, 2017
Visit Reason
Investigation of Complaint #68793-C and Incident #69209-I at Bickford Cottage Marion Assisted Living Program.
Complaint Details
Complaint #68793-C and Incident #69209-I were investigated with no regulatory insufficiencies found.
Findings
No regulatory insufficiencies were cited during the complaint investigation. The census included 36 residents across dementia-specific and general assisted living programs.
Report Facts
Number of tenants without cognitive disorder: 24
Number of tenants with cognitive disorder: 5
Total Population of Dementia-Specific Program by Definition: 29
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 7
Total Population of Dementia-Specific Program by Dedication: 7
Total census of Assisted Living Program: 36
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Date: Mar 13, 2017
Visit Reason
The inspection was conducted as an investigation of complaints #66186-C and 66188-I at the assisted living program.
Complaint Details
Investigation of complaints #66186-C and 66188-I resulted in no regulatory insufficiencies.
Findings
No regulatory insufficiencies were cited during the investigation.
Report Facts
Number of tenants without cognitive disorder: 9
Number of tenants with cognitive disorder: 29
Total population of Program at time of on-site: 38
Total census of Assisted Living Program: 38
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Date: Oct 25, 2016
Visit Reason
The inspection was conducted as part of investigations of Complaints #62035-C and #62036-C at the assisted living facility.
Complaint Details
Investigations of Complaints #62035-C and #62036-C were conducted with no regulatory insufficiencies cited.
Findings
No regulatory insufficiencies were cited during the complaint investigations.
Report Facts
Number of tenants without cognitive disorder: 21
Number of tenants with cognitive disorder: 7
Total Population of Program at time of on-site: 28
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: 35
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 3
Date: Dec 15, 2015
Visit Reason
The inspection was conducted as a Final Complaint Investigation and Recertification Monitoring Evaluation following a complaint intake #56442-C, to determine compliance with certification for an Assisted Living Program.
Complaint Details
Allegation: Service Plans. Findings: Not substantiated. Review of tenant files and policies indicated individualized tenant plans were appropriate and no concerns with service plans were identified.
Findings
No regulatory insufficiencies were cited during the complaint investigation. However, regulatory insufficiencies were found related to Dependent Adult Abuse Training, Food Service, and Dementia Specific Education for Personnel, requiring a Plan of Correction.
Deficiencies (3)
Staff had not received two hours of training related to the identification and reporting of dependent adult abuse within six months of initial employment.
An orientation on sanitation and safe food handling prior to handling food and an annual in-service training on food protection was not provided.
Personnel employed did not receive a minimum of eight hours of dementia-specific education and training within 30 days of employment and did not receive a minimum of eight hours of dementia-specific continuing education annually.
Report Facts
Number of tenants without cognitive disorder: 18
Number of tenants with cognitive disorder: 6
Total Population of Program at time of on-site: 24
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: 31
Number of staff files reviewed: 6
Date survey completed: Dec 15, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rose Boccella | Program Coordinator, Adult Services Bureau | Author of the complaint investigation report and contact person |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Date: Mar 16, 2015
Visit Reason
The inspection was conducted as a complaint/incident investigation following a tenant leaving the program after removing an electronic wandering bracelet.
Complaint Details
The tenant had not demonstrated any previous elopement tendencies and was assisted out by a visitor who did not realize the tenant resided at the program. No regulatory insufficiencies were cited during the investigation #51705-I.
Findings
No regulatory insufficiencies were identified during the investigation. Interventions were put in place to assist the tenant, and signs were posted to alert staff if someone wanted to leave the building or did not know the door code.
Report Facts
Number of tenants without cognitive disorder: 27
Number of tenants with cognitive disorder: 5
Total Population of Program at time of on-site: 32
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: 39
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Date: Nov 3, 2014
Visit Reason
The inspection was conducted as a complaint/incident investigation based on allegations regarding staffing, care, documentation, and tenant safety at Bickford Cottage Marion.
Complaint Details
The complaint investigation addressed allegations including staff not using gait belts, insufficient staff in the dementia unit, tenants exceeding level of care, tenant aggression, lack of documentation by direct care staff, pet odors, and frequent tenant falls. All allegations were found to have no regulatory insufficiencies.
Findings
The investigation found no regulatory insufficiencies related to the complaints. Staffing, tenant care, documentation, and safety concerns were reviewed and no violations were identified.
Report Facts
Total census: 37
Tenants without cognitive disorder: 25
Tenants with cognitive disorder: 5
Tenants without cognitive disorder: 0
Tenants with cognitive disorder: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Lightbody | Director | Named as facility director in relation to complaint investigation |
| Stephanie Cummins | Monitor | Conducted complaint/incident investigation |
| Stephanie Radabaugh | Monitor | Conducted complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 5
Date: Oct 1, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation and recertification monitoring evaluation for Bickford Cottage Marion, triggered by complaints and regulatory concerns regarding policies, procedures, tenant incidents, service plans, food service, dementia-specific education, and record checks.
Complaint Details
The complaint involved allegations that a tenant wandered into other tenant apartments and urinated and defecated in inappropriate places. The investigation confirmed these behaviors and identified multiple regulatory insufficiencies related to monitoring, service plans, and incident documentation.
Findings
The report found multiple regulatory insufficiencies including failure to comply with policies and procedures, incomplete evaluations and service plans, inadequate staff training, failure to follow incident reporting policies, and deficiencies in food service and dementia-specific education. Several tenant incidents were documented with incomplete follow-up and documentation.
Deficiencies (5)
Failure to comply with policies and procedures related to incident reporting and documentation.
Incomplete evaluations and service plans for tenants, including failure to complete evaluations within required timeframes.
Inadequate staff training on food safety and dementia-specific education, with multiple staff lacking required annual training.
Failure to follow incident report policy and notify RN as required.
Inadequate documentation and follow-up of tenant incidents, including inappropriate sexual behavior and falls.
Report Facts
Civil penalty amount: 500
Reduced civil penalty amount: 325
Complaint/Incident Intake numbers: 45320-C and 45462-C
Census: 35
Number of tenants without cognitive disorder: 23
Number of tenants with cognitive disorder: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Emily Lightbody | Divisional Director of Operations | Named as recipient of report and involved in program oversight |
| Stephanie Cummins | Monitor | Conducted the complaint/incident investigation and monitoring visit |
| Rose Boccella | Program Coordinator | Contact person for appeal and monitoring evaluation |
| Jim Friberg | Acting Bureau Chief, Adult Services Bureau | Signed the demand letter |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Date: Jul 9, 2013
Visit Reason
The inspection was conducted following a complaint alleging that a tenant exceeded the level of care criteria for assisted living at Bickford Cottage Marion.
Complaint Details
The complaint was substantiated. Tenant #2 was found to exceed level of care criteria for unmanageable incontinence, was a danger to self and others, and displayed unmanageable aggression and behaviors placing other tenants at risk.
Findings
The program was found to have repeated regulatory insufficiencies in the area of Criteria for Admission and Retention, including retaining a tenant who exceeded the level of care criteria, was physically aggressive, and had unmanageable incontinence. A $1,000 civil penalty was assessed.
Deficiencies (1)
Failure to comply with Criteria for Admission and Retention by retaining a tenant who exceeded level of care criteria, was physically aggressive, and had unmanageable incontinence.
Report Facts
Civil penalty amount: 1000
Reduced civil penalty amount: 650
Current census: 29
Number of tenants without cognitive disorder: 9
Number of tenants with cognitive disorder: 13
Total population of Dementia-Specific Program by Definition: 22
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 |
|---|---|---|
| Joyce Kix | RN | Monitor for the complaint/incident investigation. |
| Rose Boccella | Program Coordinator | Contact person for questions regarding the report and plan of correction. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 0
Date: Mar 19, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation following a report that Tenant #1 fell in an unlocked laundry room and suffered a fractured hip.
Complaint Details
The complaint involved Tenant #1 falling in an unlocked laundry room, sustaining a lump on the right leg and a fractured hip. The investigation included staff interviews, incident reports, and review of policies. No regulatory insufficiencies were identified.
Findings
The investigation found no regulatory insufficiencies. Tenant #1 had a fall resulting in a fractured hip, and the program completed an incident report and reviewed relevant files and policies.
Report Facts
Number of tenants without cognitive disorder: 20
Number of tenants with cognitive disorder: 9
Total Population of Program at time of on-site: 29
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 6
Total Population of Program at time of on-site: 6
TOTAL census of Assisted Living Program: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Margaret Kaltefleiter | RN MS | Monitor of the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 2
Date: Jan 8, 2013
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding allegations that a tenant exceeded the level of care and concerns about odors in the building.
Complaint Details
The complaint investigation was substantiated as Tenant #2 exceeded the level of care due to unmanageable behaviors and incontinence. The investigation included review of tenant files, staff interviews, and observations. No odor-related regulatory insufficiency was found.
Findings
The investigation found that Tenant #2 exceeded the level of care due to unmanageable behaviors and incontinence despite interventions. Service plans for tenants did not reflect identified needs. No regulatory insufficiency was noted related to odors in the building.
Deficiencies (2)
A program shall not knowingly admit or retain a tenant who is dangerous to self or others, or displays unmanageable behaviors including unmanageable incontinence despite individualized toileting program.
The service plan shall be individualized and indicate the tenant’s identified needs and preferences for assistance.
Report Facts
Number of tenants without cognitive disorder: 21
Number of tenants with cognitive disorder: 10
Total Population of Program at time of on-site: 31
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: 38
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Akers | Director | Named as Director of Bickford Cottage Marion, involved in interview and findings |
| Stephanie Cummins | Monitor | Conducted the complaint/incident investigation |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 2
Date: May 24, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation following a report of a tenant exhibiting dementia wandering away while unsupervised during an off-site activity.
Complaint Details
The complaint investigation was substantiated, noting multiple incidents of tenants eloping without staff knowledge, inadequate supervision during off-site activities, and failure to maintain required documentation of head counts following elopements.
Findings
The investigation found regulatory insufficiencies related to staffing and medications, including incidents of tenants eloping without staff knowledge and lack of documentation for head counts after elopements. The program failed to maintain adequate supervision and policies to prevent elopement and ensure tenant safety.
Deficiencies (2)
A sufficient number of trained staff shall be available at all times to fully meet tenants' identified needs.
In lieu of providing access to a personal emergency response system, a program serving one or more tenants with cognitive disorder or dementia shall follow a system, program or written staff procedures to address how the program will respond to the emergency needs of the tenant(s).
Report Facts
Civil penalty amount: 500
Complaint Intake Number: 39084
Total census: 36
Number of tenants without cognitive disorder: 19
Number of tenants with cognitive disorder: 10
Number of tenants without cognitive disorder: 0
Number of tenants with cognitive disorder: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maribeth Freland | RN | Monitor conducting the complaint/incident investigation |
| Megan Johnson | Manager | Manager of Bickford Cottage of Marion, named in the report |
| Rose Boccella | Program Coordinator | Contact person for the program and civil penalty matters |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the demand letter enclosing the investigation report |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Date: Feb 27, 2012
Visit Reason
The inspection was conducted as a complaint/incident investigation regarding allegations about tenant care and pet-related issues at Bickford Cottage Marion Assisted Living Program.
Complaint Details
Complaint/Incident Intake #37713-C involved allegations that a tenant was no longer able to care for his/her pet, a tenant's pet was aggressive, and a tenant's apartment had a bad odor. The investigation included tenant interviews, staff interviews, and review of incident reports and tenant council minutes. The pet-related complaints were found to be unsubstantiated with no regulatory insufficiencies noted.
Findings
The investigation found a regulatory insufficiency related to medication administration and nursing services. Pet-related complaints were investigated and found to be unsubstantiated with no regulatory insufficiencies noted in that area.
Deficiencies (2)
Any nursing services shall be provided in accordance with Iowa Code chapter 152 and 655-Chapter 6 (IAC r. 481-67.9(5))
The service plan did not reflect staff assistance with pet care, which did not meet the standard set forth in rule 67.10(3) for determining a regulatory insufficiency.
Report Facts
Number of tenants without cognitive disorder: 16
Number of tenants with cognitive disorder: 10
Total Population of Program at time of on-site: 26
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: 33
Date of Complaint/Incident Investigation: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephanie Cummins | Monitor | Conducted the complaint/incident investigation |
Inspection Report
Monitoring
Census: 29
Deficiencies: 3
Date: Oct 18, 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 of Marion.
Findings
The program did not receive any regulatory insufficiencies during the certification period. Staffing observations noted incomplete nurse delegations for some staff, but medication administration protocols were followed without adverse outcomes. Overall, tenants expressed satisfaction with services and staff.
Deficiencies (3)
Incomplete nurse delegations for Activities of Daily Living (ADLs) for Staff #3.
Lack of documentation for medication administration and supervision of self-injection of insulin and blood glucose checks by Staff #1 and Staff #2.
Regulatory Insufficiency: Insufficient number of trained staff available at all times to fully meet tenants' identified needs.
Report Facts
Number of tenants without cognitive disorder: 17
Number of tenants with cognitive disorder: 5
Total Population of Program at time of on-site: 22
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: 29
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 3
Date: Jun 14, 2011
Visit Reason
A complaint investigation on-site visit was conducted at Bickford Cottage on June 14, 2011, to assess regulatory insufficiencies in Evaluation of Tenant, Service Plan, and Nurse Review.
Complaint Details
The complaint alleged tenant mistreatment by an administrative staff member and that the staff member did not listen to tenants. Interviews with tenants and staff found no mistreatment and tenants reported being treated with respect. Some tenants reported concerns about communication and maintenance issues, but no regulatory insufficiencies were noted in these areas.
Findings
The investigation found regulatory insufficiencies related to tenant evaluations, service plans, and nurse reviews, but no substantiated complaints of tenant mistreatment by staff. The facility was assessed a $1,000 civil penalty and submitted a Plan of Correction.
Deficiencies (3)
Failure to complete tenant evaluations as needed and within 30 days of occupancy.
Service plans were not updated as needed and did not indicate tenants' identified needs and preferences for assistance.
Nurse reviews were not completed every 90 days as required and not completed as needed to add splints to service plans.
Report Facts
Civil penalty amount: 1000
Reduced civil penalty amount: 650
Number of tenants in Dementia Specific Program with dementia: 8
Number of tenants without cognitive disorder in Dementia Specific Program: 15
Total population in Dementia Specific Program: 23
Total population of Dementia Specific Program specialized care: 7
Total census of Assisted Living Program: 30
Number of tenant files reviewed: 6
Number of tenants interviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Hockaday | Director | Facility Director named in report and letter |
| Stephanie Cummins | Monitor | Monitor who conducted the investigation |
| Rose Boccella | Program Coordinator | Contact person for appeal and civil penalty payment |
| Ann Martin | Bureau Chief, Adult Services Bureau | Author of demand letter |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 5
Date: Feb 14, 2011
Visit Reason
A complaint investigation on-site visit was conducted at Bickford Cottage of Marion on February 14, 2011, to investigate multiple complaint allegations regarding tenant care, staffing, medication administration, activities, and structural issues.
Complaint Details
Complaint allegations included tenant inability to stand and need for two-person transfers, morphine count discrepancies, lack of nurse coverage, activity director pressuring tenants to attend activities, and non-operational heat/air conditioning units. Some allegations were substantiated with monitoring observations; others had no regulatory insufficiencies noted.
Findings
The investigation identified several regulatory insufficiencies related to tenant evaluations, nurse reviews, staffing, and structural maintenance. Some complaints were substantiated with observations of missing documentation and medication discrepancies, while others found no regulatory insufficiencies.
Deficiencies (5)
Lack of documentation of completion of functional, cognitive, and health evaluations for tenants with changes in condition.
Medication discrepancy and spilled medication due to improperly replaced lid on liquid morphine container.
Personnel records lacked documentation of nurse delegation for medication administration via gastrostomy tube.
Owner/management corporation responsible for ensuring all personnel receive appropriate training.
Building and grounds not well-maintained, clean, safe, and sanitary due to accessible chemicals and cleaning supplies in unlocked areas.
Report Facts
Complaint Intake Numbers: 3
Civil Penalty Amount: 500
Days for Plan of Correction Submission: 10
Days for Appeal: 30
Current Total Census of ALP: 35
Tenants in Dementia Specific Program with Dementia: 6
Tenants without Cognitive Disorder in DSP: 22
Total Population of Dementia Specific Program: 7
Group Meeting Attendance: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nancy Hockaday | Administrator | Named as administrator of Bickford Cottage in complaint investigation report |
| Joyce Kix | RN | Monitor during complaint investigation |
| Maribeth Freland | RN | Monitor during complaint investigation |
| Rose Boccella | Program Coordinator | Contact person for questions regarding report and plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 19, 2010
Visit Reason
The inspection was conducted as a final incident investigation following a report that a tenant was found on the floor, later complained of a headache, and became unresponsive, requiring transport to the Emergency Room.
Complaint Details
The complaint involved a tenant who fell and became unresponsive with a subdural hematoma. The tenant had a history of falls and cognitive decline. The investigation concluded no regulatory insufficiencies were noted.
Findings
The investigation found no regulatory insufficiencies. The tenant had multiple falls documented, with the most recent incident resulting in a subdural hematoma and subsequent death. Staff responded appropriately, and the program reported the incident to the Department as required.
Report Facts
Tenant age: 79
Medication dosage: 0.5
Incident dates: 9
Date of tenant death: May 24, 2010
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bonnie Smith | Director | Named as facility director in relation to the incident investigation |
| Stephanie Cummins | MA | Monitor conducting the incident investigation |
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Date: Feb 1, 2010
Visit Reason
The visit was conducted as an incident investigation and recertification monitoring evaluation following a complaint alleging possible sexual assault of a tenant at Bickford Cottage, Marion, IA.
Complaint Details
The complaint alleged that a tenant might have been sexually assaulted and that the program pushed for additional medications and relocation to discredit the tenant. The investigation found no substantiation of the allegations.
Findings
No regulatory insufficiencies were identified during the investigation. The tenant's file, staff interviews, and time log records did not confirm the alleged sexual assault or identify any perpetrator. Tenants and family members reported no mistreatment and expressed satisfaction with the program.
Report Facts
Current number of tenants in Dementia Specific Program: 21
Current number of tenants without cognitive disorder: 15
Total Population: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bonnie Smith | Director | Named as Director of Bickford Cottage, involved in the investigation |
| Stephanie Cummins | Monitor | Conducted the incident investigation and monitoring evaluation |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Date: Oct 14, 2009
Visit Reason
The inspection was conducted as a complaint investigation at Bickford Cottage, Marion, IA, regarding allegations of medication administration without physician's order, staffing issues related to tenant falls, and intimidation of staff.
Complaint Details
The complaint investigation addressed allegations including medication administered without physician's order, insufficient staffing leading to tenant falls, delayed medical attention for injured tenant, intimidation and harassment of staff by administrative personnel, illegal drug activity allegations, and alteration of nurses' notes. None of these allegations resulted in regulatory insufficiencies.
Findings
No regulatory insufficiencies were identified during the investigation. Multiple allegations were reviewed including medication administration errors, staffing adequacy, tenant falls, intimidation and harassment of staff, and alleged illegal drug activity. Staff and tenant interviews and record reviews found no substantiated regulatory violations.
Report Facts
Current number of tenants with dementia or cognitive disorder: 18
Current number of tenants without cognitive disorder: 21
Total Population: 39
Civil penalty: 4000
Civil penalty: 10000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bonnie Smith | Director | Named as Director of Bickford Cottage, involved in findings related to medication and staff intimidation |
| Stephanie Cummins | MA | Monitor during complaint investigation |
| Joyce Kix | RN | Monitor during complaint investigation |
| Staff #7 | Former nurse involved in medication administration allegation | |
| Staff #8 | Staff involved in handling medication bottle related to Staff #7 | |
| Staff #1 | Staff interviewed regarding medication and staffing allegations | |
| Staff #2 | Staff interviewed regarding tenant falls and pain management | |
| Staff #3 | Staff interviewed regarding medication and tenant pain | |
| Staff #4 | Staff interviewed regarding tenant pain and medication | |
| Staff #5 | Staff interviewed regarding tenant falls and pain management |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Date: Jun 29, 2009
Visit Reason
The visit was conducted as a complaint investigation at Bickford Cottage of Marion on June 29 and 30, 2009, in response to complaints regarding service plans, level of care appropriateness, staffing, medication management, and other care concerns.
Complaint Details
The complaint investigation addressed multiple allegations including inappropriate service plans for tenants #1, #2, #4, and #8; inappropriate level of care for tenants #1, #2, #3, #4, and #8; lack of RN coverage in certain periods; failure to call the fire department after tenant falls; unfamiliarity with hip brace and pivot disc for tenant #3; absence of protocol for tenant #7's fainting spells; and inability of tenants #1 and #5 to self-inject insulin. All allegations were reviewed and monitoring observations found no regulatory insufficiencies.
Findings
The investigation found no regulatory insufficiencies or violations. All service plans were appropriately developed and signed, staffing and nurse coverage were adequate, medication policies were followed, and no substantiated deficiencies were identified related to the complaints.
Report Facts
Current number of tenants without cognitive disorder: 22
Current number of tenants with cognitive disorder: 9
Total Population of General Population Program: 31
Total Population of Dementia Specific Program: 7
Total Census of Assisted Living Program: 38
Inspection Report
Complaint Investigation
Census: 24
Deficiencies: 0
Date: Nov 5, 2008
Visit Reason
The visit was a Final 3rd Recertification Revisit and Complaint Investigation conducted at Bickford Cottage Assisted Living to investigate complaints and verify compliance with Iowa Code and Administrative Code regulations for assisted living programs.
Complaint Details
The complaint investigation included allegations of staff involvement in illegal drug activities and staff discussing confidential tenant information in public settings. Monitoring observations found no evidence of illegal drug use or inappropriate staff behavior, and no staff discussed tenant health information publicly. All related regulatory insufficiencies were noted as none.
Findings
The program was found to be in full compliance with no regulatory insufficiencies noted during the complaint investigation. Previous sanctions were discontinued and the program was allowed to admit new tenants.
Report Facts
Current number of tenants without cognitive disorder: 11
Current number of tenants with cognitive disorder: 13
Total Population: 24
Civil penalties: 1500
Civil penalties: 4000
Civil penalties: 10000
Tenants attending community meeting: 17
Date of tenant discharge: 2008
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bonnie Smith | Director | Facility Director named in report and referenced in program history and complaint investigation |
| Hal L. Chase | RN BSN MPH | Monitor for the investigation |
| Stephanie Cummins | SW MA | Monitor for the investigation |
Inspection Report
Monitoring
Census: 38
Deficiencies: 6
Date: Aug 6, 2008
Visit Reason
The visit was a Final Recertification Monitoring Evaluation 2nd Revisit conducted to assess regulatory insufficiencies and compliance with Iowa Code and Administrative Code for assisted living programs, including evaluation of tenants, service plans, medications, and nurse review.
Complaint Details
The visit was a follow-up to a complaint investigation and recertification monitoring. The program was found noncompliant with regulatory requirements, resulting in a conditional certificate and civil penalties. The Request for Reconsideration was denied, and the Plan of Correction was accepted but not fully implemented.
Findings
The program failed to comprehensively follow regulations, resulting in regulatory insufficiencies related to tenant evaluations, service plans, medication administration, and nurse review. The program was under a Conditional Certificate and assessed civil penalties, with some corrective measures accepted but not fully implemented.
Deficiencies (6)
Failure to consistently evaluate each tenant's functional, cognitive, and health status as needed to determine continued eligibility and service modifications.
Failure to exclude tenants requiring a higher level of care or apply for written exceptions, including tenants who were aggressive or posed risks to others.
Failure to consistently update and individualize service plans based on evaluations and tenant needs.
Failure to ensure medication administration was supervised and documented by qualified nursing staff according to regulations.
Failure to ensure nurse review was completed appropriately, including documentation of physician orders and tenant health activities.
Failure to fully implement the Plan of Correction submitted in response to the recertification revisit and complaint investigation.
Report Facts
Civil penalty amount: 10000
Current number of tenants without cognitive disorder (General Population Program): 21
Current number of tenants with cognitive disorder (General Population Program): 10
Total population (General Population Program): 31
Current number of tenants in Dementia Specific Program: 7
Total population (Dementia Specific Program): 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bonnie Smith | Director | Named as program director in relation to regulatory insufficiencies and training requirements. |
| Hal Chase | RN BSN MPH | Monitor conducting the investigation. |
| Stephanie Cummins | SW MA | Monitor conducting the investigation. |
| Ann Martin | Bureau Chief, Adult Services Bureau | Signed the report letter regarding sanctions and penalties. |
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 9
Date: Apr 8, 2008
Visit Reason
A complaint investigation on-site and recertification revisit was conducted at Bickford Cottage Assisted Living on April 8, 2008, to evaluate regulatory insufficiencies and compliance with assisted living program regulations.
Complaint Details
The complaint investigation was based on allegations from December 2007 that five employees were tested on nurse delegated training tasks, with concerns about staff feeling intimidated and lack of education on some tasks. The complaint was substantiated with findings of regulatory insufficiencies.
Findings
The program had multiple regulatory insufficiencies related to evaluation of tenants, service plans, medications, and staffing. The program was under a conditional certificate with sanctions including a $4,000 civil penalty and requirements for training and documentation submission. The Plan of Correction was accepted but not fully implemented at the time of revisit.
Deficiencies (9)
The program did not consistently evaluate each tenant's functional, cognitive, and health status as needed.
The program did not consistently maintain complete tenant files including legal representative documentation.
The program did not consistently update individualized service plans when tenants had changes in condition.
Medications and treatments were not always documented properly, including refusals and administration errors.
The administration of medications was not always provided by licensed registered nurses or authorized agents as required.
The program did not consistently assess and document health status of tenants receiving personal and health-related care.
Staff training was insufficient in some areas, though nurse delegation training was provided.
The program did not consistently provide six hours of dementia-specific education annually for relevant staff.
The program did not fully implement the Plan of Correction submitted in response to the recertification visit.
Report Facts
Current number of tenants without cognitive disorder: 20
Current number of tenants with cognitive disorder: 11
Total Population: 31
Current number of tenants in Dementia Specific Program: 4
Total Population: 4
Civil penalty amount: 4000
Previous fines: 500
Previous fines: 2000
Previous fines: 1500
Nurse review frequency: 90
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 4
Date: Apr 22, 2005
Visit Reason
A complaint investigation on-site visit was conducted at Bickford Cottage on April 22, 2005, to investigate allegations that the program retained tenants requiring a higher level of care.
Complaint Details
There were substantiated complaints in the areas of criteria for exclusion of tenants and service plans during this certification period.
Findings
The program did not consistently evaluate each tenant's functional and cognitive abilities within 30 days of occupancy and as needed with condition changes. The program retained tenants requiring a higher level of care and had regulatory insufficiencies related to tenant documents and service plans not being appropriately signed or developed prior to occupancy.
Deficiencies (4)
The program did not consistently evaluate each tenant’s functional and cognitive abilities and health status prior to and within 30 days of taking occupancy and as needed with change in condition.
The program did not have appropriately signed tenant documents.
The program did not have service plans developed prior to taking occupancy.
The program did not have appropriately signed service plans.
Report Facts
Current number of tenants without cognitive disorder: 17
Current number of tenants with cognitive disorder: 12
Total Population: 29
Current number of tenants in Dementia Specific Program: 7
Current number of tenants without cognitive disorder: 0
Total Population: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Gary Schmid | Director | Named as Director of Bickford Cottage in the report header |
| Stephanie Cummins | SW, MA | Monitor conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 3
Date: Sep 14, 2004
Visit Reason
A complaint investigation was conducted at Bickford Cottage on September 14, 2004, triggered by allegations that the program retained tenants beyond the appropriate level of care and did not provide appropriate documentation on service plans.
Complaint Details
The complaint alleged that the program retained tenants beyond the appropriate level of care and failed to provide appropriate documentation on service plans. The complaint was substantiated by observations including tenant chart reviews and service plan documentation deficiencies.
Findings
The investigation found that the program retained tenants who met the criteria for exclusion due to requiring a higher level of care. Additionally, the program failed to provide documentation of tenant or legal representative signatures and did not document involvement of three staff members, including a health professional, on service plans.
Deficiencies (3)
The program retained tenants that met the criteria for exclusion of tenants.
The program did not provide documentation of tenant signatures or tenant’s legal representative signatures on service plans.
The program did not provide documentation of involvement of three staff members, including a health professional, on service plans.
Report Facts
Current number of tenants in Dementia Specific Program: 38
Number of tenant charts reviewed: 6
Number of falls by Tenant #2: 3
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