Inspection Reports for Bickford of Bloomington
14 Heartland Dr, Bloomington, IL 61704, United States, IL, 61704
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 17, 2025, identified multiple deficiencies related to residency requirements, disaster preparedness, employee training, physician assessments, service plans, tuberculosis testing, dementia program management, and resident rights. Earlier inspections and complaint investigations also cited issues with staffing levels, medication management, resident care including safe transfers, and documentation, with substantiated complaints involving neglect and failure to report abuse. Notably, a prior investigation in August 2024 found a failure to safely transfer a resident that resulted in injury and death. The facility was fined $2,000 in January 2025 for violations related to physician assessments, staffing, and medication control, but no other enforcement actions or license suspensions were listed in the available reports. The inspection history shows ongoing challenges with compliance in care and staffing, with repeated citations in similar areas over time.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
22.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
543% worse than Illinois average
Illinois average: 3.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
48 residents
Based on a September 2025 inspection.
Census over time
Inspection Report
Annual Inspection
Census: 48
Deficiencies: 9
Date: Sep 17, 2025
Visit Reason
Annual Licensure Survey conducted to assess compliance with state regulations for Bickford - Bloomington assisted living facility.
Findings
The facility was found deficient in multiple areas including residency requirements, disaster preparedness, employee training and health evaluations, physician assessments, service plans, tuberculosis testing, Alzheimer's and dementia program management, and resident rights. Several residents and employees lacked required documentation and training, and fall investigations and interventions were not adequately documented.
Deficiencies (9)
Failed to ensure only one assist was needed during transfers for one resident requiring two-person assistance.
Failed to ensure residents received orientation to disaster plans and emergency exits and failed to maintain required fire and tornado drill documentation.
Failed to ensure employee ongoing training was completed for two employees.
Failed to ensure employee immunizations and tuberculosis testing were completed as part of initial health evaluations for several employees.
Failed to ensure physician assessments were completed and signed by a physician for three residents.
Failed to update resident service plans to include therapeutic diets and health-related services for two residents.
Failed to ensure tuberculosis testing/screening was completed for three residents.
Failed to investigate resident falls and implement interventions to prevent continued falls for one resident.
Failed to ensure access to State Ombudsman contact information was available for one resident.
Report Facts
Residents currently residing: 48
Number of residents reviewed: 5
Number of employees reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 Executive Director | Executive Director | Named in findings related to employee training, health evaluations, and fall documentation. |
| E3 Health & Wellness Director | Health & Wellness Director | Confirmed resident transfer needs and lack of disaster orientation documentation; involved in fall documentation. |
| E4 CNA | Certified Nursing Assistant | Assisted with resident transfer requiring two staff. |
| E11 CNA | Certified Nursing Assistant | Assisted with resident transfer requiring two staff. |
| E16 Maintenance Director | Maintenance Director | Provided fire drill reports and confirmed lack of tornado drill documentation. |
| E2 Health & Wellness Director | Health & Wellness Director | Unable to provide tuberculosis documentation; stated Ombudsman posters were not up. |
| E6 Regional Director | Regional Director | Stated Ombudsman information should be posted. |
| E7 Divisional Director of Operations | Divisional Director of Operations | Confirmed physician certifications not signed by physicians. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 17, 2025
Visit Reason
An inspection was conducted on 9/17/25 by the Illinois Department of Public Health to determine compliance with the Assisted Living and Shared Housing Establishment Code.
Findings
Findings and violations were identified during the inspection, and an acceptable Statement of Correction (SOC) has been received by the Department.
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Jun 4, 2025
Visit Reason
The document is a response to a complaint investigation regarding regulatory violations identified at the facility. The investigation addresses specific complaints numbered IL190787, IL190858, IL190933, IL190931, and IL190932 at the Blooming Bickford facility.
Complaint Details
Complaint investigation in response to complaints IL190787, IL190858, IL190933, IL190931, and IL190932 at Blooming Bickford. The complaints were substantiated with multiple regulatory violations identified.
Findings
The report identifies multiple regulatory violations related to residency requirements, incident and accident reporting, personnel qualifications and training, service plans, mandatory services, Alzheimer's and dementia programs, and resident rights. The facility failed to meet several regulatory standards, including failure to find appropriate placement for a resident, failure to report an incident, failure to maintain training and documentation, and failure to provide adequate care and supervision.
Deficiencies (12)
Failed to find appropriate placement for one resident (R9) out of three residents reviewed for residency.
Failed to report an incident of elopement for one resident (R9) out of one resident reviewed for incident reporting.
Failed to have sufficient staffing to meet the needs of residents during routine branch visits.
Failed to train staff on safe resident transfers and failed to maintain training records.
Failed to complete required training for all direct care staff within 30 days of hire.
Failed to complete an audit of direct care staff on medication variance and wellness for the next 90 days.
Failed to create and revise service plans for residents (R1, R2, R3) out of 10 residents in the sample.
Failed to provide activities of daily living for 3 residents (R5, R8, R11) and failed to feed one resident (R10).
Failed to track and dispose of discontinued narcotic medications for residents (R8, R13) out of four residents reviewed for medications.
Failed to identify and report immediate medical attention and orders for treating, addressing pain, administering medication timely and securing immediate hospital attention as needed.
Failed to identify and treat pressure ulcers for two residents (R1, R2) and failed to report a change in condition and leave sending resident (R2) needing immediate medical attention to the hospital.
Failed to update R1 Service Plan by June 21, 2025.
Report Facts
Complaint numbers: 5
Residents reviewed for residency: 3
Residents reviewed for incident reporting: 1
Residents in sample for service plan: 10
Residents affected by ADL failures: 3
Residents reviewed for medication: 4
Days for training completion: 30
Days for audit completion: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Place | Executive Director | Named in response letter and responsible for corrective action plans |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: May 2, 2025
Visit Reason
Complaint investigations were conducted related to multiple regulatory citations and concerns at Bickford - Bloomington assisted living facility.
Complaint Details
The complaint investigation revealed substantiated deficiencies related to resident care, safety, staffing, medication administration, and facility security.
Findings
The investigation found multiple deficiencies including failure to re-evaluate residents' needs after condition changes, inadequate staffing and training, failure to provide required care and services, medication administration issues, unsecured facility access, and failure to report incidents. Several residents had untreated wounds, unmet care needs, and safety risks. One resident was found to have eloped multiple times without proper supervision or reporting. Staffing shortages led to missed care and medication administration. The facility failed to maintain proper service plans and training documentation, especially for dementia care.
Deficiencies (10)
Failure to re-evaluate and address the needs of a resident (R9) after a change in condition, including cognitive decline and elopement risk.
Failure to provide appropriate placement for a resident (R9) needing memory care rather than assisted living.
Failure to maintain secure access to the facility; front door was found unlocked multiple times allowing residents to exit unsupervised.
Insufficient staffing to meet residents' safety and care needs, including instances of single staff working alone without CPR certification.
Failure to properly train staff on safe resident transfers, incontinence care, and hand hygiene; observed unsafe transfer and care practices.
Failure to provide adequate assistance with activities of daily living, including missed showers, delayed feeding, and residents left in bed without care.
Failure to maintain and update individualized service plans reflecting residents' wounds, care needs, and transfer requirements.
Failure to provide required dementia-specific training to staff working in the memory care unit; untrained housekeeper assigned to resident care.
Failure to properly administer medications, including failure to dispose of discontinued narcotics and failure to administer medications due to lack of nursing coverage.
Failure to respect and protect resident rights including dignity, privacy, and timely medical care; delayed hospital transfer and delayed administration of PRN pain medication.
Report Facts
Residents reviewed for services: 3
Residents reviewed for care plans: 10
Residents reviewed for medications: 4
Residents reviewed for neglect: 6
Residents in memory care unit: 14
Residents in assisted living and memory care: 57
Wound size: 3
Wound size: 1
Wound size: 8
Wound size: 3
Wound size: 13
Wound size: 4
Pain rating: 8
Heart rate: 160
Time nurse absent: 90
Staff working alone: 3
Hours worked: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing | Named in relation to resident R9's care and elopement issues, medication administration, and staffing |
| E4 | Licensed Practical Nurse | Named in relation to medication administration, wound care, and staffing |
| E5 | Caregiver | Named in relation to resident care, transfer assistance, and staffing |
| E6 | Caregiver | Named in relation to resident care, transfer assistance, and hygiene |
| E7 | Area Health and Wellness Coordinator | Named in relation to resident care, elopement, and medication administration |
| E8 | Caregiver | Named in relation to resident R6's acute change in condition and delayed reporting |
| E9 | Licensed Practical Nurse | Named in relation to staffing and resident care issues |
| E10 | Caregiver | Named in relation to staffing and CPR certification issues |
| E11 | Licensed Practical Nurse | Named in relation to facility access control |
| E12 | Caregiver | Named in relation to resident R9's elopement |
| E13 | Caregiver | Named in relation to resident care and feeding |
| E14 | Maintenance | Named in relation to facility access control |
| E15 | Caregiver | Named in relation to CPR certification and staffing |
| E16 | Caregiver | Named in relation to CPR certification and staffing |
| E17 | Caregiver | Named in relation to CPR certification and staffing |
| E18 | Housekeeper | Named in relation to untrained staff providing resident care |
| E19 | Caregiver | Named in relation to resident transfer assistance |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 18, 2025
Visit Reason
Original investigation of multiple complaints (2563126 / IL 189934, 2563192 / IL 190034, 2563322 / IL 190293, 2563344 / IL 190322) regarding regulatory compliance at Bickford - Bloomington.
Complaint Details
Investigation was based on complaints 2563126, 2563192, 2563322, and 2563344. Only complaint 2563192 / IL 190034 resulted in a violation related to medication supervision; others had no violations cited.
Findings
The facility failed to have approved medication policies and a system in place to keep an appropriate count of discontinued narcotics for seven of eight sampled residents. Discontinued controlled medications were locked in a cabinet but lacked records and a control system from discontinuation to disposal.
Deficiencies (1)
Failed to have policies and a system to keep appropriate count of discontinued narcotics for seven of eight sampled residents.
Report Facts
Tablets of Lorazepam: 31
Tablets of Tramadol: 43
Tablets of Tramadol: 58
Tablets of Lorazepam: 26
Tablets of Tramadol: 12
Tablets of Lorazepam: 16
Tablets of Alprazolam: 11
Tablets of Apap / Codeine: 21
Tablets of Lorazepam: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wellness Director | Identified as E3, confirmed lack of system and policy for medication control and disposal |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 5
Date: Mar 14, 2025
Visit Reason
The inspection was conducted in response to original complaints regarding personnel qualifications, Alzheimer's and dementia program compliance, and resident rights violations.
Complaint Details
The investigation was triggered by complaints involving three residents. One resident (R2) reported abuse by a caregiver (E4), including being dropped on the floor and intimidation by flickering lights. The facility failed to report this allegation to the State Department within the required timeframe. Another resident (R1) was neglected in hygiene and care. The abuse allegation investigation was incomplete and did not include all relevant statements.
Findings
The facility failed to have CPR certified staff on duty 24 hours a day, did not provide adequate staffing for the memory care unit as specified in their Special Care Disclosure, and failed to follow policies regarding abuse reporting and resident care. Specific abuse allegations involving a caregiver were not reported to the State Department as required.
Deficiencies (5)
Failed to have CPR certified staff on duty 24 hours a day affecting all 51 residents.
Failed to provide staffing for the memory care unit as specified in their Special Care Disclosure affecting 14 residents.
Failed to follow policy regarding reporting of potential abuse, investigation, and immediate removal of alleged abuser for one resident.
Failed to assist one resident with hygiene and care as specified in her service plan.
Failed to report an allegation of abuse to the State Department for one resident.
Report Facts
Residents present: 51
Residents in memory care unit: 14
Residents in assisted living side: 37
Days without CPR certified staff on all shifts: 6
Caregivers on night shift: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E4 | Caregiver Assistant | Named in abuse allegation involving resident R2 |
| E1 | Executive Director | Provided census and statements regarding CPR certification and abuse reporting |
| E2 | Health and Wellness Director | Interviewed regarding abuse allegations and staffing |
| E5 | Caregiver Assistant | Interviewed regarding staffing and abuse allegations |
| E7 | Assistant Director | Involved in abuse allegation reporting and investigation |
| E12 | Wellness Nurse | Reported abuse allegation and attempted to notify management |
| E18 | Certified Nursing Assistant | Reported staffing concerns for memory care unit |
| E6 | Caregiver Assistant | Mentioned in resident care neglect incident |
| Z1 | Family member of resident R1 | Reported neglect of resident R1 |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Date: Jan 7, 2025
Visit Reason
The inspection was conducted as a complaint survey by the Illinois Department of Public Health on 1/7/25 to investigate allegations that the establishment did not meet compliance requirements of the Assisted Living and Shared Housing Establishment Code Section 295.
Complaint Details
The complaint investigation was substantiated with findings of violations related to physician assessments, staffing in the Alzheimer's unit, and medication management. The facility was fined a total of $2000.00 for violations of sections 295.4000, 295.4060, and 295.5000.
Findings
The facility failed to obtain annual physician assessments for three residents, lacked sufficient staff on duty in the Alzheimer's unit, and failed to accurately control and count scheduled medications for six residents. These deficiencies were supported by interviews, record reviews, and observations.
Deficiencies (3)
Failed to obtain annual physician assessments for three residents, assessments were about 13-14 months overdue.
Failed to have sufficient staff on duty in the Alzheimer's unit to meet the required resident to staff ratios and ensure at least one staff member awake and on duty at all times.
Failed to accurately control and count scheduled II medications, with inconsistent controlled substance counts and missing reconciliation for controlled substances.
Report Facts
Fine amount: 2000
Residents with overdue physician assessments: 3
Residents in Alzheimer's unit: 13
Residents on assisted living side receiving narcotic medications: 6
Census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tracy Place | Executive Director | Named in relation to findings and statement of correction |
| Erin Rife | Assistant Bureau Chief, Division of Assisted Living | Signed complaint survey letter |
| E1 | Executive Director | Interviewed regarding physician assessments and controlled substance counts |
| E2 | Acting Health and Wellness Director | Interviewed regarding medication counts and staffing |
| E4 | CNA/Certified Nursing Assistant | Reported staffing shortages on Alzheimer's unit |
| E5 | Nurse | Observed not acting as nurse on duty during night shift |
| E7 | CNA | Reported staffing shortages on Alzheimer's unit |
| E9 | CNA | Reported staffing shortages on Alzheimer's unit |
| E10 | CNA | Reported staffing shortages on Alzheimer's unit |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 3
Date: Jan 3, 2025
Visit Reason
The inspection was conducted as an original complaint investigation (#2460385/IL182955) to assess compliance with physician assessments, staffing levels in the Alzheimer's unit, medication supervision, and controlled substance management.
Complaint Details
Original complaint investigation #2460385/IL182955. The complaint was substantiated based on findings of overdue physician assessments, insufficient staffing, and medication control issues.
Findings
The facility failed to obtain annual physician assessments for three residents, lacked sufficient staffing in the Alzheimer's unit affecting 13 residents, and failed to accurately control and count scheduled II narcotic medications for six residents on the assisted living side.
Deficiencies (3)
Failed to obtain annual physician assessments for three of three residents reviewed.
Failed to have sufficient staff on duty in the Alzheimer's unit as per the Special Care Disclosure, potentially affecting all 13 residents in the unit.
Failed to accurately control and count scheduled II medications, affecting six residents receiving narcotic medications.
Report Facts
Residents with overdue physician assessments: 3
Residents in Alzheimer's unit: 13
Residents receiving narcotic medications: 6
Total residents in facility: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Stated physician assessments were the most current available; presented Shift Change History Log. |
| E2 | Acting Health and Wellness Director | Conducted narcotic counts; verified controlled substance reports; stated controlled substance counts were not consistently done. |
| E4 | Certified Nursing Assistant | Reported working with insufficient staff and no nurse on duty at times. |
| E5 | Nurse | Was on duty but acting as caregiver while orienting to shift. |
| E10 | Certified Nursing Assistant | Reported residents needing two caregivers for transfers and care; stated staffing was insufficient. |
| E7 | Certified Nursing Assistant | Reported working as only caregiver on memory care unit on many occasions. |
| E9 | Certified Nursing Assistant | Reported working as only caregiver on memory care unit on many occasions. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 26, 2024
Visit Reason
Original investigation of Complaint 2466680 / IL 177037 regarding alleged neglect during resident transfer.
Complaint Details
Complaint 2466680 / IL 177037 was substantiated based on record review and interviews indicating neglect in transferring resident R1, leading to serious injury and death.
Findings
The facility neglected to safely transfer one resident (R1) from a wheelchair to a bed using a mechanical lift, resulting in the resident slipping from the sling, falling, sustaining a subarachnoid hemorrhage, and subsequently dying. Interviews and incident reports confirmed the strap securing the sling was unhooked, causing the fall and injury.
Deficiencies (1)
Failure to safely transfer resident using mechanical lift, resulting in injury and death.
Report Facts
Complaint number: 2466680
Complaint number: 177037
Date of incident: Aug 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| E3 | Caregiver | Involved in transferring resident and noted strap came off causing fall |
| E4 | Caregiver | Assisted in transfer and controlled lift; noticed strap unhooked after fall |
| E5 | Floor Nurse | Provided initial care after fall, wrapped resident's leg, notified hospice and emergency contacts |
| Z1 | Resident's Sister and Power of Attorney (POA) | Provided information about resident's condition and decisions after hospitalization |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 26, 2024
Visit Reason
The inspection was conducted in response to Complaint #246680 regarding resident rights violations at Bickford Bloomington House.
Complaint Details
Complaint #246680 was substantiated as a Type 1 violation involving neglect and abuse of resident rights, specifically failure to safely transfer a resident leading to injury and death.
Findings
The investigation found a Type 1 violation involving neglect of a resident (R1) who suffered a hematoma and subsequent injury due to failure to safely transfer the resident from a wheelchair to bed, resulting in the resident's death. The facility failed to ensure proper mechanical lift use and staff training.
Deficiencies (1)
Failure to safely transfer resident (R1) from wheelchair to bed, resulting in injury and subsequent death.
Report Facts
Fine amount: 20000
Days to file Statement of Correction: 15
Date of survey: Aug 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Danielle Poliak | Divisional Director of Health and Wellness | Signed letter responding to Statement of Correction |
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