Inspection Reports for Bickford of Champaign
1002 S Staley Rd, Champaign, IL 61822, United States, IL, 61822
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Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 21, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about resident R1's care, specifically regarding falls and the adequacy of the service plan and staff assessments following these incidents.
Findings
The facility failed to properly assess resident R1 after multiple unwitnessed falls and did not update the service plan with new fall interventions or include all assistive devices and assistance needs. These failures resulted in multiple falls and a fractured pelvis. Documentation and communication regarding R1's condition and care changes were incomplete.
Complaint Details
Complaint 2563150/IL190023 was substantiated with violations cited. The complaint involved concerns about R1's falls, injuries, and the facility's failure to report and properly manage these incidents.
Deficiencies (2)
| Description |
|---|
| Failure to ensure R1 was properly assessed after falls and failure to update R1's service plan with new fall interventions following multiple falls. |
| Failure to update R1's service plan to include all assistive devices used and the amount of assistance required with activities of daily living. |
Report Facts
Number of falls: 4
Hospital admission dates: R1 admitted to hospital on 02-12-2025 and 04-10-2025
Service plan last update date: Service plan last updated on 02-10-2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Interviewed regarding R1's care, fall incidents, and service plan updates |
| Z1 | Complainant interviewed about R1's emergency room visits and observations of bruising and pain |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 5, 2025
Visit Reason
The inspection was conducted in response to multiple original complaints numbered IL187282, IL1877005, IL186537, and IL186407.
Findings
The establishment was found to be in compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act for all complaints investigated.
Complaint Details
Four original complaints (IL187282, IL1877005, IL186537, IL186407) were investigated and all were found to be unsubstantiated as the establishment was in compliance with applicable regulations.
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 25, 2024
Visit Reason
The inspection was conducted in response to an original complaint #179089 to assess compliance with Part 295 Assisted Living and Shared Housing Establishment Administrative Code and 210 ILCS 9/1 Assisted Living and Shared Housing Act.
Findings
The establishment was found to be in compliance with the applicable assisted living regulations and acts during this survey.
Complaint Details
Original complaint #179089; the survey found the establishment in compliance.
Inspection Report
Annual Inspection
Deficiencies: 4
Oct 25, 2024
Visit Reason
Annual Survey conducted on 10/25/2024 to assess compliance with state regulations for Bickford - Champaign Cottage.
Findings
The facility was found deficient in multiple areas including disaster preparedness drills, CPR certified staff coverage, and tuberculosis skin test compliance for employees and residents. Several violations were cited indicating substantial probability of harm to residents.
Severity Breakdown
Type 1: 1
Type 2: 3
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to conduct 2 of the 6 required disaster preparedness drills, including night drills, as required by Section 295.2040. | Type 2 |
| Failed to have a CPR certified direct care staff on duty for 8 partial shifts in October 2024 as required by Section 295.3000. | Type 1 |
| Failed to complete tuberculin skin tests for employees in accordance with Control of Tuberculosis Code as required by Section 295.3030. | Type 2 |
| Failed to complete tuberculin skin tests for employees and residents in accordance with Control of Tuberculosis Code as required by Section 295.4050. | Type 2 |
Report Facts
Deficiencies cited: 4
CPR uncertified shifts: 8
Missing fire drills: 2
Employee files reviewed for TB testing: 6
Resident files reviewed for TB testing: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Interviewed staff member who confirmed findings related to missing drills, CPR certification, and TB testing records. |
Inspection Report
Annual Inspection
Deficiencies: 6
Oct 25, 2024
Visit Reason
The inspection was conducted as an annual survey visit on October 25, 2024, at the Champaign Bickford facility to assess compliance with regulatory requirements.
Findings
The establishment failed to ensure tornado drills were conducted in June, July, and August shifts, violating administrative code and posing potential health and safety risks. Additionally, the facility failed to ensure employees have tuberculosis (TB) skin testing done as required and did not provide a designated individual for direct care in the absence of the manager. Multiple corrective actions were outlined to address these deficiencies.
Severity Breakdown
E1: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure tornado drills were conducted in June, July, and August shifts. | E1 |
| Failure to ensure residents have tuberculosis (TB) skin testing done as required. | — |
| Failure to provide a designated individual in the absence of the manager. | — |
| Failure to ensure employees have tuberculosis (TB) skin testing done as required. | — |
| Failure to ensure all employees have a Tuberculin test prior to employment. | — |
| Failure to ensure all employees are CPR certified at the start date of employment. | — |
Report Facts
Inspection date: Oct 25, 2024
Number of tornado drills missed: 3
Timeframe for tuberculosis skin test completion: 10
Timeframe for tuberculosis test completion for new employees: 90
Timeframe for CPR training: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Roxanne Kelley | Executive Director | Named in multiple findings and responsible for corrective actions |
Inspection Report
Plan of Correction
Deficiencies: 0
6021036 View POC 005 SOC
Visit Reason
This document is a Plan of Action responding to Complaint IL190023, addressing personnel requirements, qualifications, training, and service plans to ensure proper care for residents.
Findings
The plan outlines immediate corrective actions including comprehensive onboarding, ongoing education for staff, maintaining up-to-date records, and ensuring service plans are reviewed annually or after significant changes in residents' conditions.
Complaint Details
Plan of Action responding to Complaint IL190023; no substantiation status provided.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Roxanne Kelley | Executive Director | Named as responsible for corrective actions and signed the Plan of Action. |
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