Inspection Reports for Bickford of Portage

The inspection was conducted in response to a complaint alleging that Resident A's mental health was untreated at the facility.

The investigation found that Resident A exhibited aggressive and exit-seeking behaviors from admission on 03/10/2025, and the facility delayed communication with a licensed medical professional until 04/13/2025 for medical intervention. The facility failed to ensure Resident A's safety and protection by waiting an extended time to manage behaviors medically, establishing a violation.

Complaint alleged Resident A's mental health was untreated. The complaint was substantiated based on findings that the facility delayed medical intervention and failed to manage Resident A's aggressive and exit-seeking behaviors appropriately.

The inspection was conducted as a Renewal Licensing Study to assess compliance with licensing rules and regulations for the facility.

The facility was found to be in non-compliance with multiple rules including employee health screening, solid waste management, kitchen and dietary sanitation, food labeling, and safe storage of hazardous materials. Violations were established for each of these areas.

The investigation was initiated due to a complaint alleging that Resident A was violent towards staff and other residents and that the facility did not appropriately address these behaviors.

The investigation found that Resident A exhibited numerous aggressive and violent behaviors from September to November 2024, resulting in staff injury, resident injury, and self-injury. The facility had directives in the service plan to address these behaviors, but they were ineffective and lacked evidence of additional staff training or advanced directives. The facility also failed to update Resident A's service plan to reflect preventative measures for exit-seeking behaviors and did not document incidents in accordance with reporting guidelines.

The complaint alleged that Resident A was violent towards staff and other residents and that the facility did not appropriately address it. The allegation was substantiated. Another allegation that the facility did not have a working staff schedule was not substantiated.

The investigation was initiated due to a complaint alleging that Resident A was observed with bruising on 10/30/2024.

The investigation found that Resident A incurred a fall on 10/17/2024 and later bruising was observed by hospice. Staff inconsistently used transfer methods, sometimes not using the prescribed Hoyer lift, potentially contributing to bruising. The facility failed to maintain an organized program to provide adequate protection and supervision, and Resident A's service plan was not updated to reflect current care needs. Incident reporting did not meet regulatory guidelines.

Complaint received on 11/27/2024 alleging Resident A was observed with bruising on 10/30/2024. Violation was established based on investigation findings.

The investigation was initiated due to a complaint received from Adult Protective Services alleging that caregivers provided care to residents positive for Covid-19 and also to residents without Covid-19, residents were not changed and showered, the facility had insufficient staff, and food was cold.

The investigation found no violation regarding caregivers providing care to both Covid-19 positive and negative residents, residents not being changed and showered, or food being cold. However, a violation was established for insufficient staffing, with multiple shifts not meeting required staffing levels, especially in assisted living and memory care units.

Complaint received from Adult Protective Services on 08/19/2024 alleging Covid-19 outbreak management issues, inadequate resident care, insufficient staffing, and cold food. Investigation concluded violation established only for insufficient staffing; other allegations were not substantiated.

The inspection was conducted as a renewal inspection to review licensing activity and compliance with public health code and administrative rules regulating home for the aged facilities.

The facility was found to be in compliance with all applicable rules and statutes. Renewal of the license is recommended.

The investigation was initiated due to a complaint alleging that staff did not provide care in accordance with Resident A’s service plan.

The investigation found that the facility had a detailed service plan and plan of care for Resident A’s nephrostomy tube, which was signed by facility management and staff but not by Resident A or their authorized representative. Evidence showed that Resident A’s nephrostomy tube was found kinked and tubing underneath Resident A, violating the facility's plan of care. The facility communicated consistently with the authorized representative, physician, and home health company, and Resident A was discharged after exceeding the level of care the facility could provide.

The complaint alleged that the facility did not provide appropriate care for Resident A’s nephrostomy tube and that the home health company should have provided more visits. The complaint was substantiated with violation established.

The inspection was conducted as a Renewal Licensing Study to evaluate compliance with licensing rules and to determine if the facility's license should be renewed.

The facility was found to be in non-compliance with rules related to kitchen and dietary practices, specifically the lack of labeling open dates on food items, and unsafe storage of hazardous and toxic materials accessible to residents in the memory care unit.

The inspection was conducted in response to a complaint alleging the facility had insufficient staff, specifically that on 9/2 and 9/9 there was only one staff member for the first shift.

Interviews with staff and review of schedules revealed staffing levels were below desired levels, with frequent use of agency staff and insufficient caregivers on shifts. Call light response times averaged 12 minutes. Despite these findings, the violation was not established.

Complaint received from Adult Protective Services on 09/13/2022 alleging insufficient staffing. Investigation included interviews with staff and administrator, schedule reviews, and call light response time analysis. Violation was not established.

The inspection was conducted to review and approve the addition of a 16-bed memory care unit attached to the existing facility and to update the facility's licensed bed capacity from 55 to 71.

The memory care unit was found to meet all safety and program requirements, including fire safety certification, occupancy approval, and compliance with Alzheimer's program standards. The unit includes secure access, emergency call systems, and life skills programming tailored to residents.

The inspection was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for Portage Bickford Cottage.

The facility was found to be in substantial compliance with licensing requirements, with no rule or statutory violations noted. The report recommends issuance of a six-month temporary license with a maximum capacity of 55 residents.