Inspection Reports for Bickford of Rockford
960 N Mulford Rd, Rockford, IL 61107, United States, IL, 61107
Back to Facility Profile
Inspection Report
Complaint Investigation
Capacity: 65
Deficiencies: 5
Sep 16, 2025
Visit Reason
Investigation of multiple complaints and allegations regarding resident care and facility compliance conducted on 9/15/2025-9/16/2025.
Findings
The facility failed to meet residency requirements by allowing residents requiring higher levels of care than licensed for, failed to ensure physician assessments were completed by a physician, failed to follow service plans resulting in neglect, and failed to properly investigate and report injuries of unknown origin. These failures created substantial probabilities of harm and severe harm to residents.
Complaint Details
The complaint alleged neglect of resident R1, including failure to follow toileting and hydration care plans, leading to untreated urinary tract infection and death. The investigation also included injuries of unknown origin for residents R4 and R8.
Severity Breakdown
Type 1 Violation: 4
Type 2 Violation: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Allowed residents to remain who required levels of service the establishment was not licensed to provide, including total assistance with 2 or more activities of daily living and assistance from more than one paid caregiver. | Type 1 Violation |
| Failed to ensure physician assessments were completed by a physician as required. | Type 2 Violation |
| Failed to follow the service delivery contract by not following the service plan, including failure to provide required toileting and safety checks. | Type 1 Violation |
| Failed to ensure a resident was free from neglect by not following the service plan and failing to provide timely antibiotic treatment, contributing to a resident's death. | Type 1 Violation |
| Failed to investigate and report injuries of unknown origin, including multiple rib fractures and a spiral fracture, within required timeframes and to the Department. | Type 1 Violation |
Report Facts
Licensed assisted living units: 65
Days resident R1 required maximum assistance: 267
Urine E.Coli count: 39000000
Deficiency count: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Confirmed concern about injury investigation was not conducted |
| E7 | LPN | Interviewed regarding resident R1's use of call pendant and assistance needs |
| E13 | Family Advisor | Conducted investigation related to injury of unknown origin |
| E14 | LPN | Notified of resident R4's bruising of unknown origin |
| E15 | Caregiver | Reported bruising to resident R4 |
| E17 | Health and Wellness Director | Responsible for conducting investigations of injuries and reporting |
Loading inspection reports...
