Inspection Reports for Bickford of St. Charles
2875 Campton Hills Rd, St. Charles, IL 60175, United States, IL, 60175
Back to Facility ProfileDeficiencies per Year
12
9
6
3
0
High
Moderate
Low
Unclassified
Inspection Report
Complaint Investigation
Deficiencies: 3
Oct 7, 2025
Visit Reason
The inspection was conducted due to substantiated incidents reported involving residents, including medication ingestion and multiple falls, to assess compliance with incident reporting, service plan updates, and medication administration regulations.
Findings
The facility failed to report significant incidents within 24 hours for 4 residents, did not revise service plans after falls for 3 residents, and failed to ensure medications were administered by licensed staff and properly stored, with medications found unsecured in a resident's apartment.
Complaint Details
The visit was complaint-related with substantiated incidents IL197453 (9/9/25) and IL197555 (9/5/25) involving medication ingestion and falls.
Severity Breakdown
Type 3 Violation: 1
Type 2 Violation: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to report serious incidents or accidents to the Department within 24 hours for 4 of 4 residents reviewed. | Type 3 Violation |
| Failure to revise service plans immediately after significant changes following falls for 3 of 4 residents reviewed. | Type 2 Violation |
| Failure to ensure medication administration by licensed healthcare professionals and proper medication storage for 1 of 5 residents reviewed. | Type 2 Violation |
Report Facts
Residents reviewed for accidents and incidents: 5
Residents with unreported incidents: 4
Residents reviewed for falls: 5
Residents with service plan not revised after fall: 3
Residents reviewed for medication administration: 5
Residents with medication administration/storage deficiencies: 1
Number of pills ingested by R1 in suicide gesture: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Health and Wellness Director | Named in findings related to incident reporting failures and medication administration oversight |
| E3 | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration policies |
| E4 | Certified Nursing Assistant (CNA) | Accompanied surveyor during medication storage observation |
| E5 | Registered Nurse (RN) | Interviewed regarding medication self-administration and safety |
Inspection Report
Annual Inspection
Deficiencies: 4
Sep 4, 2025
Visit Reason
Annual licensure survey conducted including a facility reported investigation and a complaint investigation.
Findings
The facility failed to meet residency requirements by admitting a resident with a stage 3 pressure ulcer requiring total assistance with all ADLs. The facility also failed to maintain complete employee files, develop and update individualized service plans for residents receiving outside services, and ensure resident rights were upheld, particularly for wound care and service planning for resident R6.
Complaint Details
Complaint Investigation IL 195724 was conducted with no deficiency cited.
Severity Breakdown
General Violation: 2
Type 3 Violation: 1
Type 2 Violation: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to meet residency requirements by admitting a resident with a stage 3 pressure ulcer and total assistance needs. | General Violation |
| Incomplete employee files missing initial health evaluations and TB testing for 7 of 9 employees reviewed. | Type 3 Violation |
| Failure to develop and update individualized service plans addressing outside vendor services for 3 residents. | Type 2 Violation |
| Failure to develop a preventative plan of care and individualized service plan for resident R6 resulting in unstageable wound. | General Violation |
Report Facts
Residents reviewed: 3
Employee files reviewed: 9
Employee files deficient: 7
Resident wound size: 5
Resident wound size: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E2 | Director of Nursing (DON) | Noted failure to document resident R6's stage 3 pressure ulcer prior to admission and inability to obtain employee file information. |
| E7 | Assistant Director of Nursing (ADON) | Assessed resident R6 prior to admission and did not document stage 3 pressure ulcer; admitted resident against guidelines. |
| E1 | Executive Director | Responsible for employee files; on maternity leave during survey. |
Inspection Report
Annual Inspection
Deficiencies: 9
Sep 5, 2024
Visit Reason
Annual licensure survey conducted to assess compliance with Illinois Department of Public Health regulations for assisted living facilities.
Findings
The facility was found deficient in multiple areas including disaster preparedness, manager qualifications, employee orientation and training, initial health evaluations, health care worker background checks, physician assessments, service plans, tuberculosis testing, and medication administration.
Severity Breakdown
Type 3: 8
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to conduct fire extinguisher training for eight new employees, emergency and evacuation orientation for five residents, and document resident participation and assistance during drills. | Type 3 |
| Failed to notify the department within 10 days of change in Executive Director. | Type 3 |
| Failed to complete required employee orientation topics within required timeframes for five employees. | Type 3 |
| Failed to complete initial health evaluations including physical exams and tuberculosis testing for five employees within required timeframes. | Type 3 |
| Failed to complete Health Care Worker Background checks including verification within 30 days of hire, internet registry searches, and annual verification for employees. | Type 3 |
| Physician assessments for three residents were completed by nurse practitioners instead of physicians. | Type 3 |
| Service plans for residents with wounds, dialysis, and Foley catheter did not include appropriate interventions or care instructions. | — |
| Failed to initiate or complete tuberculosis testing for eight new employees as required by the Control of Tuberculosis Code. | Type 3 |
| Failed to administer medications as ordered by physician for two residents, including missed doses of multiple medications. | Type 3 |
Report Facts
Number of new employees reviewed for fire extinguisher training: 8
Number of residents reviewed for emergency orientation: 5
Number of employees reviewed for orientation: 8
Number of employees reviewed for initial health evaluation: 8
Number of employees reviewed for Health Care Worker Background Check: 8
Number of residents with physician assessment issues: 3
Number of employees reviewed for tuberculosis testing: 8
Number of residents with medication administration issues: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Executive Director | Failed to notify department of change in Executive Director; lacked tuberculosis testing; lacked background check verification. |
| E2 | Health and Wellness Director | Interviewed regarding lack of fire extinguisher training, resident orientation, tuberculosis testing, and medication administration expectations. |
| E4 | Breadbasket Manager | Lacked fire extinguisher training, timely orientation, initial health evaluation, tuberculosis testing, and background check verification. |
| E5 | Nurse | Lacked fire extinguisher training, timely orientation, initial health evaluation, and tuberculosis testing. |
| E6 | Certified Caregiver | Lacked fire extinguisher training, timely orientation, initial health evaluation, and tuberculosis testing. |
| E7 | Caregiver Assistant | Lacked fire extinguisher training, timely orientation, initial health evaluation, tuberculosis testing, and background check verification. |
| E8 | Caregiver Assistant | Lacked fire extinguisher training, initial health evaluation, tuberculosis testing, and background check verification. |
| E9 | Caregiver Assistant | Lacked fire extinguisher training, timely orientation, tuberculosis testing, and background check verification. |
| E10 | Caregiver Assistant | Lacked fire extinguisher training, initial health evaluation, tuberculosis testing, and background check verification. |
| E15 | Nurse | Reported on resident Foley catheter bleeding and hospice notification. |
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