Inspection Reports for Randall Residence of Decatur
1415 W Mound Rd, Decatur, IL 62526, IL, 62526
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Inspection Report
Annual Inspection
Census: 53
Deficiencies: 4
Jul 7, 2025
Visit Reason
Annual licensure survey conducted to assess compliance with health and safety regulations for the facility.
Findings
The facility was found deficient in multiple areas including failure to obtain timely tuberculin skin tests for employees, incomplete or unsigned physician assessments for residents, incomplete resident service plans, and missing tuberculosis testing results in resident records.
Severity Breakdown
Type 3: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to obtain tuberculin skin tests for two employees and late testing for one employee. | Type 3 |
| Physicians' assessments were not completed annually and signed by a physician for four of five residents reviewed. | Type 3 |
| One resident's service plan was incomplete, missing documentation of activities of daily living including diet, grooming, dressing, and toileting. | Type 3 |
| Resident records for two residents did not include tuberculosis testing results. | Type 3 |
Report Facts
Residents affected: 53
Residents reviewed for physician assessments: 5
Residents with incomplete physician assessments: 4
Residents reviewed for tuberculosis testing: 5
Residents missing tuberculosis test results: 2
Residents reviewed for service plans: 5
Residents with incomplete service plans: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E8 | Caregiver | Tuberculin skin test obtained late |
| E9 | Certified Nursing Assistant | No tuberculin skin test documentation |
| E11 | Caregiver | No tuberculin skin test documentation |
| E2 | Wellness Director | Confirmed lack of tuberculin test documentation for E9 and E11 and late test for E8 |
| E6 | Nurse Practitioner | Signed physician assessment for resident R4 |
| E7 | Nurse Practitioner | Signed physician assessment for resident R5 |
| E3 | Assistant Director of Nursing | Confirmed absence of tuberculosis test results in resident records |
Inspection Report
Annual Inspection
Deficiencies: 4
Jul 7, 2025
Visit Reason
An Annual Survey was conducted by the Illinois Department of Public Health on July 7, 2025, at Randall Residence of Decatur to assess compliance with the Assisted Living and Shared Housing Establishment Code.
Findings
The facility did not meet all compliance requirements, resulting in multiple Type 3 violations related to initial health evaluations, physician assessments, service plans, and tuberculosis skin test procedures. A Plan of Correction was immediately implemented addressing retraining and procedural updates.
Severity Breakdown
Type 3: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to obtain tuberculin skin tests for direct care and food service employees within required timeframes. | Type 3 |
| Failure to ensure physicians' assessments were completed annually and signed by a physician for residents reviewed. | Type 3 |
| Failure to develop and mutually agree upon a written service plan addressing level of service and health-related needs for residents. | Type 3 |
| Failure to ensure resident records included tuberculosis testing results for two of five residents reviewed. | Type 3 |
Report Facts
Residents potentially affected: 53
Residents reviewed for physician assessments: 5
Residents reviewed for tuberculosis testing: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beth Bolyard | Director | Named in Plan of Correction retraining and correspondence. |
| Beth Bolyard | CDP, LNHA | Signed Plan of Correction letter. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Nov 13, 2024
Visit Reason
The inspection was conducted as a complaint investigation to determine the validity of the complaint numbered 2468730/IL179866.
Findings
The complaint was not substantiated and no violations were cited. The facility 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.
Complaint Details
Complaint cannot be substantiated. No violations cited.
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