Inspection Reports for Randall Residence of Decatur

1415 W Mound Rd, Decatur, IL 62526, IL, 62526

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Inspection Report Summary

The most recent inspection on July 7, 2025, identified deficiencies related to employee tuberculosis testing, incomplete physician assessments, resident service plans, and missing tuberculosis test results in resident records. Earlier inspections showed similar issues with initial health evaluations, physician assessments, service plans, and tuberculosis testing procedures, resulting in multiple Type 3 violations and a Plan of Correction. Complaint investigations conducted in November 2024 were unsubstantiated and did not result in any citations. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. The facility’s inspection history shows consistent areas needing improvement, particularly in documentation and tuberculosis testing compliance.

Deficiencies (last 2 years)

Deficiencies (over 2 years) 4 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

14% worse than Illinois average
Illinois average: 3.5 deficiencies/year

Deficiencies per year

4 3 2 1 0
2024
2025

Inspection Report

Annual Inspection
Census: 53 Deficiencies: 4 Date: 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.

Deficiencies (4)
Failure to obtain tuberculin skin tests for two employees and late testing for one employee.
Physicians' assessments were not completed annually and signed by a physician for four of five residents reviewed.
One resident's service plan was incomplete, missing documentation of activities of daily living including diet, grooming, dressing, and toileting.
Resident records for two residents did not include tuberculosis testing results.
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
NameTitleContext
E8CaregiverTuberculin skin test obtained late
E9Certified Nursing AssistantNo tuberculin skin test documentation
E11CaregiverNo tuberculin skin test documentation
E2Wellness DirectorConfirmed lack of tuberculin test documentation for E9 and E11 and late test for E8
E6Nurse PractitionerSigned physician assessment for resident R4
E7Nurse PractitionerSigned physician assessment for resident R5
E3Assistant Director of NursingConfirmed absence of tuberculosis test results in resident records

Inspection Report

Annual Inspection
Deficiencies: 4 Date: 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.

Deficiencies (4)
Failure to obtain tuberculin skin tests for direct care and food service employees within required timeframes.
Failure to ensure physicians' assessments were completed annually and signed by a physician for residents reviewed.
Failure to develop and mutually agree upon a written service plan addressing level of service and health-related needs for residents.
Failure to ensure resident records included tuberculosis testing results for two of five residents reviewed.
Report Facts
Residents potentially affected: 53 Residents reviewed for physician assessments: 5 Residents reviewed for tuberculosis testing: 5

Employees mentioned
NameTitleContext
Beth BolyardDirectorNamed in Plan of Correction retraining and correspondence.
Beth BolyardCDP, LNHASigned Plan of Correction letter.

Inspection Report

Complaint Investigation
Deficiencies: 0 Date: Nov 13, 2024

Visit Reason
The inspection was conducted as a complaint investigation to determine the validity of the complaint numbered 2468730/IL179866.

Complaint Details
Complaint cannot be substantiated. No violations cited.
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.

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