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Inspection Reports for Bickford of Rockford

960 N Mulford Rd, Rockford, IL 61107, United States, IL, 61107

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Inspection Report Summary

The most recent inspection on September 16, 2025, identified deficiencies related to resident care and compliance with licensing requirements. Earlier inspections were not provided for comparison, but this report noted issues including allowing residents to remain who required higher levels of care than the facility was licensed to provide, failure to ensure physician assessments were completed, and not following service plans, which contributed to neglect and a resident’s death. Inspectors also cited failures to investigate and report injuries of unknown origin within required timeframes. No fines, immediate jeopardy findings, or enforcement actions were listed in the available reports. There is no information on prior complaint investigations to indicate a trend.

Deficiencies (last 1 years)

Deficiencies (over 1 years) 5 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

43% worse than Illinois average
Illinois average: 3.5 deficiencies/year

Deficiencies per year

8 6 4 2 0
2025
Severe (Immediate Jeopardy) High (Actual Harm)
State average

Inspection Report

Complaint Investigation
Capacity: 65 Deficiencies: 5 Date: 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.
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.
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.
Deficiencies (5)
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.
Failed to ensure physician assessments were completed by a physician as required.
Failed to follow the service delivery contract by not following the service plan, including failure to provide required toileting and safety checks.
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.
Failed to investigate and report injuries of unknown origin, including multiple rib fractures and a spiral fracture, within required timeframes and to the Department.
Report Facts
Licensed assisted living units: 65 Days resident R1 required maximum assistance: 267 Urine E.Coli count: 39000000 Deficiency count: 5
Employees mentioned
NameTitleContext
E1Executive DirectorConfirmed concern about injury investigation was not conducted
E7LPNInterviewed regarding resident R1's use of call pendant and assistance needs
E13Family AdvisorConducted investigation related to injury of unknown origin
E14LPNNotified of resident R4's bruising of unknown origin
E15CaregiverReported bruising to resident R4
E17Health and Wellness DirectorResponsible for conducting investigations of injuries and reporting

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