Inspection Reports for Bickford of Carmel
5829 E 116th St East, Carmel, IN 46033, United States, IN, 46033
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 29, 2025, found Bickford of Carmel in compliance with no deficiencies cited related to a prior complaint investigation. Earlier inspections showed a pattern of deficiencies primarily involving resident neglect and abuse, as well as issues with safety procedures, kitchen sanitation, and documentation. Notable substantiated complaints included failure to prevent physical abuse between residents, inadequate investigation and service plan updates, and neglect related to exit-seeking behaviors and fall safety. Complaint investigations were mixed, with several substantiated cases primarily concerning resident care and safety, while others were unsubstantiated or corrected upon follow-up. The facility appears to have addressed many prior deficiencies, as recent inspections show improvement and compliance with state regulations.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
74% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
45 residents
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 45
Deficiencies: 0
Date: May 29, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00456858 completed on April 15, 2025.
Complaint Details
Complaint IN00456858 was corrected.
Findings
Bickford of Carmel was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00456858.
Inspection Report
Complaint Investigation
Census: 44
Deficiencies: 3
Date: Apr 15, 2025
Visit Reason
This visit was for the investigation of complaints IN00456021 and IN00456858. Complaint IN00456021 had no deficiencies cited, while complaint IN00456858 resulted in state deficiencies related to resident abuse and management.
Complaint Details
Complaint IN00456858 involved substantiated allegations of physical abuse by Resident B against Resident C, with multiple witnessed incidents and inadequate facility response. Complaint IN00456021 had no deficiencies related to the allegations.
Findings
The facility failed to prevent physical abuse of Resident C by Resident B, despite multiple incidents and reports. The facility also failed to thoroughly investigate these incidents and update service plans to prevent further abuse. Resident B exhibited ongoing aggressive behavior towards Resident C, which was inadequately managed by staff interventions limited to separating the residents after incidents.
Deficiencies (3)
Failed to ensure a resident with dementia was free from physical abuse by another resident, resulting in repeated harassment and assault without effective interventions.
Failed to ensure incidents of abuse were thoroughly investigated to prevent further altercations between residents.
Failed to update service plans for residents involved in physical altercations to identify and document necessary interventions.
Report Facts
Resident census: 44
Date of survey: Apr 15, 2025
Completion date for corrective actions: Apr 28, 2025
Completion date for service plan updates: Apr 29, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Wafford | Administrator | Signed the inspection report |
Inspection Report
Renewal
Census: 36
Deficiencies: 5
Date: Dec 12, 2024
Visit Reason
This visit was for a State Residential Licensure Survey conducted on December 12 and 13, 2024, to assess compliance with state regulations for the facility.
Findings
The facility was found noncompliant in several areas including failure to conduct monthly fire and disaster drills for two months, lack of documentation for fire department participation, failure to inspect HVAC system annually, unsafe kitchen sanitation and food storage practices, and unsafe water temperatures in one apartment.
Deficiencies (5)
Failed to ensure fire and disaster drills were conducted monthly for December 2023 and January 2024 and lacked documentation of fire department participation in drills.
Failed to ensure the heating, ventilation and air conditioning system (HVAC) was inspected at least yearly.
Failed to ensure the kitchen was maintained in a safe, sanitary manner and in good repair for 2 kitchens observed, including missing cabinet doors, soiled bulk food bins, unlabeled and undated food items, and broken refrigerator thermometer.
Failed to ensure sanitizer concentration was adequate; sanitizer tested at 0 parts per million.
Failed to ensure water temperatures were maintained at a safe temperature in one apartment (Room 145) where water temperature was 130 degrees.
Report Facts
Residential Census: 36
Fire drill missing months: 2
Sanitizer concentration: 0
Water temperature: 130
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Wafford | Administrator | Signed report and referenced as Executive Director during interviews |
| Maintenance Director | Interviewed regarding HVAC inspection and water temperature issues; name not provided | |
| Kitchen Staff 1 | Interviewed regarding kitchen sanitation and food labeling deficiencies; name not provided | |
| QMA 2 | Interviewed regarding broken refrigerator thermometer and food safety; name not provided |
Inspection Report
Follow-Up
Census: 38
Deficiencies: 0
Date: Jun 28, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to multiple investigations of complaints completed between October 30, 2023, and April 2, 2024, to verify correction of previously identified deficiencies.
Complaint Details
This visit was related to the follow-up of complaints IN00429284, IN00428410, IN00428097, IN00419622, and IN00431347, all of which were corrected.
Findings
The facility was found to be in compliance with the relevant regulations regarding the PSRs to the investigations of complaints IN00429284, IN00428410, IN00428097, IN00419622, and IN00431347, all of which were corrected.
Report Facts
Residential Census: 38
Inspection Report
Follow-Up
Census: 38
Deficiencies: 0
Date: Jun 28, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigations of multiple complaints (IN00428410, IN00428097, IN00419622, IN00429284, IN00431347) to verify correction of previously identified deficiencies.
Complaint Details
This visit was related to the investigation of complaints IN00428410, IN00428097, IN00419622, IN00429284, and IN00431347. All complaints were found to be corrected.
Findings
The facility was found to be in compliance with relevant regulations regarding the complaints investigated, with all cited complaints corrected.
Report Facts
Residential Census: 38
Inspection Report
Follow-Up
Census: 38
Deficiencies: 0
Date: Jun 28, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to multiple complaint investigations completed previously, including complaints IN00431347, IN00428410, IN00428097, IN00419622, and IN00429284.
Complaint Details
This visit was related to multiple complaint investigations, all of which were corrected as noted: IN00431347, IN00428410, IN00428097, IN00419622, and IN00429284.
Findings
The facility was found to be in compliance with relevant regulations regarding the PSR to the Investigation of Complaint IN00431347, and all referenced complaints were corrected.
Report Facts
Residential Census: 38
Inspection Report
Follow-Up
Census: 38
Deficiencies: 0
Date: Jun 28, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to multiple prior complaint investigations completed between October 30, 2023, and April 2, 2024, to verify correction of cited deficiencies.
Complaint Details
This visit was related to the investigation of complaints IN00419622, IN00428410, IN00428097, IN00429284, and IN00431347, all of which were found to be corrected.
Findings
Bickford of Carmel was found to be in compliance with the applicable regulations regarding the prior complaint investigations, with all complaints corrected.
Report Facts
Residential Census: 38
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 0
Date: Apr 19, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00432374.
Complaint Details
Complaint IN00432374-No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR 483, Subpart B and 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 1
Date: Apr 2, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00430797, IN00431347, and IN00431545 at Bickford of Carmel.
Complaint Details
Complaint IN00430797 and IN00431545 had no deficiencies related to the allegations. Complaint IN00431347 was substantiated with state deficiencies cited related to failure to update service plans for fall and elopement safety.
Findings
The facility failed to update the service plan to reflect services provided for fall safety and elopement safety after a change in the resident's condition for 1 of 3 residents reviewed (Resident F). No deficiencies were cited for complaints IN00430797 and IN00431545, but state deficiencies related to complaint IN00431347 were cited.
Deficiencies (1)
Facility failed to update the service plan to reflect services provided for fall safety and elopement safety after a change in the resident’s condition for 1 of 3 residents reviewed (Resident F).
Report Facts
Residential Census: 36
Survey Dates: 2
Fall incidents: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Langhans | Divisional Director of Health & Operations | Signed as Laboratory Director's or Provider/Supplier Representative |
| Health and Wellness Director | Provided elopement risk list and interviewed regarding service plan updates | |
| Interim Executive Director | Interviewed regarding knowledge of Resident F's exit seeking behavior |
Inspection Report
Complaint Investigation
Census: 41
Deficiencies: 1
Date: Mar 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00429284 regarding allegations of neglect at the facility.
Complaint Details
Complaint IN00429284 was substantiated with state deficiencies cited related to neglect of Resident B with Lewy Bodies Dementia.
Findings
The facility failed to ensure a dependent resident with Lewy Bodies Dementia was free from neglect, resulting in the resident not being put to bed all night, falling, and being found stuck under her bed for an undetermined amount of time. This neglect likely caused recurrent fear and anxiety for the resident.
Deficiencies (1)
Facility failed to ensure a dependent resident with Lewy Bodies Dementia was free from neglect, resulting in the resident not being put to bed all night, falling, and being found stuck under her bed.
Report Facts
Residential Census: 41
Survey dates: March 11 and 12, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Langhans | Divisional Director of Health & Operations | Signed as Laboratory Director's or Provider/Supplier Representative's Signature |
| LPN 1 | Indicated night shift aide peeked in every two hours but did not check or change Resident B as per family request | |
| CNA 5 | Reported taking Resident B to restroom and assumed family placed resident on couch or bed; did not check on resident rest of night | |
| CNA 4 | Did not provide ADL care during night shift per family request but peeked in every two hours as per service plan | |
| CNA 7 | Found Resident B under bed between 7:00 and 7:30 a.m. on 2/21/24 | |
| LPN 8 | Assisted in lifting Resident B from under bed and assessed resident's condition |
Inspection Report
Re-Inspection
Census: 48
Deficiencies: 1
Date: Feb 19, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00419622 completed on October 30, 2023, conducted in conjunction with the Investigation of Complaints IN00428410 and IN00428097.
Complaint Details
Complaint IN00419622 was not corrected. Complaints IN00428410 and IN00428097 had state deficiencies related to the allegations cited at R0090, R0052, and R0154 respectively.
Findings
The facility failed to protect a resident with dementia and a history of exit seeking behaviors from neglect, as the resident exited the facility without staff knowledge on multiple occasions and was found outside the facility. The facility had not implemented a systemic plan of correction to prevent recurrence of this issue.
Deficiencies (1)
Facility failed to protect a resident with dementia and a history of exit seeking behaviors from neglect when the resident exited the facility without staff knowledge on 2/2/24 and 2/4/24.
Report Facts
Residential Census: 48
Survey Dates: 3
Plan of Correction Completion Date: Apr 5, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 5 | Licensed Practical Nurse | Interviewed regarding the resident elopement incident on 2/2/24 |
| LPN 6 | Licensed Practical Nurse | Interviewed regarding the resident exit on 2/4/24 |
| Director of Nursing | Director of Nursing | Interviewed about resident exit incidents and facility policies |
| Executive Director | Executive Director | Involved in redirecting resident during exit seeking behavior |
| Happiness Director | Happiness Director | Assisted in safely returning resident to room during exit seeking |
Inspection Report
Complaint Investigation
Census: 48
Deficiencies: 4
Date: Feb 15, 2024
Visit Reason
This visit was for the investigation of complaints IN00428410 and IN00428097, in conjunction with a Post Survey Revisit to complaint IN00419622.
Complaint Details
Complaint IN00428410 and IN00428097 were investigated. Complaint IN00428410 involved neglect related to resident exit-seeking behavior. Complaint IN00428097 involved failure to report incidents and sanitation issues. Complaint IN00419622 was not corrected.
Findings
The facility failed to protect a resident with dementia and exit-seeking behavior from neglect, failed to timely report an elopement and drug paraphernalia incidents, failed to complete required employee fingerprinting, and failed to maintain sanitary and good repair conditions in two kitchens.
Deficiencies (4)
Facility failed to protect a resident with dementia and exit-seeking behavior from neglect when the resident exited the facility without staff knowledge on multiple occasions.
Facility failed to timely report an elopement incident and an incident involving drug paraphernalia and unidentified white powder.
Facility failed to have an employee fingerprint completed when the Indiana State Police background check was inconclusive and fingerprinting was recommended.
Facility failed to maintain sanitary and good repair kitchens for 2 of 2 kitchens observed (Assisted Living and Memory Care Kitchens).
Report Facts
Deficiencies cited: 4
Resident census: 48
Survey dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Langhans | Divisional Director of Health & Operations | Signed the report and mentioned in interviews regarding reporting and oversight. |
| Maintenance Coordinator 4 | Employee involved in drug paraphernalia incident and had incomplete fingerprinting. | |
| LPN 5 | Licensed Practical Nurse | Interviewed regarding resident elopement incident. |
| Director of Nursing | Interviewed regarding incident reporting and facility policies. | |
| Family Advocate | Involved in drug paraphernalia incident and interviews. |
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Oct 30, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00419622 related to allegations of neglect at Bickford of Carmel.
Complaint Details
Complaint IN00419622 was substantiated with state deficiencies cited related to neglect when Resident B exited the facility without staff knowledge and was found walking outside. The resident had a history of exit-seeking behavior, cognitive impairment, and no elopement risk assessment was documented. The facility failed to ensure door alarms functioned properly and the resident removed a wander guard device.
Findings
The facility failed to protect a resident with dementia from neglect when the resident exited the facility without staff knowledge and was found walking on the city sidewalk by an off-duty staff member. The resident had cognitive impairment, exit-seeking behaviors, and no elopement risk assessment was found in the record. Door alarms did not sound during the incident, and the resident removed a wander guard device. The facility updated service plans and implemented corrective actions to address exit-seeking behaviors.
Deficiencies (1)
Facility failed to protect a resident with dementia from neglect when the resident exited the facility without staff knowledge and was found walking on the city sidewalk.
Report Facts
Residential Census: 40
Mini Mental State Examination (MMSE) score: 19
Global Deterioration Scale (GDS) level: 4
Service plan review interval: 180
15-minute checks: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Langhans | RN | Signed the inspection report |
| LPN 3 | Reported resident was found walking outside and that no alarms sounded when resident left | |
| LPN 4 | Observed resident walking on city sidewalk and convinced resident to return | |
| CNA 2 | Reported resident exited facility at lunch using door code | |
| Director of Nursing | Provided information about resident history and facility policies | |
| Corporate Support Nurse | Provided interviews and facility policy information | |
| Maintenance Staff 1 | Reported door codes had to be changed due to resident behavior |
Inspection Report
Renewal
Census: 39
Deficiencies: 6
Date: Oct 3, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on October 2 and 3, 2023.
Findings
The facility was found noncompliant in several areas including failure to update ombudsman contact information, failure to conduct monthly fire drills and involve the local fire department biannually, insufficient staff certified in First Aid and CPR on multiple shifts, multiple food safety and sanitation violations in the kitchen, failure to document annual health statements indicating residents were free of contagious disease, and failure to complete annual tuberculosis screening for residents.
Deficiencies (6)
Failure to ensure the ombudsman information posted in the facility was up to date with the correct ombudsman and contact information.
Failure to conduct monthly fire and disaster drills and failure to provide information showing local fire department participation every six months.
Failure to ensure every shift was covered with staff certified in First Aid and Cardiopulmonary Resuscitation (CPR) for 19 of 42 shifts from 9/25/23 to 10/1/23.
Failure to maintain food and nutritional services in accordance with state and local sanitation and safe food handling standards, including uncovered equipment, unlabeled and undated food items, lack of lids on trash cans, improper storage of freezer items, kitchen cabinet disrepair, improper facial hair coverings, and improper chemical storage.
Failure to document annual health statements indicating residents were free of contagious disease for 2 of 7 residents reviewed.
Failure to ensure an annual tuberculosis skin test or tuberculosis assessment had been completed on 1 of 7 residents reviewed.
Report Facts
Residential Census: 39
Shifts without certified staff: 19
Food storage audit date: Oct 4, 2023
Fire drill completion date: Oct 26, 2023
Plan of correction completion date: Nov 24, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Langhans | Divisional Director of Health & Wellness | Signed the report as the Laboratory Director's or Provider/Supplier Representative. |
| Maintenance Employee 3 | Mentioned as hired on 7/3/23 and not having conducted fire drills since hire. | |
| Director of Nursing | Interviewed regarding fire drills, First Aid/CPR certifications, and ombudsman information. | |
| Dietary Manager | Interviewed and observed regarding food safety and sanitation deficiencies. | |
| Corporate Support Nurse | Interviewed regarding annual health statements and tuberculosis screening policies. |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 0
Date: Sep 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416541.
Complaint Details
Complaint IN00416541 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations regarding the complaint.
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