Inspection Report
Annual Inspection
Census: 58
Deficiencies: 8
Mar 13, 2025
Visit Reason
This visit was for a State Residential Licensure Survey conducted on March 12 and 13, 2025.
Findings
The facility was found noncompliant in several areas including residents' rights, administration and management, sanitation and safety standards, health services, food and nutritional services, and clinical records. Deficiencies included failure to have survey results readily available, incomplete fire drills, missing HVAC inspection, outdated pet vaccinations, medication errors, improper food preparation and holding temperatures, and incomplete emergency binder information.
Deficiencies (8)
| Description |
|---|
| Failed to ensure the most recent annual survey results were readily available for review. |
| Failed to ensure fire drills were completed on each shift quarterly as required. |
| Failed to ensure the HVAC system was inspected annually. |
| Failed to ensure pets were up to date on vaccinations for 1 of 4 pet vaccination records reviewed. |
| Failed to ensure Physician Orders were followed during medication pass for 1 of 5 residents observed, including blood pressure medication given outside parameters and not documenting insulin amounts. |
| Failed to ensure modified diets were prepared properly according to the recipe and were the proper consistency. |
| Failed to maintain proper food sanitation related to low food holding temperature. |
| Failed to ensure the resident Emergency Binder contained all necessary information for 3 of 5 residents reviewed. |
Report Facts
Residents potentially affected: 58
Residents affected by medication offense: 3
Residents affected by puree diet deficiency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beth Tengerstrom | Executive Director | Named in relation to responsibility for ensuring compliance and corrective actions. |
| QMA 1 | Observed preparing medications and involved in medication errors. | |
| Director of Nursing | Interviewed regarding fire drills, HVAC inspection, medication administration, and emergency binder deficiencies. | |
| Maintenance Director | Interviewed regarding fire drills and HVAC inspection. | |
| Administrative Assistant | Interviewed regarding pet vaccination records. | |
| Health and Wellness Director | Responsible for auditing medication orders, emergency binder, and corrective actions. | |
| Cook 1 | Observed taking food temperatures and involved in food sanitation deficiency. | |
| Server 1 | Observed preparing puree modified diet and involved in food preparation deficiency. |
Inspection Report
Complaint Investigation
Census: 58
Deficiencies: 0
Sep 11, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441128.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Complaint Details
Complaint IN00441128 was investigated and found to have no deficiencies related to the allegations.
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Jun 20, 2024
Visit Reason
This visit was conducted for the investigation of complaint IN00432249 regarding potential theft and misappropriation of resident property.
Findings
No deficiencies related to the complaint allegations were cited; however, an unrelated deficiency was found where the facility failed to protect a resident's privacy related to staff going through the resident's belongings without permission.
Complaint Details
Complaint IN00432249 involved a potential theft of money from a resident's purse observed on video by the resident's family. The CNA involved denied knowledge and resigned. The resident's family filed a police report and charges were pressed against the CNA for conversion and exploitation of an endangered adult. The Health and Wellness Director was unable to confirm if money was actually taken due to lack of verification of the amount prior to the incident.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure a resident's privacy was protected related to staff going through a resident's belongings without permission for 1 of 1 residents reviewed for misappropriation or property. |
Report Facts
Residential Census: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in the complaint and investigation related to alleged theft and privacy violation; resigned from position. |
| Health and Wellness Director | Interviewed during investigation, reviewed video evidence, and involved in corrective actions. | |
| Executive Director | Involved in corrective actions and staff re-education. | |
| Divisional Director of Operations | Responsible for reviewing state reportable incidents and ensuring compliance. | |
| Health and Wellness Coordinator | Participates in random observations of CNAs providing care. |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 10
Feb 27, 2024
Visit Reason
This visit was for a State Residential Licensure Survey and included the Investigation of Complaint IN00425516.
Findings
No deficiencies were cited related to the complaint allegations. Multiple deficiencies were found including failure to have a current Alzheimer's/Dementia Special Care Unit disclosure form, expired employee license, missing resident weights on admission, unsigned service plans, lack of authorization for PRN medication administration by QMAs, improper preparation of modified diets, poor food sanitation, unsecured medications in a dementia unit resident's room, incomplete clinical records related to fall follow-up, and missing annual health statements for some residents.
Complaint Details
Complaint IN00425516 was investigated with no deficiencies related to the allegations cited.
Deficiencies (10)
| Description |
|---|
| Failed to have a current Alzheimer's/Dementia Special Care Unit disclosure form. |
| Failed to ensure an employee had an active license/certification; QMA license expired. |
| Failed to record weights upon admission for 2 of 7 residents reviewed. |
| Failed to ensure the Service Plan was signed by the resident and/or responsible party for 1 of 7 records reviewed. |
| Failed to ensure qualified medication aides received authorization from a licensed nurse or physician prior to giving PRN medications for 4 of 7 records reviewed. |
| Failed to ensure modified diets were prepared properly according to the recipe; puree diet was too thin. |
| Failed to maintain proper food sanitation related to hairnets and beard guards not worn, unlabeled and undated food and drinks, dirty refrigerators and freezers, dirty floors, and debris on shelves. |
| Failed to ensure medications were secured in a resident's room in the dementia unit. |
| Failed to maintain clinical records that were complete and accurately documented related to follow-up documentation after a fall for 1 of 2 residents reviewed. |
| Failed to ensure residents had an annual signed health statement for 3 of 7 residents reviewed. |
Report Facts
Residents affected by census: 57
Dates of survey: 2
Number of residents reviewed for weights: 7
Residents with missing admission weights: 2
Residents reviewed for service plan signatures: 7
Residents with unsigned service plans: 1
Residents reviewed for PRN medication authorization: 7
Residents with PRN medication authorization issues: 4
Residents reviewed for annual health statements: 7
Residents missing annual health statements: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jillian Sell | Executive Director | Named as facility representative and responsible for corrective actions |
| QMA 4 | Employee with expired license who worked while unlicensed | |
| Director of Nursing | DON | Interviewed regarding PRN medication authorization and other deficiencies |
| Registered Nurse Coordinator | RN Coordinator | Interviewed regarding missing weights, PRN medication authorization, and clinical records |
| Kitchen Manager | Interviewed regarding food preparation and sanitation deficiencies | |
| Health and Wellness Director | Responsible for audits and corrective actions related to medication, service plans, and health statements | |
| Divisional Director of Operations | Responsible for re-education and monitoring corrective actions |
Inspection Report
Complaint Investigation
Census: 57
Deficiencies: 0
Oct 4, 2023
Visit Reason
This visit was conducted to investigate complaints IN00416924 and IN00418435 at the facility.
Findings
No deficiencies related to the allegations in complaints IN00416924 and IN00418435 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaints IN00416924 and IN00418435 found no deficiencies related to the allegations; facility was in compliance.
Inspection Report
Follow-Up
Census: 54
Deficiencies: 0
Aug 25, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00410515 completed on July 5, 2023.
Findings
Bickford of Crown Point was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to the Investigation of Complaint IN00410515.
Complaint Details
Complaint IN00410515 - Corrected
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Jul 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410515 regarding allegations of resident safety related to elopement.
Findings
The facility failed to implement effective supervision of a resident with known exit-seeking behaviors, resulting in two elopements from the facility without staff awareness. The resident left the facility on two separate occasions in a busy traffic area, once found by police and once by a former neighbor. There was no documentation of door alarms sounding or increased monitoring after the elopements, and the facility did not document proper functioning or monitoring of the Wander Guard system.
Complaint Details
Complaint IN00410515 was substantiated with a state deficiency cited at R0052 related to resident rights offense involving elopement and inadequate supervision.
Deficiencies (1)
| Description |
|---|
| Failed to implement effective supervision of a resident with known exit-seeking behaviors resulting in elopements. |
Report Facts
Residential Census: 50
Number of missing resident drills to be held: 3
Number of residents affected: 1
Potential residents affected: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jillian Sell | Executive Director | Signed the report and involved in administrative oversight |
Inspection Report
Re-Inspection
Census: 58
Deficiencies: 1
Sep 8, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00381025 completed on 7/14/22, which resulted in unrelated deficiencies cited.
Findings
The facility failed to ensure adequate provision of medical care related to residents who had fallen being assessed by QMAs instead of Licensed Medical Professionals, with no follow-up assessments by licensed staff for 3 of 4 residents reviewed. The facility did not implement a systemic plan of correction to prevent recurrence of this deficiency.
Complaint Details
This was a Post Survey Revisit related to Complaint IN00381025. The deficiency cited was unrelated to the original complaint. The facility failed to ensure licensed medical assessments after resident falls as required.
Deficiencies (1)
| Description |
|---|
| Administrator failed to ensure adequate provision of medical care related to residents who had fallen being assessed by QMAs and not by a Licensed Medical Person, and no follow-up assessment by licensed staff for 3 of 4 residents reviewed. |
Report Facts
Residential Census: 58
Deficiency cited: 1
Residents reviewed: 4
Residents harmed: 2
Completion date for corrective actions: Oct 7, 2022
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