Inspection Reports for Bickford of Greenwood
3021 Stella St, Greenwood, IN 46143, United States, IN, 46143
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 3, 2025, found Bickford of Greenwood to be in compliance with no deficiencies cited. Earlier inspections showed a pattern of deficiencies related primarily to medication administration, resident neglect, and staff-to-resident abuse, including a substantiated complaint in May 2025 where a resident was hospitalized due to missed medications. Prior reports also noted issues with supervision during outings, failure to protect residents from neglect, and lapses in staff certification and documentation. Several complaint investigations were substantiated, particularly those involving medication errors and abuse, while most other complaints were unsubstantiated or corrected upon revisit. The facility appears to have addressed recent deficiencies as indicated by the clean result in the latest inspection, suggesting some improvement over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
26% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
44 residents
Based on a June 2025 inspection.
Occupancy over time
Inspection Report
Re-Inspection
Census: 44
Deficiencies: 0
Date: Jun 3, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00458539 completed on May 1, 2025.
Complaint Details
Complaint IN00458539 was investigated and found to be corrected.
Findings
Bickford Of Greenwood was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00458539.
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Date: May 1, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00458539 and was conducted in conjunction with a Post Survey Revisit to the State Residential Licensure Survey completed on March 11, 2025.
Complaint Details
Complaint IN00458539 was substantiated with a state deficiency cited at R241 related to medication administration resulting in resident hospitalization.
Findings
The facility failed to ensure that a resident (Resident B) received physician-prescribed medications, resulting in hospitalization due to medication omission over four days. The family provided a pill organizer but not the original medication bottles, and facility staff did not administer medications not in original containers nor contact the family further, leading to Resident B's hospitalization for dehydration and abnormal labs.
Deficiencies (1)
Facility failed to ensure that a resident received physician prescribed medications which resulted in resident requiring hospitalization for 1 of 2 residents reviewed for medication administration.
Report Facts
Days medication not received: 4
Resident census: 43
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Provided policy titled Policy and Procedures Category: Medication and Nursing and gave information about facility practices. | |
| Health and Wellness Director | Responsible for medication audits, training nurses and QMA’s, and overseeing corrective actions. |
Inspection Report
Follow-Up
Census: 43
Deficiencies: 0
Date: May 1, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the State Residential Licensure Survey completed on March 11, 2025, conducted in conjunction with the Investigation of Complaint IN00458539.
Complaint Details
Complaint IN00458539 - State deficiencies related to the allegations are cited at R241.
Findings
Bickford of Greenwood was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to the State Residential Licensure Survey.
Report Facts
Residential Census: 43
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 4
Date: Mar 11, 2025
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00450622 and IN00453793.
Complaint Details
Complaint IN00450622 and Complaint IN00453793 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies were cited related to the complaints investigated. However, deficiencies were found related to failure to notify physician of changes in condition, failure to protect resident from neglect related to elopement, failure to ensure First Aid certification coverage on all shifts, and failure to document annual health statements for residents.
Deficiencies (4)
Facility failed to notify the physician of changes in condition for 1 of 3 residents reviewed (Resident 20).
Facility failed to protect the resident's right to be free from neglect for 1 of 1 residents reviewed for elopement (Resident 26).
Facility failed to ensure all shifts had at least one staff member who was First Aid certified for 1 of 21 shifts reviewed (CNA 2 on 3/9/25 third shift).
Facility failed to ensure that annual health statements were documented for 7 of 7 residents reviewed (Residents 3, 18, 20, 26, 43, 44, 45).
Report Facts
Residents present: 40
Deficiency completion dates: Apr 30, 2025
Blood glucose result: 489
Number of shifts reviewed for First Aid certification: 21
Number of residents reviewed for annual health statements: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Langhans | Administrator | Signed the report |
| CNA 2 | Worked third shift on 3/9/25 and was identified as certified First Aid staff member, but certification could not be verified | |
| CNA 3 | Indicated staff were to keep facility pagers on person to monitor exit doors | |
| CNA 4 | Staff member working during Resident 26 elopement without pager | |
| CNA 5 | Staff member working during Resident 26 elopement without pager | |
| Director of Nursing | DON | Interviewed regarding physician notification and elopement incident |
| Executive Director | Provided policies and information about elopement and staff pager issues |
Inspection Report
Follow-Up
Census: 44
Deficiencies: 0
Date: Sep 30, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00438988 completed on August 9, 2024.
Complaint Details
Complaint IN00438988 was investigated and found to be corrected.
Findings
Bickford of Greenwood was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00438988.
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 3
Date: Aug 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00438988 regarding allegations of staff-to-resident abuse at the facility.
Complaint Details
Complaint IN00438988 was substantiated with state deficiencies cited related to staff-to-resident abuse by QMA 1 against Residents B and C. The abuse included yelling, physical grabbing, pushing, and intimidation. The facility failed to report the abuse timely to the Administrator and the State department of health.
Findings
The facility failed to ensure cognitively-impaired residents on the Memory Care Unit were free from staff-to-resident abuse by QMA 1, who was verbally and physically abusive to Residents B and C. The facility also failed to immediately report the abuse allegations to the Administrator and failed to notify the State department of health timely. QMA 1 was suspended and terminated. The Executive Director and Health and Wellness Director will be re-educated on resident rights and abuse reporting policies.
Deficiencies (3)
Failed to ensure cognitively-impaired residents on the Memory Care Unit were free from staff-to-resident abuse.
Failed to immediately report allegations of abuse to the Administrator for 2 of 3 residents reviewed.
Failed to notify the State department of health within 24 hours of becoming aware of an allegation of resident abuse.
Report Facts
Residential Census: 43
Residents potentially affected: 13
Completion date for corrective actions: Sep 20, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Julie Madison | Executive Director | Named as the Executive Director responsible for facility oversight and re-education on resident rights |
Inspection Report
Complaint Investigation
Census: 38
Deficiencies: 0
Date: Jul 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437358.
Complaint Details
Complaint IN00437358 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00437358 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint.
Inspection Report
Re-Inspection
Census: 38
Deficiencies: 0
Date: Apr 25, 2024
Visit Reason
This visit was for a Post Survey Revisit (PSR) to the State Residential Licensure Survey completed on March 6, 2024.
Findings
Bickford of Greenwood was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to the State Residential Licensure Survey.
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 8
Date: Mar 6, 2024
Visit Reason
This visit was for a State Residential Licensure Survey which included the investigation of Complaint IN00429658.
Complaint Details
Complaint IN00429658 was investigated and no deficiencies related to the allegations were cited.
Findings
The facility was found noncompliant in several areas including accessibility of previous survey results, failure to conduct monthly fire drills for 3 of 12 months, incomplete personnel records and missing reference inquiries for 2 employees, lack of CPR and First Aid certified staff on 5 of 21 shifts, missing tuberculosis skin test documentation for 1 employee, unsecured hazardous materials accessible to residents, failure to ensure pets had current rabies vaccinations and veterinary exams, and unsigned service plans for 2 of 7 clinical records reviewed.
Deficiencies (8)
The facility failed to ensure the previous survey results and corresponding plan of correction data were readily accessible for 1 of 3 days of the survey.
The facility failed to ensure monthly fire drills were conducted for 3 of 12 calendar months reviewed.
The facility failed to maintain accurate personnel records and reference inquiries for 2 of 5 employee records reviewed.
The facility failed to ensure all shifts had at least one staff member working who was CPR and First Aid certified for 5 of 21 shifts reviewed.
The facility failed to provide documentation for an employee's tuberculosis (TB) skin test for 1 of 5 employees reviewed.
The facility failed to ensure potentially hazardous materials were kept secure and behind locked doors to prevent resident's access to the materials.
The facility failed to ensure pets who resided in the facility had received the rabies vaccinations prior to its end date and that annual veterinary examinations were completed for 2 of 2 residents who housed pets in the facility.
The facility failed to ensure service plans were signed and dated by the resident for 2 of 7 clinical record reviews.
Report Facts
Survey dates: 3
Residential Census: 37
Months lacking fire drills: 3
Shifts lacking CPR/First Aid certified staff: 5
Employees with missing reference inquiries: 2
Employees missing TB documentation: 1
Pets without current vaccination records: 2
Clinical records with unsigned service plans: 2
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 0
Date: Jan 18, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00422071, IN00425112, and IN00425928.
Complaint Details
Complaints IN00422071, IN00425112, and IN00425928 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation of these complaints.
Report Facts
Residential Census: 36
Inspection Report
Complaint Investigation
Census: 35
Deficiencies: 1
Date: Sep 21, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00417176 regarding allegations related to resident neglect.
Complaint Details
Complaint IN00417176 was substantiated with state deficiencies cited related to neglect of a resident who exited a secured unit unnoticed.
Findings
The facility failed to protect the right of a cognitively impaired resident to be free from neglect when the resident exited a secured unit without staff knowledge. The alarm system was found to be inadequate, and staff pagers were on vibrate, preventing timely alerts.
Deficiencies (1)
Facility failed to protect the resident's right to be free from neglect for 1 of 3 residents reviewed; a cognitively impaired resident exited a secured unit without staff knowledge.
Report Facts
Residential Census: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Langhans | Divisional Director of Health & Wellness | Signed the report and involved in the investigation |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 1
Date: Sep 5, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00416173 regarding pharmaceutical services at the facility.
Complaint Details
Complaint IN00416173 was investigated and state deficiencies related to the allegations were cited at R0297.
Findings
The facility failed to ensure prescribed medications were available for a resident (Resident B) after transferring from another facility, specifically missing insulin and Clonazepam. The facility lacked signed prescriptions from the physician, delaying medication administration.
Deficiencies (1)
Facility failed to ensure prescribed medications were available for a resident after transferring from another facility.
Report Facts
Resident census: 32
Medication dosage: 0.05
Medication administration dates: 6
Completion date for corrective actions: Oct 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Langhans | Divisional Director of Health & Wellness | Signed the report and involved in oversight |
Inspection Report
Renewal
Census: 33
Deficiencies: 2
Date: Apr 19, 2023
Visit Reason
This visit was for a State Residential Licensure Survey conducted on April 17, 18, and 19, 2023.
Findings
The facility failed to conduct the required 12 fire drills in the calendar year, completing only 7 drills. Additionally, the facility failed to maintain current and accurate personnel records for 2 of 5 employee records reviewed.
Deficiencies (2)
Failed to ensure 12 fire drills were conducted in the calendar year for 6 of 12 months reviewed.
Failed to maintain current and accurate personnel records for 2 of 5 employee records reviewed (Maintenance Coordinator 2 and Wellness Nurse 3).
Report Facts
Fire drills conducted: 7
Employee records reviewed: 5
Employee records missing: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keith Wilson | Executive Director | Signed the report. |
| Divisional Director of Operations | Provided documentation and interviews related to fire drills and personnel records. | |
| Maintenance Coordinator 2 | Maintenance Coordinator | Employee record missing during review. |
| Wellness Nurse 3 | Wellness Nurse | Employee record missing during review. |
Inspection Report
Follow-Up
Census: 38
Deficiencies: 0
Date: Feb 28, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00398786 completed on January 10, 2023.
Complaint Details
Complaint IN00398786 was corrected.
Findings
Bickford of Greenwood was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00398786.
Inspection Report
Complaint Investigation
Census: 40
Deficiencies: 1
Date: Jan 10, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00398786, which was substantiated with state deficiencies related to the allegations cited.
Complaint Details
Complaint IN00398786 was substantiated. The facility failed to ensure proper supervision of residents during an outing, leading to Resident B being left behind and taken to a hospital.
Findings
The facility neglected to ensure residents were supervised for 1 of 3 residents reviewed. Resident B went on a facility outing and was not properly accounted for, resulting in the resident being taken to a local hospital. The facility lacked a policy related to resident outings.
Deficiencies (1)
Facility neglected to ensure residents were supervised during an outing, resulting in Resident B not returning with the group and being taken to a hospital.
Report Facts
Residential Census: 40
Residents reviewed: 3
Residents on outing: 7
Systemic changes completion date: Feb 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Langhans | Divisional Director of Health & Wellness | Signed the report and provided training on resident supervision during outings |
Inspection Report
Complaint Investigation
Census: 51
Deficiencies: 0
Date: Sep 23, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00388589 and IN00390069.
Complaint Details
Complaint IN00388589 - Substantiated with no deficiencies cited. Complaint IN00390069 - Unsubstantiated due to lack of evidence.
Findings
Complaint IN00388589 was substantiated but no deficiencies related to allegations were cited. Complaint IN00390069 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations regarding these complaints.
Report Facts
Residential Census: 51
Inspection Report
Follow-Up
Census: 48
Deficiencies: 0
Date: Aug 23, 2022
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00384922 completed July 13, 2022.
Complaint Details
Complaint IN00384922 was corrected.
Findings
Bickford of Greenwood was found to be in compliance with 410 IAC 16.2-5 in regard to the PSR to Investigation of Complaint IN00384922.
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