Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Beech Grove Meadows during CMS and state inspections, most recent first.
A resident with dementia, malnutrition, heart failure, severe cognitive impairment, swallowing difficulties, and a mechanically altered diet was observed sitting in bed with an uncovered, uneaten meal tray placed in front of her, showing no acknowledgment of the food and speaking nonsensically. Over a prolonged period, no staff assisted her with eating despite a care plan indicating she required help with ADLs, including eating. A CNA later entered, questioned why the resident had not eaten, and began to offer food, and an RN confirmed the tray should not have been left without immediate assistance.
A resident with dementia, malnutrition, heart failure, and documented swallowing difficulties, who was on a mechanically altered diet with a physician order and care plan specifying a regular diet with ground meats, was served a whole sausage patty without gravy at breakfast instead of ground meat with pork gravy as indicated on the meal ticket. A CNA and the Dietary Manager both confirmed the sausage should have been ground before service, contrary to the facility’s diet orders policy that requires diet therapy to match each resident’s medical condition and needs.
A resident with dementia, malnutrition, heart failure, and a mechanically altered diet was observed with a full, untouched breakfast tray and wrapped silverware while speaking nonsensically. Despite the lack of consumption, a CNA had already documented in the EMR that the resident had eaten 26–50% of the meal prior to entering the room. The resident’s care plan required monitoring food and fluid intake due to risk for unintentional weight loss, and facility competency materials specified documenting meal intake only after the meal was finished.
Surveyors found that resident documents containing PHI, including names, room numbers, code status, allergies, diet orders, ADL assistance needs, behavioral notes, fall and elopement risk, presence of catheters and wounds, hospice involvement, dialysis schedule, and caregiver preferences, were left unattended and face up on a low table near the main entrance with no staff present. Multiple residents’ clinical and personal details were visible in this public area, contrary to the facility’s HIPAA and privacy policy, and the ED acknowledged the documents should not have been left out.
A resident with a diagnosis including acute respiratory failure and no documented cognitive impairment was observed on multiple occasions with nasal spray and eye drops left on the over-bed table for apparent self-use, but the clinical record lacked a required self-administration of medication assessment. The DON acknowledged that no assessment had been completed, despite a facility policy stating that the IDT must assess competence and complete a Self-Administration of Medication Assessment when a resident participates in self-administration. This failure to follow policy and document the assessment resulted in a cited deficiency.
Surveyors found that care plans for two residents were not revised to accurately reflect their current DNR code status. In both cases, physician orders and state DNR/POST documents clearly indicated DNR, but the admission care plans continued to list the residents as Full Code while later care plan entries documented DNR, creating conflicting information within each plan. During interview, the ED and DNS confirmed that the care plans should have been updated to show only the current DNR status, as required by the facility’s IDT comprehensive care plan policy.
A resident with osteomyelitis of the left ankle and foot, moderate cognitive impairment, and a chronic wound with exposed surgical hardware received wound care without implementation of Enhanced Barrier Precautions (EBP). During observed care, an LPN wore gloves but no gown, and there were no signs in the room indicating EBP were required. The clinical record documented old hardware/screw coming through the skin, yet there was no order for EBP. The DON reported that the interdisciplinary team did not believe EBP criteria were met because the skin was not open, despite the facility’s policy requiring EBP for residents with chronic wounds and/or indwelling medical devices regardless of MDRO status.
A resident with dementia and a history of exit-seeking behaviors eloped from a secured memory care unit by breaking and manipulating his window hardware, exiting the building, and being found by staff walking alone near a nearby store. The resident had been persistently attempting to leave, and staff failed to provide the required supervision, resulting in the resident's unsupervised exit.
The facility failed to maintain sanitary conditions in the kitchen and pantry areas. Observations included dust and debris buildup, mouse-like droppings, and improperly stored food in the dry food storage room. In the pantry refrigerator, undated and unlabeled food items were found, including spoiled strawberries and a tipped-over cup with brown liquid. Staff were unaware of these issues, despite cleaning protocols being in place.
A facility failed to conduct a Level II PASRR evaluation for a resident who received a new diagnosis of delusional disorder. The resident was admitted with a PASRR Level I, but after the new diagnosis, no Level II evaluation was completed. The Administrator confirmed the oversight, despite the facility's policy requiring screenings for mental illness.
The facility failed to maintain a clean area around the trash dumpster, with untied trash bags and debris observed on the ground during inspections. Both the Dietary Manager and Maintenance Director confirmed that trash should be tied and placed inside the dumpster, and the area kept clean, as per the facility's policy and sanitation requirements.
Failure to Assist Dependent Resident With Eating
Penalty
Summary
The deficiency involves the facility’s failure to provide needed assistance with eating to a dependent resident. During an observation on 3/26/26 from 9:11 a.m. to 9:35 a.m., Resident B, who was sitting up in bed with a blank stare and speaking nonsensically and repetitively, had a meal tray placed in front of her on a bedside table. The food on the tray was uncovered and uneaten, and throughout the observation period Resident B did not acknowledge the meal tray. At 9:31 a.m., a CNA entered the room, questioned why Resident B had not eaten, and then picked up a spoon and offered her scrambled eggs. The CNA stated that staff should have been in the room to assist Resident B with eating. Record review showed that Resident B had diagnoses including dementia, malnutrition, and heart failure. An Annual MDS dated 12/22/26 documented that Resident B was severely cognitively impaired, had complaints of difficulty and pain with swallowing, and was on a mechanically altered diet. A care plan dated 9/24/20 and current through 6/9/26 indicated that Resident B required assistance with ADLs, including eating, related to a recent hospitalization, with interventions that included assisting with eating and drinking as needed. During an interview, an RN stated the meal tray should not have been left in front of Resident B and that the CNA should have brought the tray in, prepared the meal, and assisted her to eat immediately.
Failure to Provide Prescribed Ground Meat for Mechanically Altered Diet
Penalty
Summary
The facility failed to ensure that a resident on a mechanically altered diet received food in the prescribed form. During a breakfast meal observation, a resident with severe cognitive impairment was seen sitting up in bed with a meal tray in front of her. The meal ticket indicated she was on a regular diet with ground meat and was to receive scrambled eggs, a ground meat sausage patty with pork gravy, toast, butter, and jelly. Instead, a whole, unground sausage patty without pork gravy was present on the tray. A CNA confirmed that the sausage patty should have been ground and served with pork gravy. Record review showed the resident had diagnoses including dementia, malnutrition, and heart failure. An Annual MDS assessment documented that she was severely cognitively impaired, had complaints of difficulty and pain with swallowing, and was on a mechanically altered diet. The care plan, current through the survey period, identified risk for unintentional weight loss and included an intervention for a regular diet with ground meats and monitoring of food and fluid intake. A current physician’s order also specified a regular diet with ground meats. The Dietary Manager stated that the sausage patty should have been ground before leaving the kitchen. The facility’s Diet Orders policy indicated that the RD or designee would evaluate diet therapy according to each resident’s individual medical condition, needs, desires, and rights.
Inaccurate Pre-Meal Documentation of Resident’s Food Intake
Penalty
Summary
The deficiency involves inaccurate documentation of a resident’s meal consumption. Surveyors observed Resident B, who had diagnoses including dementia, malnutrition, and heart failure, sitting up in bed with a breakfast tray in front of her. The food items, including scrambled eggs, toast, a sausage patty, oatmeal, and orange juice, were uncovered and uneaten, and the silverware remained wrapped in the napkin. When a CNA entered the room, the CNA asked the resident why she had not eaten and then attempted to feed her, while the resident spoke nonsensically and repeated the same words. Record review showed that Resident B’s MDS documented severe cognitive impairment, complaints of difficulty and pain with swallowing, and a mechanically altered diet. A care plan identified the resident as being at risk for unintentional weight loss and directed staff to monitor food and fluid intake at meals. Despite this, the electronic medical record showed that the CNA had documented that the resident consumed 26–50% of her breakfast approximately ten minutes before entering the room and seeing that no food had been eaten. An RN confirmed that the CNA should not have documented meal consumption before checking whether the resident had actually eaten, and the facility’s skills competency for assisting to eat required documenting meal consumption after the meal is finished.
Unsecured Resident PHI Left Unattended in Public Area
Penalty
Summary
Surveyors identified a failure by the facility to maintain the privacy and security of residents’ clinical information for 13 of 93 residents reviewed. On the morning of 2/17/26, resident documents containing protected health information (PHI) were observed unattended and spread out face up on a low table near the front entrance, between the receptionist’s desk and the Executive Director’s office, with no staff present in the area. The documents were not secured and included residents’ names, room numbers, code status, allergies, diet orders, activity of daily living (ADL) assistance needs, behavioral information, fall risk status, elopement risk, presence of medical devices such as catheters and wander guards, wound presence and locations, hospice involvement, dialysis schedule, and other clinical and personal details. The exposed information included, for example, a resident with DNR status and multiple medication allergies, a resident on hospice with high fall risk and behavioral symptoms, a resident with an elopement risk and a wander guard, residents with paraplegia, catheters, wounds, and enhanced barrier precautions, and a resident with a preference for no male caregivers. Another resident’s record noted a left below-knee amputation, use of a brace, and thrice-weekly dialysis appointments. During interview, the Executive Director acknowledged that these resident documents should not have been left out on the table. Review of the facility’s HIPAA and Privacy Compliance and Complaint Policy, dated October 2018, showed the facility is required to maintain the privacy, security, and confidentiality of residents’ PHI in compliance with state and federal laws and regulations.
Failure to Complete Required Self-Administration Assessment for Bedside Medications
Penalty
Summary
Surveyors found that the facility failed to complete a required self-administration of medication assessment for a resident who had medications left at the bedside. During an initial tour, the resident was observed with a bottle of nasal spray and a bottle of Refresh eye drops on the over-bed table. Record review showed the resident had a diagnosis that included acute respiratory failure and an admission MDS indicating no cognitive impairment, but the clinical record did not contain a self-administration of medication assessment. On a subsequent observation, the same medications remained at the bedside, and in an interview the Director of Nursing confirmed that the resident did not have the required self-administration assessment despite facility policy requiring an IDT assessment and completion of a Self-Administration of Medication Assessment when a resident participates in self-administration. The facility’s written policy titled “Self Administration of Medications,” with a revision date of 1/2015 and identified by the DON as currently in use, states that if a resident desires to participate in self-administration, the Interdisciplinary Team will assess the resident’s competence by completing the Self-Administration of Medication Assessment observation. Despite this policy, the resident’s record lacked such an assessment while medications were accessible at the bedside, leading to the cited deficiency under 3.1-11(a).
Inaccurate Care Plan Documentation of Resident Code Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that comprehensive care plans were revised to accurately reflect residents’ current code status. For one resident with diagnoses including pressure ulcers and congestive heart failure, an active physician’s order and a POST form dated 12/8/25 documented a DNR (Do Not Resuscitate) status. However, the resident’s care plan created at admission on 10/20/25 contained an approach stating the resident’s code status as Full, while a later care plan dated 12/8/25 indicated a preferred code status of DNR, resulting in conflicting code status information within the care plan. For another resident with diagnoses including acute kidney failure and cerebral infarction, an active physician’s order dated 1/23/24 and an Indiana Out of Hospital DNR Declaration and Order form signed in 2022 documented a DNR status. Despite this, the admission care plan dated 1/19/24 included an approach listing the resident’s code status as Full, while a subsequent care plan dated 1/24/24 indicated a preferred DNR status. During interview, the Executive Director and DNS acknowledged that both residents’ care plans contained both Full Code and DNR designations and confirmed that the care plans should have been revised to reflect only the current DNR code status, contrary to the facility’s policy requiring periodic review and revision of care plan problems, goals, and interventions.
Failure to Implement Enhanced Barrier Precautions for Resident With Chronic Wound and Hardware
Penalty
Summary
The facility failed to implement its Enhanced Barrier Precautions (EBP) infection control practices for a resident with a chronic wound and indwelling hardware. The resident had diagnoses including osteomyelitis of the left ankle and foot and had moderate cognitive impairment. A wound assessment dated 10/24/25 documented old hardware/screw coming through the skin. During an observation of wound care on 2/19/26, an LPN gathered supplies and entered the resident’s room, where there were no indications that EBP should be followed. The LPN performed wound care to the left ankle, removing a light brown crusted covering and exposing a silver metal screw head protruding just above the skin surface, while wearing gloves but not a gown. In an interview immediately after the observation, the LPN stated there were no signs indicating that nursing staff should follow EBP and that they would check records to clarify whether EBP was required for this wound care. Review of the clinical record confirmed the presence of old hardware/screw coming through the skin, and the facility lacked an order to follow EBP for this resident. The DON indicated that the wound was from an old surgery and that, because the skin was not open, the interdisciplinary team did not feel the wound met EBP criteria. However, the facility’s current EBP policy, revised 3/2025, stated that EBP are used for residents with chronic wounds and/or indwelling medical devices regardless of MDRO status, as well as for residents with infection or colonization with a CDC-targeted MDRO when contact precautions do not apply.
Failure to Supervise Resident with Exit-Seeking Behaviors Resulting in Elopement
Penalty
Summary
A facility failed to provide adequate supervision to a resident with dementia and a known history of exit-seeking behaviors, resulting in the resident eloping from the secured memory care unit through a window in his room. The resident had been displaying persistent exit-seeking actions since admission, including packing belongings, attempting to open various doors, and expressing a strong desire to leave. On the day of the incident, the resident was observed to be angry, repeatedly trying to leave, and stating he needed to get out. Despite being identified as an elopement risk and assigned a security bracelet, the resident was able to manipulate and break the window hardware in his room, lay the window flat, and exit the building. Staff last observed the resident heading to his room after dinner, and he was later found by the ADON walking alone near a store approximately 100 yards from the facility. The nurse assigned to the unit was not present at the time, and the incident was not discovered until the resident was returned to the facility. The resident's clinical record documented multiple instances of exit-seeking and agitation, including attempts to leave and statements about not wanting to stay. The facility's policy required staff to know the location of residents under their care, but this was not followed, resulting in the resident's unsupervised exit from the secured unit.
Removal Plan
- audits of elopement evaluations and care plans
- inservicing staff on elopement procedures
- ongoing monitoring
Sanitation Deficiencies in Kitchen and Pantry Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and pantry areas, as observed during a survey. In the dry food storage room, there was a buildup of dust and debris under metal shelving units, and food items such as cheddar crackers and apple sauce were found on the floor. Mouse-like droppings were observed on a plastic bin containing corn starch and on a plastic-wrapped bag of brown powder, which had been chewed through, resulting in powder spillage. Additionally, droppings were found on a board along the wall. The kitchen area also had a buildup of dust and debris under preparation tables and warming tables. Dietary staff indicated that cleaning was supposed to occur at the beginning and end of each shift, but they were unaware of the droppings and debris present. In the unit pantry refrigerator, unsanitary conditions were also noted. A dried brown substance covered the bottom door shelf and the bottom of the refrigerator. An undated and unlabeled plastic cup with brown liquid was tipped over, and a glass container with slimy, discolored strawberries was found. A styrofoam container with undated and unlabeled food items was also present. An RN confirmed that all items should have been dated and labeled with the resident's name. The facility's policy on food storage, which was provided by the Administrator, indicated that food should be stored to prevent contamination, but this was not adhered to in practice.
Failure to Conduct Level II PASRR Evaluation for New Mental Illness Diagnosis
Penalty
Summary
The facility failed to ensure that a resident was referred for a Level II Preadmission Screening and Resident Review (PASRR) evaluation following a new diagnosis of mental illness. Resident 65, who was admitted to the facility with a PASRR Level I completed, received a new diagnosis of delusional disorder on 10/15/24. However, the facility did not conduct a new Level II PASRR evaluation for this diagnosis. A review of the resident's clinical record on 1/16/25 confirmed the absence of the required evaluation. During an interview, the Administrator acknowledged that the evaluation had not been completed. The facility's policy, which was provided by the Administrator, indicated that screenings should be conducted to identify residents with mental illness, but this was not adhered to in this case.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain a clean and debris-free area around the trash dumpster container, as observed during two separate inspections. During an initial tour with the Dietary Manager, three large untied trash bags filled with soiled briefs and other debris were found on the ground next to the dumpster. Additionally, multiple used plastic gloves and other debris were scattered around the area. The Dietary Manager confirmed that all trash bags should be tied and placed inside the dumpster, and the surrounding area should be kept clean. A follow-up observation with the Maintenance Director revealed similar issues, with multiple used plastic gloves and other debris still present on the ground near the dumpster. The Maintenance Director also acknowledged that all trash should be placed inside the dumpster and the area kept free of debris. The facility's Trash Removal policy, dated April 2018, was reviewed and indicated that trash should always be disposed of in the container outside, and any unsightly areas should be cleaned or reported to a supervisor. The facility's practices were found to be inconsistent with the Retail Food Establishment Sanitation Requirements, which mandate that receptacles and waste handling units be kept covered and free of debris accumulation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 890 citations issued within 25 miles in the last 12 months — including the 9 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Beech Grove
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Envive Of Beech Grove | 0.5 mi | ★★★★★ | 5 | 0 |
| Brickyard Healthcare - Churchman Care Center | 0.6 mi | ★★★★★ | 9 | 0 |
| Fairway Village | 1 mi | ★★★★★ | 8 | 0 |
| Altenheim Health & Living Community | 1 mi | ★★★★★ | 2 | 0 |
| Waters Of Indianapolis, The | 1.3 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Beech Grove Meadows.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.