Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Envive Of Beech Grove during CMS and state inspections, most recent first.
The facility failed to follow the posted lunch menu during a dining observation. A resident and family member noted that the meal served did not match the menu, as mashed potatoes were served instead of scalloped potatoes listed on the posted menu. The Administrator stated he was not aware of the discrepancy, and the facility policy required staff to check tray items against the tray ticket to ensure all necessary items were provided.
Food storage practices were not sanitary when an ED observed a gallon container of white milk in the resident snack pantry refrigerator with a grayish thick substance inside and a manufacturer use-by date that had passed, along with a pan of applesauce that was only partially covered with torn plastic wrap. The DON later provided the facility's food storage policy stating foods must be covered or wrapped tightly and may not exceed the manufacturer's use-by-date.
A resident with hemiplegia and hemiparesis had an OT order for a Kennedy cup and scoop plate during all meals, but dining observations showed the resident using a regular plate and regular cup instead, with the ordered adaptive equipment not visible or accessible. An OT note identified self-feeding goals using built-up utensils, a scoop dish with plate guard, and a Kennedy cup, while a PTA said the facility was to provide the proper feeding utensils and the DON said she was not aware of the order.
A resident with a urinary catheter was observed sitting in the dining room with the catheter drainage bag hanging from the wheelchair and touching the floor. A CNA stated the bag was not supposed to touch the floor, and the DON later provided the Catheter Care policy stating the tubing and drainage bag should be kept off the floor.
The facility failed to maintain sanitary food handling practices as the Dietary Manager was observed with uncovered facial hair while in food preparation and serving areas. This was contrary to the facility's policy and sanitation requirements, which mandate the use of hair restraints to prevent hair from contacting exposed food.
A resident with a history of cognitive impairment and potential for impaired skin integrity had a healed skin tear, yet the facility continued daily dressing changes without updating the physician's orders. The dressings lacked documentation of application dates and initials, contrary to facility policy. Despite the wound being healed, the facility did not notify the physician or update the treatment plan, as required.
A facility failed to document the drug dispositions for a resident upon discharge. The resident, with conditions including hypertension and hyperlipidemia, was discharged with medications but without a record of the number of pills provided. Interviews revealed that the facility lacked a drug disposition record, and the Director of Nursing was unsure of the medication quantities sent home. The facility did not adhere to its policy requiring documentation of medication details upon discharge.
The facility did not maintain the security of a soiled utility room, which was found unlocked with a broken lock and taped latch. The room contained barrels of trash, soiled linen, and biohazard bags, despite being marked as a restricted area. Staff acknowledged the door should have been locked, and a work order was expected for repair.
Posted Menu Not Followed at Lunch
Penalty
Summary
The facility failed to follow the posted menu prepared in advance for 1 of 1 dining observations. On 12/10/25 at 1:00 p.m., the posted menu outside the main dining room listed scalloped potatoes for lunch, but during a dining observation at 1:10 p.m., Resident 44, Resident 24, Resident 29, and Resident 42 were observed receiving mashed potatoes instead of the scalloped potatoes listed on the menu. At that time, Resident 42's family member stated the meals served to Resident 42 did not match the posted menu. During an interview on 12/19/25 at 1:00 p.m., the Administrator stated he was not aware of the discrepancy and said the posted menu should match the served meal. The Executive Director provided the facility policy titled Kitchen operations: Meal Service and Distribution, dated December 2022, which stated staff should check items on the tray against the tray ticket to assure all necessary items are provided.
Food Storage and Coverage Deficiencies
Penalty
Summary
The facility failed to ensure food was served in a sanitary manner during an observation of the resident snack pantry refrigerator. During the initial tour with the ED on 12/9/25 at 9:45 a.m., a plastic gallon container of Country Fresh white milk was observed on the refrigerator door shelf with a grayish thick substance covering the bottom of the container and similar substance adhered to the sides. The milk container also displayed a manufacturer pre-printed Use By Date of 11/30/25. Also observed in the same refrigerator was a medium-sized plastic pan on the top shelf that was approximately ten percent full of applesauce. The pan was only partially covered with loose plastic wrap that was torn in half, leaving most of the pan uncovered. During interview, the ED stated the milk should have been discarded by the use-by date and the applesauce pan should have been completely covered. The facility's Kitchen Operations: Food Storage policy stated all foods shall be covered or wrapped tightly and may not exceed the manufacturer's use-by-date.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide special eating utensils for Resident 42, who had diagnoses including hemiplegia and hemiparesis. The physician’s orders dated 11/9/25 included a regular diet with pureed texture and nectar/mildly thick fluids, and an OT clarification order dated 11/17/25 directed that the resident use a Kennedy cup and scoop plate during all meals. An OT note from December 2025 also identified a goal for the resident to safely perform self-feeding tasks with minimal assist using built-up utensils, a scoop dish with a plate guard, and a Kennedy cup. During dining observations, Resident 42 was seen eating lunch with a regular plate and regular cup instead of the ordered scoop plate and Kennedy cup, and the Kennedy cup was not visible or accessible. The same issue was observed again during another dining observation, and later the resident was again observed eating lunch without the required scoop plate. A family member stated the resident had begun using the Kennedy cup 3 days earlier. During interviews, a PTA stated the facility was to provide the proper feeding utensils, while the DON stated she was not aware of the order for the eating utensils. The facility policy stated that all residents would be provided with the proper assistive devices when consuming meals and snacks.
Catheter Drainage Bag Touched Floor
Penalty
Summary
Provide and implement an infection prevention and control program was cited after surveyors observed that infection control practices were not implemented for 1 of 1 residents with a urinary catheter. Resident 26 was observed sitting in the dining room with the catheter drainage bag hanging from the wheelchair and touching the floor from 12:10 p.m. until 12:30 p.m. During interview, CNA 2 stated the catheter drainage bag was not supposed to touch the floor. At 12:35 p.m., the Assistant Director of Nursing adjusted the drainage bag so it was no longer touching the floor. The DON later provided the facility's Catheter Care policy, dated August 2024, which stated that the catheter tubing and drainage bag should be kept off the floor.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to ensure that food was maintained and served in a sanitary and safe manner, as observed during multiple inspections. The Dietary Manager (DM) was seen in the kitchen and dining areas with multiple loose facial chin hairs that were not covered, despite being in close proximity to food preparation and serving areas. This was observed during the initial kitchen tour, a follow-up kitchen observation, and during the noon meal service, where the DM was responsible for taking and recording food temperatures. The facility's policy, as outlined in the Envive Healthcare Policies and Procedures Manual, requires that hair nets and beard restraints be worn when cooking, preparing, or assembling food to prevent hair from contacting exposed food and clean equipment. Additionally, the Retail Food Establishment Sanitation Requirements mandate that food employees wear hair restraints to effectively keep hair from contacting exposed food. Despite these policies, the DM did not adhere to the required hygiene practices, leading to the deficiency noted in the report.
Failure to Discontinue Dressing Changes After Wound Healed
Penalty
Summary
The facility failed to adhere to a physician's ordered treatment for a resident's skin tear, which was observed during a survey. The resident, who was severely cognitively impaired and had a history of anemia, generalized weakness, dementia, restless leg syndrome, tremors, and potential for impaired skin integrity, was found with a dressing on her left mid-shin that lacked documentation of when and by whom it was applied. The dressing was observed on multiple occasions without any indication of the date or initials of the person who applied it, contrary to the facility's policy. The resident's clinical records indicated that the skin tear was initially identified on 10/5/24, and a physician's order was in place for daily dressing changes until the wound healed. However, skin assessments from 11/23/24 onwards showed no impairments in skin integrity, indicating the wound had healed. Despite this, the facility continued to apply dressings daily without obtaining a revised treatment order from the physician, as required by the facility's policy. Interviews with the resident and staff, including the Director of Nursing Services (DNS), revealed that the continued application of dressings was done as a preventative measure at the request of the resident's family, but without proper documentation or physician notification. The facility's policies required that any changes in a resident's condition be promptly communicated to the physician and documented in the resident's medical record, which was not done in this case.
Failure to Document Drug Dispositions for Discharged Resident
Penalty
Summary
The facility failed to document the drug dispositions for a resident, identified as Resident 47, upon discharge. Resident 47 had a clinical record with diagnoses including hypertension, cerebral infarction, and hyperlipidemia. A physician's order summary report listed medications such as hydralazine, atorvastatin, carvedilol, and hydrochlorothiazide. The Envive Discharge Summary document was initiated in anticipation of Resident 47's discharge, indicating that current medications were to be sent home with the resident. However, the record did not specify the actual number of pills per medication to be provided upon discharge. Interviews with RN 3 and the Director of Nursing Services (DNS) revealed that Resident 47 was discharged home, but the facility lacked a drug disposition record for the medications. The DNS was unsure of the number of pills sent home or returned to the pharmacy. An undated copy of the Discharge Medications policy was provided, which stated that medications should be counted or estimated, and details such as date, name, strength, and quantity should be documented. The facility did not adhere to this policy, resulting in the deficiency.
Failure to Secure Soiled Utility Room
Penalty
Summary
The facility failed to ensure the security and proper maintenance of a soiled utility room, which was observed to be unlocked and had a malfunctioning lock. The door to the room, located between two resident rooms, was missing numerical keypads, and the door latch was taped to prevent it from locking. Inside the unlocked room, there were barrels labeled as trash, soiled linen, and biohazard bags, despite a sign indicating it was a restricted area for authorized personnel only. During interviews, both a Qualified Medication Aide and the Director of Nursing acknowledged that the door should have been locked, and there was an expectation of a work order for the repair. The facility's current policy, based on CDC Infection Control guidelines, requires a regulated medical waste management plan to ensure health and environmental safety, which was not adhered to in this instance.
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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.
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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) |
|---|---|---|---|---|
| Beech Grove Meadows | 0.5 mi | ★★★★★ | 12 | 0 |
| Brickyard Healthcare - Churchman Care Center | 0.5 mi | ★★★★★ | 9 | 0 |
| Fairway Village | 1 mi | ★★★★★ | 8 | 0 |
| Altenheim Health & Living Community | 1.5 mi | ★★★★★ | 2 | 0 |
| Waters Of Indianapolis, The | 1.7 mi | ★★★★★ | 2 | 0 |
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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.