Beech Grove Meadows

In the surveyor’s words

From the most serious findings on record at Beech Grove Meadows, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 28, 2025

  Based on observation, interview, and record review, the facility failed to provide supervision to a resident that resided on the secured memory unit and had a history of exit seeking behaviors, from exiting the facility through a window in his room. The day of the elopement the resident was angry, exit seeking, trying to leave, stated he needed out of there. (Resident B) This deficient practice resulted in an Immediate Jeopardy. The Immediate Jeopardy began on, 4/15/25 at approximately 6:20 p.m., when the facility failed to provide supervision to a cognitively impaired resident, that resided on the memory care unit, to prevent an elopement. […]

• Actual harm, isolatedF689Jun 25, 2021

  Based on interview and record review, the facility failed to ensure 2 staff provided in bed activities of daily living care for a resident assessed to require 2 person assistance, which caused a fall from the bed resulting in a fracture of the distal right thigh bone for 1 of 3 residents reviewed for accidents (Resident B). Findings include: On 6/23/21 at 1:00 p.m., Resident B's clinical record was reviewed. Diagnoses included, but not limited to: [CONDITION(S)] (paralysis of lower body), [CONDITION(S)] with right amputated toe, and [CONDITION(S)]. An Admission Minimum Data Set (MDS) Assessment, dated 6/4/21, indicated Resident B was cognitively intact. Bed mobility (turning a resident from side to side positions body while in bed) required a two person assist. […]

• No harm, potential for more than minimal, widespreadF812Mar 6, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was stored in a sanitary manner for 1 of 1 kitchen observations and 1 of 1 pantry observations. Dry food storage room and kitchen were not thoroughly cleaned and food was not labeled and dated. Findings include: 1. During the initial tour of the kitchen, on 3/6/25 from 7:11 a.m. until 7:22 a.m., observed the dry food storage room. Inside the dry food storage room the following was observed: - On the floor, under the metal shelving units, observed a buildup of dust and debris, two unopened 0.75 ounce bags of cheddar crackers and two unopened 4 ounce containers of unsweetened apple sauce. - Five - 16 ounce boxes of corn starch sitting inside a hard plastic bin with a hard plastic lid. […]

• No harm, potential for more than minimal, patternF583Feb 23, 2026

  Based on observation, interview, and record review, the facility failed to ensure clinical information was kept confidential and located in a secure location for 13 of 93 residents who reside in the facility reviewed for confidentiality of records. (Residents 9, Resident 58, Resident 62, Resident 74, Resident 76, Resident 86, Resident 96, Resident 101, Resident 103, Resident 104, Resident 105, Resident 115, Resident 116) Finding includes: On 2/17/26 at 8:20 a.m., resident documents were observed unattended and spread out face up on a low table. The table was located in front of a couch just inside the front entrance of facility between the receptionist's desk and the Executive Director's (ED) office. No staff were visible in the area at the time. […]

• No harm, potential for more than minimal, isolatedF677Mar 27, 2026

  Based on observation, interview, and record review, the facility failed to ensure a dependent resident received assistance eating for 1 of 3 residents reviewed for assistance with activities of daily living (ADL). (Resident B) Findings include:On 3/26/26 from 9:11 a.m. until 9:35 a.m., Resident B was sitting up in bed looking forward with a blank star. Resident B spoke nonsensical and repeated the same words. Sitting in front of Resident B was a meal tray on the bedside table which had been pulled up to her. The food had been uncovered and was uneaten. During the observation, Resident B never acknowledged the meal tray that had been sitting in front of her.On 3/26/26 at 9:31 a.m., CNA 1 walked into Resident B's room and asked Resident B why she hadn't eaten any of her food. […]