Beech Grove Meadows
BEECH GROVE MEADOWS in BEECH GROVE, IN — inspection on February 23, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 2/18/26 at 8:33 a.m., the Director of Nursing indicated Resident 79 did not have a self-administration of medication assessment and should have had one completed. On 2/19/26 at 8:10 a.m., the Director of Nursing provided a policy titled Self Administration of Medications, American Senior Services, with revision date of 1/2015 and indicated that the policy is currently being observed by the facility. A review of the policy indicated if a resident desires to participate in self-administration, the Interdisciplinary Team will assess the competence of the resident to participate by completing the Self-Administration of Medication Assessment observation. 3.1-11(a)
155072 02/23/2026
Beech Grove Meadows 2002 Albany St Beech Grove, IN 46107
During an interview on 2/17/26 at 8:30 a.m., the Executive Director (ED), indicated that the resident documents should not have been left out on the table. On 2/23/26 at 10:20 a.m., the ED provided a policy titled HIPAA and Privacy Compliance and Complaint Policy, dated October 2018, and indicated it was the policy currently in use by the facility.
A review of the policy indicated that the facility is required to maintain the privacy, security, and confidentiality of residents' Protected health Information (PHI) in compliance with state and federal laws and regulations and with ASC Policies.which. includes any information about health status, provision of care, or payment that can be linked to an individual. 3.1-3(o)
155072 02/23/2026
Beech Grove Meadows 2002 Albany St Beech Grove, IN 46107
reviewed, and revised by a team of health professionals.
reflect accurate code status for 2 of 22 residents reviewed for care plan accuracy. (Resident 12 and
p.m.
The diagnoses included, but were not limited to, pressure ulcers and congestive heart failure.An active physician's order, initiated 12/8/25, indicated resident's code status was DNR (Do Not Resuscitate)An Indiana Physician Orders for Scope of Treatment form, or POST form, dated 12/8/25, indicated Resident 12 had elected a DNR code status.A care plan, dated 10/20/25, regarding the resident as a new admission to the facility included an approach with a start date of 10/20/25 which stated, Honor resident wishes including discharge goal: Return to community/possibly long term care, code status: Full.A care plan, dated 12/8/25, indicated resident had a preferred code status of DNR.2.
The clinical record for Resident 60 was reviewed on 2/17/26 at 12:05 p.m.
The diagnoses included, but were not limited to, acute kidney failure and cerebral infarction (where blood flow to part of the brain is blocked or reduced, also called an ischemic stroke).An active physician's order, dated 1/23/24, indicated resident's code status was DNR.An Indiana Out of Hospital Do Not Resuscitate Declaration and Order form, was signed by the resident and witnessed on 2/15/22 and signed by the physician on 2/16/22.A care plan, dated 1/19/24 regarding the resident as a new admission to the facility included an approach with a start date of 1/19/24 which stated, Honor resident wishes including discharge goal: Remain in Long term, code status: Full.A care plan, dated 1/24/24 indicated resident had a preferred code status of DNR.
During an interview on 2/23/26 at 8:50 a.m., the Executive Director (ED) and Director of Nursing Services (DNS) indicated that Resident 12 and Resident 60's care plans indicated both a full code and a DNR code status.
Both care plans should have been revised to reflect only the current code status preferences of DNR for each of the two residents.On 2/23/26 at 8:45 a.m., the ED provided a copy of a policy titled IDT Comprehensive Care Plan Policy, and indicated it was the policy currently in use by the facility. A review of the policy indicated that, Care plan problems, goals, and interventions must be reviewed and revised by the interdisciplinary team periodically and following completion of each OBRA MDS assessment.3.1-35(d)(2)(B)
155072 02/23/2026
Beech Grove Meadows 2002 Albany St Beech Grove, IN 46107
During an interview on 2/19/26 at 2:15 p.m., LPN 2 indicated that there were no signs indicating that nursing staff should follow Enhanced Barrier Precautions but would check records to clarify if Resident 45's wound care required Enhanced Barrier Precautions. On 2/19/26 at 2:20 p.m., Resident 45's clinical record was reviewed. A wound assessment, dated 10/24/25, indicated old hardware/screw coming through the skin.
The facility lacked an order to follow Enhanced Barrier Precautions.
During an interview on 2/19/26 at 2:50 p.m., the Director of Nursing indicated that Resident 45's left ankle wound was from an old surgery, and the skin was not open therefore the Interdisciplinary Team did not feel Resident 45's wound met Enhanced Barrier Precaution criteria. On 2/19/26 at 2:50 p.m., the Administrator provided a copy of policy titled, American Senior Communities Policy Title: Enhanced Barrier Precautions (EBP), revised 3/2025 and indicated it was the current policy in use by the facility, A review of the policy indicated: Enhanced Barrier Precautions are used for: .Resident (s) with chronic wound and or indwelling medical devices regardless of their MDRO status and Resident(s) who have an infection or colonization with a CDC-targeted MDRO when contact precautions do not apply . 3.1-18(b)(1)