Beech Grove, IN

Beech Grove Meadows

4-star overall rating with 3-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

2002 Albany St, Beech Grove, IN

(317) 783-2911

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

118

Certified beds

Average residents

90

Average occupied residents

Ownership

Government

Publicly displayed owner type

Chain

American Senior Communities

Operator or chain grouping

Approved since

1968-04-29

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

91 facilities

Chain averages 4 overall / 3 health / 2 staffing / 5 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.39

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.93

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.22

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.54

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.32

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

3.11

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.25

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.36

CMS adjusted RN staffing hours

Adjusted total hours

3.35

CMS adjusted total nurse staffing hours

Case-mix index

1.45

Higher values indicate more complex resident acuity

RN turnover

22%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

36%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,111

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

8.30

Composite VBP score used to determine payment impact.

Payment multiplier

0.9807

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 20.70% · Performance 25.45% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

0

Baseline 6.96% · Performance 11.90% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

2.45

Baseline 58.75% · Performance 53.66% · Measure score 2.45 · Achievement 2.45 · Improvement 1

Adjusted total nurse staffing

0.87

Baseline 2.81 hours · Performance 3.21 hours · Measure score 0.87 · Achievement 0 · Improvement 0.87

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	13.03%	10.72% 2.3 pts worse	No Different than the National Rate · Eligible stays 101 · Observed rate 19.8% · Lower 95% interval 9.34%
Discharge to community	45.94%	50.57% 4.6 pts worse	No Different than the National Rate · Eligible stays 105 · Observed rate 36.19% · Lower 95% interval 35.02%
Medicare spending per beneficiary	1.13	1.02 0.1 pts worse
Drug regimen review with follow-up	94.81%	95.27% 0.5 pts worse	Numerator 73 · Denominator 77
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 77
Discharge self-care score	52.73%	53.69% 1 pts worse	Numerator 29 · Denominator 55
Discharge mobility score	49.09%	50.94% 1.8 pts worse	Numerator 27 · Denominator 55
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 76 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	11.9%	7.12% 4.8 pts worse	Worse than the National Rate · Eligible stays 72 · Observed rate 20.83% · Lower 95% interval 7.63%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 110
Staff flu vaccination coverage	33.59%	42% 8.4 pts worse	Numerator 43 · Denominator 128
Discharge function score	58.18%	56.45% 1.7 pts better	Numerator 32 · Denominator 55
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 34 · Denominator 34
Transfer of health information to patient	96.3%	96.28% About the same	Numerator 26 · Denominator 27
Resident COVID-19 vaccinations up to date	15.63%	25.2% 9.6 pts worse	Numerator 5 · Denominator 32

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.7	1.6 0.9 pts better	1.9 1.2 pts better	Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 1.2 · Expected 3.0 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	0.6	1.5 0.9 pts better	1.8 1.2 pts better	Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.8 · Expected 2.1 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	94.5%	93.6% 0.9 pts better	93.4% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 92.5% · Q2 98.6% · Q3 93.4% · Q4 93.6% · 4Q avg 94.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.4% 4.6 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.7%	3.8% 3.1 pts better	3.3% 2.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 1.3% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	12.9%	24.6% 11.7 pts better	11.4% 1.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 11.8% · Q3 6.9% · Q4 14.7% · 4Q avg 12.9%
Percentage of long-stay residents who lose too much weight	5.4%	5.6% 0.2 pts better	5.4% About the same	Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 4.9% · Q3 5.7% · Q4 1.5% · 4Q avg 5.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	14.5%	23.5% 9 pts better	19.6% 5.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 16.1% · Q3 12.9% · Q4 16.2% · 4Q avg 14.5%
Percentage of long-stay residents who received an antipsychotic medication	6.6%	14.8% 8.2 pts better	16.7% 10.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 8.9% · Q3 2.1% · Q4 8.3% · 4Q avg 6.6% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	4.7%	13.3% 8.6 pts better	16.3% 11.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 7.2% · Q3 2.9% · Q4 4.4% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	4.0%	11.7% 7.7 pts better	14.9% 10.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 6.8% · Q3 3.0% · Q4 0.0% · 4Q avg 4.0% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.4% 0.4 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.3%	1.2% 0.9 pts better	1.7% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	23.4%	24.2% 0.8 pts better	19.8% 3.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 35.5% · Q2 24.6% · Q3 9.8% · Q4 25.0% · 4Q avg 23.4%
Percentage of long-stay residents with pressure ulcers	2.6%	4.1% 1.5 pts better	5.1% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.8% · Q3 2.6% · Q4 2.4% · 4Q avg 2.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	91.9%	81.6% 10.3 pts better	81.7% 10.2 pts better	Short Stay · 2024Q4-2025Q3 · Q1 89.7% · Q2 89.1% · Q3 94.9% · Q4 94.9% · 4Q avg 91.9%
Percentage of short-stay residents who had an outpatient emergency department visit	12.7%	10.5% 2.2 pts worse	12.0% 0.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 13.7% · Expected 12.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.8%	1.3% 0.5 pts better	1.6% 0.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.1%	79.0% 14.1 pts better	79.7% 13.4 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 93.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.4%	22.4% 1 pts better	23.9% 2.5 pts better	Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 23.5% · Expected 26.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-22 · Fire 2025-01-22

4 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2024-02-26 · Fire 2024-02-26

2 health deficiencies

Top issue: Nursing and Physician Services (1 deficiency)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2023-03-31 · Fire 2023-03-31

0 health deficiencies

No concentrated health issue counts in this cycle.

6 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-01-22

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2025-02-21

E · Potential for more than minimal harm 2025-01-22

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-02-21

E · Potential for more than minimal harm 2025-01-22

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2025-02-21

E · Potential for more than minimal harm 2025-01-22

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2025-02-21

D · Potential for more than minimal harm 2025-01-22

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2025-02-21

F · Potential for more than minimal harm 2024-02-26

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2024-03-27

F · Potential for more than minimal harm 2024-02-26

K300 · Egress Deficiencies

Fire Safety

Meet other general requirements that are deficient.

Corrected 2024-03-27

E · Potential for more than minimal harm 2024-02-26

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-03-27

F · Potential for more than minimal harm 2023-03-31

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2023-07-10

F · Potential for more than minimal harm 2023-03-31

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-07-11

F · Potential for more than minimal harm 2023-03-31

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2023-07-10

E · Potential for more than minimal harm 2023-03-31

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-07-10

E · Potential for more than minimal harm 2023-03-31

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-07-10

E · Potential for more than minimal harm 2023-03-31

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2023-07-10

Inspection history

Recent health citations

J · Immediate jeopardy 2025-04-28

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-04-16

F · Potential for more than minimal harm 2025-03-06

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-03-12

D · Potential for more than minimal harm 2025-01-22

F644 · Resident Assessment and Care Planning Deficiencies

Health

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Corrected 2025-01-24

C · Minimal harm 2025-01-22

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2025-01-24

D · Potential for more than minimal harm 2024-02-26

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-03-19

C · Minimal harm 2024-02-26

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2024-03-19

Penalties and ownership

What sits behind the stars

Ownership

The Health And Hospital Corporation Of Marion County

5% Or Greater Direct Ownership Interest · Organization

100% 70 facilities 2003-01-01

American Senior Communities LLC

Operational/Managerial Control · Organization

0% 89 facilities 2003-01-01

Babcock, Paul

Corporate Officer · Individual

0% 72 facilities 2020-09-30

Caine, Virginia

Corporate Officer · Individual

0% 52 facilities 1994-01-10

Dice, Mark

Contracted Managing Employee · Individual

0% 64 facilities 2023-06-01

Drummer, Carl