Cycle 1
Health 2024-12-18 · Fire 2024-12-18
4 health deficiencies
Top issue: Environmental (1 deficiency)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Beech Grove, IN
Envive Of Beech Grove
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
501 N 17th Ave, Beech Grove, IN
(317) 786-2261
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
52
Certified beds
Average residents
48
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Envive Healthcare
Operator or chain grouping
Approved since
2022-10-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 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
0.55
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.81
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.51
CMS adjusted RN staffing hours
Adjusted total hours
3.03
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,685
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9830
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.75
Performance 19.69% · Measure score 3.75 · Achievement 3.75 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
1.09
Performance 7.51% · Measure score 1.09 · Achievement 1.09 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
2.03
Performance 3.65 hours · Measure score 2.03 · Achievement 2.03 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.03% |
10.72%
0.7 pts better
|
No Different than the National Rate · Eligible stays 40 · Observed rate 5% · Lower 95% interval 6.16% |
| Discharge to community | 39.73% |
50.57%
10.8 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 31.43% · Lower 95% interval 26.81% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.77% |
95.27%
1.5 pts better
|
Numerator 30 · Denominator 31 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 31 |
| Discharge self-care score | 62.5% |
53.69%
8.8 pts better
|
Numerator 15 · Denominator 24 |
| Discharge mobility score | 70.83% |
50.94%
19.9 pts better
|
Numerator 17 · Denominator 24 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 31 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.51% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 8.33% · Lower 95% interval 3.65% |
| Staff COVID-19 vaccination coverage | 17.81% |
8.2%
9.6 pts better
|
Numerator 13 · Denominator 73 |
| Staff flu vaccination coverage | 33.33% |
42%
8.7 pts worse
|
Numerator 40 · Denominator 120 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 16 · Denominator 24 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.6
0.8 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.5
0.7 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.1% |
93.6%
10.5 pts worse
|
93.4%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 87.0% · Q2 83.7% · Q3 86.4% · Q4 75.0% · 4Q avg 83.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 93.5% |
95.4%
1.9 pts worse
|
95.5%
2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.8%
1 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 0.0% · Q3 2.3% · Q4 4.5% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 37.2% |
24.6%
12.6 pts worse
|
11.4%
25.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.9% · Q2 37.2% · Q3 29.3% · Q4 32.6% · 4Q avg 37.2% |
| Percentage of long-stay residents who lose too much weight | 3.9% |
5.6%
1.7 pts better
|
5.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 5.4% · Q3 5.4% · Q4 2.5% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.7% |
23.5%
3.8 pts better
|
19.6%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 23.7% · Q3 18.4% · Q4 15.0% · 4Q avg 19.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.7% |
14.8%
0.1 pts better
|
16.7%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 15.2% · Q3 12.1% · Q4 13.9% · 4Q avg 14.7% · 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 | 7.7% |
13.3%
5.6 pts better
|
16.3%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 4.2% · Q4 21.9% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.2% |
11.7%
4.5 pts worse
|
14.9%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 8.1% · Q3 8.6% · Q4 40.5% · 4Q avg 16.2% · 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 | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 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 new or worsened bowel or bladder incontinence | 31.4% |
24.2%
7.2 pts worse
|
19.8%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 36.6% · Q3 32.0% · Q4 27.6% · 4Q avg 31.4% |
| Percentage of long-stay residents with pressure ulcers | 3.2% |
4.1%
0.9 pts better
|
5.1%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 0.0% · Q3 2.9% · Q4 6.8% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 28.6% |
81.6%
53 pts worse
|
81.7%
53.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 37.0% · Q3 28.6% · Q4 25.0% · 4Q avg 28.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.9% |
10.5%
3.4 pts worse
|
12.0%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 13.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 35.7% |
79.0%
43.3 pts worse
|
79.7%
44 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 35.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.7% |
22.4%
6.7 pts better
|
23.9%
8.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.7% · Observed 13.0% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-20 · Fire 2023-12-20
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-01-12 · Fire 2023-01-12
0 health deficiencies
No concentrated health issue counts in this cycle.
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-12-18
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-01-10
F · Potential for more than minimal harm
2023-12-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-30
F · Potential for more than minimal harm
2023-01-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-02-26
F · Potential for more than minimal harm
2023-01-12
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-02-26
F · Potential for more than minimal harm
2023-01-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-26
F · Potential for more than minimal harm
2023-01-12
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-02-26
F · Potential for more than minimal harm
2023-01-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-26
F · Potential for more than minimal harm
2023-01-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-26
F · Potential for more than minimal harm
2023-01-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-26
E · Potential for more than minimal harm
2023-01-12
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-02-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-18
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 2025-01-10
D · Potential for more than minimal harm
2024-12-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-12-18
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-01-10
D · Potential for more than minimal harm
2023-12-20
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-01-11
D · Potential for more than minimal harm
2023-12-20
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-01-11
C · Minimal harm
2023-12-20
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-01-11
Penalties and ownership
What sits behind the stars
Ownership
Bankwell Bank
5% Or Greater Mortgage Interest · Organization
Benson, David
Operational/Managerial Control · Individual
Borne-Bauman, Candice
Operational/Managerial Control · Individual
Flueckiger, Russell
Operational/Managerial Control · Individual
Lehman, Scott
Operational/Managerial Control · Individual
Lt Care Acquisition Corp
Operational/Managerial Control · Organization
Macklin, Larry
Operational/Managerial Control · Individual
Mustaklem, Marwan
Operational/Managerial Control · Individual
Paul Hermitage Operator LLC
Operational/Managerial Control · Organization
Smith, Scott
Operational/Managerial Control · Individual
Smith, Scott
Corporate Officer · Individual
Sprunger, Kyle
Operational/Managerial Control · Individual
Sprunger, Kyle
Corporate Officer · Individual
Wheeler, Dane
Operational/Managerial Control · Individual
Wheeler, Dane
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Beech Grove Meadows
Beech Grove, IN
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Brickyard Healthcare - Churchman Care Center
Indianapolis, IN
4-star overall rating with 3-star inspections with $25,298 in total fines with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Fairway Village
Indianapolis, IN
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
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