A list of the most recent deficiencies for Beech Grove Meadows. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-19 | 2023-07-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-19 | 2023-07-10 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-04-19 | 2023-07-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-19 | 2023-07-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-19 | 2023-07-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-19 | 2023-07-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-28 | 2022-07-26 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-05-24 | 2022-06-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-24 | 2022-06-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-25 | 2021-07-13 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-02 | 2020-02-11 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-10-16 | 2019-11-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-10-16 | 2019-11-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-16 | 2019-11-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-16 | 2019-11-15 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-10-16 | 2019-11-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-16 | 2019-11-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-16 | 2019-11-15 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-10-16 | 2019-11-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-16 | 2019-11-15 | N |
| Dispose of garbage and refuse properly. | Health | 2019-10-16 | 2019-11-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-16 | 2019-11-15 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-10-16 | 2019-11-15 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2019-10-16 | 2019-11-15 | N |
