Cycle 1
Health 2025-08-14 · Fire 2025-08-14
0 health deficiencies
No concentrated health issue counts in this cycle.
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Ligonier, IN
Avalon Village
5-star overall rating with 5-star inspections with 12 fire-safety deficiencies in the latest cycle
200 Kingston Cir, Ligonier, IN
(260) 894-7131
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
67
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
American Senior Communities
Operator or chain grouping
Approved since
1986-08-26
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
0.58
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.30
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.06
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.70
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
2.63
CMS adjusted total nurse staffing hours
Case-mix index
1.71
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,730
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9959
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
7.90
Baseline 52.94% · Performance 31.37% · Measure score 7.90 · Achievement 7.90 · Improvement 7.18
Adjusted total nurse staffing
0.68
Baseline 2.46 hours · Performance 2.85 hours · Measure score 0.68 · Achievement 0 · Improvement 0.68
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 23 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 19 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.66% |
8.2%
4.5 pts worse
|
Numerator 3 · Denominator 82 |
| Staff flu vaccination coverage | 11.11% |
42%
30.9 pts worse
|
Numerator 9 · Denominator 81 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · 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 | 1.5 |
1.6
0.1 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.0 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 | 4.6% |
3.8%
0.8 pts worse
|
3.3%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.3% · Q3 4.3% · Q4 5.8% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 29.3% |
24.6%
4.7 pts worse
|
11.4%
17.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 37.2% · Q3 20.0% · Q4 27.1% · 4Q avg 29.3% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
5.6%
5.6 pts better
|
5.4%
5.4 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 who received an antianxiety or hypnotic medication | 19.0% |
23.5%
4.5 pts better
|
19.6%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 19.0% · Q3 19.6% · Q4 19.6% · 4Q avg 19.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.4% |
14.8%
7.4 pts better
|
16.7%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.9% · Q3 10.3% · Q4 9.8% · 4Q avg 7.4% · 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 · Q4 4.3% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.9% |
11.7%
7.8 pts better
|
14.9%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 4.9% · Q3 0.0% · Q4 4.1% · 4Q avg 3.9% · 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 | 0.5% |
1.2%
0.7 pts better
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.2% |
24.2%
8 pts better
|
19.8%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 9.1% · Q3 10.1% · Q4 19.9% · 4Q avg 16.2% |
| Percentage of long-stay residents with pressure ulcers | 4.3% |
4.1%
0.2 pts worse
|
5.1%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 5.3% · Q3 5.1% · Q4 4.5% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
81.6%
17.1 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 97.7% · Q3 97.7% · Q4 100.0% · 4Q avg 98.7% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 4.2% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.7% |
79.0%
18.7 pts better
|
79.7%
18 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-06 · Fire 2024-11-06
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-11-16 · Fire 2023-11-16
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-14
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-10-06
F · Potential for more than minimal harm
2025-08-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-06
F · Potential for more than minimal harm
2025-08-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-10-10
F · Potential for more than minimal harm
2025-08-14
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-10-06
F · Potential for more than minimal harm
2025-08-14
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-10-06
F · Potential for more than minimal harm
2025-08-14
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-10-06
F · Potential for more than minimal harm
2025-08-14
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2025-10-06
E · Potential for more than minimal harm
2025-08-14
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-10-06
E · Potential for more than minimal harm
2025-08-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-10-06
E · Potential for more than minimal harm
2025-08-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-10-06
D · Potential for more than minimal harm
2025-08-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-10-10
E · Potential for more than minimal harm
2024-11-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-11-06
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-12-10
F · Potential for more than minimal harm
2023-11-16
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-11-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-01-15
E · Potential for more than minimal harm
2023-11-16
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 2024-01-15
E · Potential for more than minimal harm
2023-11-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-11-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-11-23
D · Potential for more than minimal harm
2024-11-06
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 2024-11-23
D · Potential for more than minimal harm
2024-11-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-11-23
D · Potential for more than minimal harm
2024-11-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-11-23
D · Potential for more than minimal harm
2024-07-11
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 2024-07-10
D · Potential for more than minimal harm
2023-11-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-16
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-16
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-16
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-16
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-16
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 2023-12-08
Penalties and ownership
What sits behind the stars
Ownership
The Health And Hospital Corporation Of Marion County
5% Or Greater Direct Ownership Interest · Organization
American Senior Communities LLC
Operational/Managerial Control · Organization
Babcock, Paul
Corporate Officer · Individual
Dice, Mark
Contracted Managing Employee · Individual
Gross, Mary
Operational/Managerial Control · Individual
Horn, Brenda
Corporate Director · Individual
Slone, Jessica
Operational/Managerial Control · Individual
Van Camp, Steven
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Waters Of Syracuse Skilled Nursing Facility, The
Syracuse, IN
1-star overall rating with 1-star inspections with 17 recent health deficiencies
#2
Waterford Crossing
Goshen, IN
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Majestic Care Of Goshen
Goshen, IN
1-star overall rating with 1-star inspections with $16,036 in total fines with 15 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
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