Mooresville, IN

Meadow Lakes

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

200 Meadow Lake Dr, Mooresville, IN

(317) 834-1791

Compare this facility

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

137

Certified beds

Average residents

122

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

American Senior Communities

Operator or chain grouping

Approved since

2006-03-22

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

0.49

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

0.89

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.07

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

3.45

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

1.38

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

2.91

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.27

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.08

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

0.45

CMS adjusted RN staffing hours

Adjusted total hours

3.20

CMS adjusted total nurse staffing hours

Case-mix index

1.47

Higher values indicate more complex resident acuity

RN turnover

44%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

45%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,733

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

Performance score

38.78

Composite VBP score used to determine payment impact.

Payment multiplier

0.9918

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.24

Baseline 19.77% · Performance 19.93% · Measure score 3.24 · Achievement 3.24 · Improvement 0

Healthcare-associated infections

6.97

Baseline 9.51% · Performance 6.13% · Measure score 6.97 · Achievement 5.69 · Improvement 6.97

Total nurse turnover

4.32

Baseline 70.97% · Performance 48.72% · Measure score 4.32 · Achievement 3.66 · Improvement 4.32

Adjusted total nurse staffing

0.97

Baseline 2.83 hours · Performance 3.26 hours · Measure score 0.97 · Achievement 0.66 · Improvement 0.97

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.14%	10.72% 1.4 pts worse	No Different than the National Rate · Eligible stays 147 · Observed rate 15.65% · Lower 95% interval 8.85%
Discharge to community	58.83%	50.57% 8.3 pts better	No Different than the National Rate · Eligible stays 118 · Observed rate 51.69% · Lower 95% interval 48.7%
Medicare spending per beneficiary	0.92	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 100 · Denominator 100
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 100
Discharge self-care score	61.33%	53.69% 7.6 pts better	Numerator 46 · Denominator 75
Discharge mobility score	54.67%	50.94% 3.7 pts better	Numerator 41 · Denominator 75
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 99 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	6.13%	7.12% 1 pts better	No Different than the National Rate · Eligible stays 72 · Observed rate 4.17% · Lower 95% interval 3.29%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 169
Staff flu vaccination coverage	32.46%	42% 9.5 pts worse	Numerator 62 · Denominator 191
Discharge function score	61.33%	56.45% 4.9 pts better	Numerator 46 · Denominator 75
Transfer of health information to provider	90.91%	95.95% 5 pts worse	Numerator 20 · Denominator 22
Transfer of health information to patient	97.92%	96.28% 1.6 pts better	Numerator 47 · Denominator 48
Resident COVID-19 vaccinations up to date	28.85%	25.2% 3.7 pts better	Numerator 15 · Denominator 52

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 0.7 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.0	1.5 0.5 pts better	1.8 0.8 pts better	Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.0%	93.6% 5.4 pts better	93.4% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.1% · Q4 99.0% · 4Q avg 99.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	99.1%	95.4% 3.7 pts better	95.5% 3.6 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1%
Percentage of long-stay residents experiencing one or more falls with major injury	4.7%	3.8% 0.9 pts worse	3.3% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 6.1% · Q3 3.8% · Q4 2.9% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	26.7%	24.6% 2.1 pts worse	11.4% 15.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 28.7% · Q2 23.7% · Q3 9.2% · Q4 45.4% · 4Q avg 26.7%
Percentage of long-stay residents who lose too much weight	3.8%	5.6% 1.8 pts better	5.4% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 4.8% · Q3 2.3% · Q4 4.5% · 4Q avg 3.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	23.5%	23.5% About the same	19.6% 3.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 20.2% · Q3 25.6% · Q4 22.2% · 4Q avg 23.5%
Percentage of long-stay residents who received an antipsychotic medication	13.8%	14.8% 1 pts better	16.7% 2.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 15.8% · Q3 8.9% · Q4 14.1% · 4Q avg 13.8% · 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	5.9%	13.3% 7.4 pts better	16.3% 10.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 8.7% · Q3 6.6% · Q4 4.4% · 4Q avg 5.9% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	5.4%	11.7% 6.3 pts better	14.9% 9.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 6.2% · Q3 4.7% · Q4 7.1% · 4Q avg 5.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.2%	0.4% 0.2 pts better	1.0% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · 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	19.7%	24.2% 4.5 pts better	19.8% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 18.9% · Q2 17.5% · Q3 20.3% · Q4 21.9% · 4Q avg 19.7%
Percentage of long-stay residents with pressure ulcers	1.2%	4.1% 2.9 pts better	5.1% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.1% · Q3 1.0% · Q4 1.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	96.4%	81.6% 14.8 pts better	81.7% 14.7 pts better	Short Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 96.9% · Q3 95.6% · Q4 94.2% · 4Q avg 96.4%
Percentage of short-stay residents who had an outpatient emergency department visit	4.4%	10.5% 6.1 pts better	12.0% 7.6 pts better	Short Stay · 20240701-20250630 · Adjusted 4.4% · Observed 4.5% · Expected 11.3% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.2%	1.3% 0.1 pts better	1.6% 0.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	88.6%	79.0% 9.6 pts better	79.7% 8.9 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 88.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.3%	22.4% 1.1 pts better	23.9% 2.6 pts better	Short Stay · 20240701-20250630 · Adjusted 21.3% · Observed 19.4% · Expected 21.8% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-03-18 · Fire 2025-03-18

4 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 2 Health 2024-06-05 · Fire 2024-06-05

3 health deficiencies

Top issue: Infection Control (1 deficiency)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 3 Health 2023-06-02 · Fire 2023-06-02

2 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

5 fire-safety deficiencies

Top issue: Egress (3 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-03-18

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-04-02

E · Potential for more than minimal harm 2025-03-18

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-05-07

E · Potential for more than minimal harm 2025-03-18

K927 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Corrected 2025-04-18

E · Potential for more than minimal harm 2024-06-05

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-07-09

E · Potential for more than minimal harm 2024-06-05

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2024-07-09

E · Potential for more than minimal harm 2023-06-02

K271 · Egress Deficiencies

Fire Safety

Have exits that are accessible at all times.

Corrected 2023-06-14

E · Potential for more than minimal harm 2023-06-02

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2023-06-14

E · Potential for more than minimal harm 2023-06-02

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-06-14

D · Potential for more than minimal harm 2023-06-02

K211 · Egress Deficiencies

Fire Safety

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

Corrected 2023-06-14

D · Potential for more than minimal harm 2023-06-02

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-06-14

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-03-18

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2025-04-14

D · Potential for more than minimal harm 2025-03-18

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-04-14

D · Potential for more than minimal harm 2025-03-18

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-04-14

D · Potential for more than minimal harm 2025-03-18

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-04-14

D · Potential for more than minimal harm 2024-12-12

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 2024-12-27

E · Potential for more than minimal harm 2024-06-05

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2024-06-21

D · Potential for more than minimal harm 2024-06-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-21

G · Actual harm 2024-01-10

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2024-02-02

D · Potential for more than minimal harm 2024-01-10

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-02-02

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 2009-02-01

American Senior Communities LLC

Operational/Managerial Control · Organization

0% 89 facilities 2009-02-01

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