Cycle 1
Health 2025-08-05 · Fire 2025-08-05
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Indianapolis, IN
Spring Mill Meadows
3-star overall rating with 2-star inspections with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2140 W 86th St, Indianapolis, IN
(317) 872-7211
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
81
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
American Senior Communities
Operator or chain grouping
Approved since
1974-03-13
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
0.76
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.63
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.62
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.44
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,581
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.61% · Performance 22.00% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.25
Baseline 6.14% · Performance 6.26% · Measure score 5.25 · Achievement 5.25 · Improvement 0
Total nurse turnover
0
Baseline 62.67% · Performance 63.73% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
1.22
Baseline 2.91 hours · Performance 3.41 hours · Measure score 1.22 · Achievement 1.15 · Improvement 1.22
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.94% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 172 · Observed rate 9.3% · Lower 95% interval 7.43% |
| Discharge to community | 56.08% |
50.57%
5.5 pts better
|
No Different than the National Rate · Eligible stays 172 · Observed rate 50% · Lower 95% interval 47.69% |
| Medicare spending per beneficiary | 1.01 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.47% |
95.27%
2.2 pts better
|
Numerator 77 · Denominator 79 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 79 |
| Discharge self-care score | 34.48% |
53.69%
19.2 pts worse
|
Numerator 20 · Denominator 58 |
| Discharge mobility score | 12.07% |
50.94%
38.9 pts worse
|
Numerator 7 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 79 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.27% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 101 · Observed rate 4.95% · Lower 95% interval 3.8% |
| Staff COVID-19 vaccination coverage | 12.12% |
8.2%
3.9 pts better
|
Numerator 16 · Denominator 132 |
| Staff flu vaccination coverage | 41.04% |
42%
1 pts worse
|
Numerator 55 · Denominator 134 |
| Discharge function score | 27.59% |
56.45%
28.9 pts worse
|
Numerator 16 · Denominator 58 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 27.5% |
25.2%
2.3 pts better
|
Numerator 11 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 68.9% |
93.6%
24.7 pts worse
|
93.4%
24.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 63.8% · Q2 66.2% · Q3 75.0% · Q4 70.6% · 4Q avg 68.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.1% |
95.4%
9.3 pts worse
|
95.5%
9.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.8%
2.4 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 0.0% · Q4 2.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.2% |
24.6%
7.4 pts better
|
11.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 13.2% · Q3 20.3% · Q4 19.0% · 4Q avg 17.2% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
5.6%
0.6 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 4.5% · Q3 7.6% · Q4 4.6% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.4% |
23.5%
8.1 pts better
|
19.6%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 17.9% · Q3 10.4% · Q4 11.9% · 4Q avg 15.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.5% |
14.8%
4.3 pts better
|
16.7%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 5.0% · Q3 13.1% · Q4 11.9% · 4Q avg 10.5% · 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 | 6.5% |
13.3%
6.8 pts better
|
16.3%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 0.0% · Q3 7.5% · Q4 8.0% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
11.7%
4.6 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 7.9% · Q3 6.8% · Q4 10.3% · 4Q avg 7.1% · 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 | 2.5% |
1.2%
1.3 pts worse
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.4% · Q3 0.0% · Q4 7.5% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.0% |
24.2%
2.8 pts worse
|
19.8%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 26.2% · Q3 28.5% · Q4 25.5% · 4Q avg 27.0% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
4.1%
2.8 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 8.0% · Q3 9.3% · Q4 5.9% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 77.7% |
81.6%
3.9 pts worse
|
81.7%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 71.3% · Q2 71.0% · Q3 83.6% · Q4 85.2% · 4Q avg 77.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.7% |
10.5%
3.8 pts better
|
12.0%
5.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.7% · Observed 6.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.3%
1 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.9% |
79.0%
6.1 pts worse
|
79.7%
6.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
22.4%
2.3 pts worse
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 21.7% · Expected 20.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-28 · Fire 2024-08-28
8 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2023-06-30 · Fire 2023-06-30
7 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-03
F · Potential for more than minimal harm
2025-08-05
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-10-03
E · Potential for more than minimal harm
2025-08-05
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-10-03
E · Potential for more than minimal harm
2025-08-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-10-03
E · Potential for more than minimal harm
2024-08-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-10-07
E · Potential for more than minimal harm
2023-06-30
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-06-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-08-18
C · Minimal harm
2023-06-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-08-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-08-05
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 2025-08-27
E · Potential for more than minimal harm
2025-08-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-27
D · Potential for more than minimal harm
2025-08-05
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-08-27
D · Potential for more than minimal harm
2025-08-05
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-08-27
D · Potential for more than minimal harm
2025-08-05
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 2025-08-27
D · Potential for more than minimal harm
2025-08-05
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 2025-08-27
D · Potential for more than minimal harm
2025-08-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-27
D · Potential for more than minimal harm
2025-08-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-08-27
D · Potential for more than minimal harm
2025-08-05
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-08-27
D · Potential for more than minimal harm
2025-08-05
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 2025-08-27
D · Potential for more than minimal harm
2025-08-05
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 2025-08-27
G · Actual harm
2025-05-28
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 2025-05-05
G · Actual harm
2025-02-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-05
E · Potential for more than minimal harm
2024-08-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-08-28
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-08-28
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 2024-03-17
D · Potential for more than minimal harm
2024-08-28
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-08-28
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 2024-09-25
D · Potential for more than minimal harm
2024-08-28
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-08-28
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 2024-09-25
D · Potential for more than minimal harm
2024-02-02
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-01-18
G · Actual harm
2023-11-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-11-17
D · Potential for more than minimal harm
2023-10-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-11-01
D · Potential for more than minimal harm
2023-06-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-30
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 2023-08-01
D · Potential for more than minimal harm
2023-06-30
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-08-01
D · Potential for more than minimal harm
2023-06-30
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 2023-08-01
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
Kelsey, Donna
Contracted Managing Employee · Individual
Kump, Cynthia
Operational/Managerial Control · Individual
Tucker, Erin
Operational/Managerial Control · Individual
Van Camp, Steven
Contracted Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Brickyard Healthcare - Willow Springs Care Center
Indianapolis, IN
1-star overall rating with 1-star inspections with $17,131 in total fines with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
St Augustine Home For The Aged
Indianapolis, IN
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Marquette
Indianapolis, IN
5-star overall rating with 3-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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