Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Meadow Lakes during CMS and state inspections, most recent first.
Missing Staff Education for Resident-Specific Transanal Irrigation: The facility failed to document in-services for nursing staff on a resident-specific transanal irrigation device and treatment. A resident with quadriplegia and central cord syndrome had a physician order for daily transanal irrigation with specific instructions for water volume, balloon inflation, and documentation. The ADNS stated staff on the rehab hallway and later in LTC received in-person education, written steps, and a video link, but the in-service documentation could not be found; the ED also stated the facility had no specific policy for in-services.
A resident with Parkinson’s disease, psychotic disorder, and dementia had an Annual MDS that incorrectly indicated a current PASRR Level II. The PASRR notice showed a Level I outcome of Dementia/MI Exclusion and no Level II was required, and both the SS director and MDS assistant confirmed the MDS A1500 entry was marked in error.
A facility failed to conduct a self-medication administration assessment for a resident who was observed with a medication cup on her bedside table. The resident, diagnosed with gastroesophageal reflux disease, was instructed to take her stomach medication after meals. Despite this, there was no documentation of an assessment in her clinical record. The DON admitted the oversight, noting the medication was a gas pill and needed to be taken post-meal. Facility policy prohibits leaving medications at the bedside.
A facility failed to accurately complete the MDS assessment for a resident with a Level II PASARR and serious mental illness. The resident's record showed diagnoses of anxiety, psychotic disorder with delusions, and anorexia nervosa. Despite a Level II PASARR indicating a serious mental illness, the MDS assessment incorrectly stated otherwise. The Social Services Assistant confirmed the error, and the facility's RAI manual did not provide correct coding guidance.
A resident with significant weight loss was not provided with an updated care plan, despite having diagnoses of hemiplegia, adult failure to thrive, and unspecified protein-calorie malnutrition. Observations showed uneaten meals and no staff assistance, and the care plan had not been revised since August 2023, contrary to the facility's weight monitoring policy.
A facility failed to assist a resident with personal hygiene, specifically shaving chin whiskers, despite the resident's need for substantial assistance due to medical conditions. The resident expressed sadness about her appearance, and an RN confirmed the need for grooming assistance.
A CNA in Training attempted to transfer a resident with cerebral infarction and hemiparesis without the required assistance of a second staff member, resulting in both sliding to the floor. Despite being informed by the resident's roommate of the need for two-person assistance, the CNA proceeded alone. The resident was not injured, but the incident highlighted a failure to adhere to the established Fall Care Plan.
The facility failed to provide written notification of transfer and discharge to residents and their representatives for four residents hospitalized. Despite phone contact, the required written notices were not documented, violating the facility's policy.
A facility failed to prevent infection by allowing a urinary drainage bag to touch the floor for a resident with neurogenic bladder. Despite the care plan's requirement to keep the bag off the floor, observations over several days showed non-compliance. The facility's policy, last reviewed in 2012, did not address this requirement, as confirmed by a CNA and the DON.
Missing Staff Education for Resident-Specific Transanal Irrigation
Penalty
Summary
The facility failed to ensure education in-services were completed for nursing staff regarding a resident-specific treatment need for Resident B. Resident B’s clinical record showed diagnoses including quadriplegia and central cord syndrome at C4. A physician’s order dated 4/15/26 directed transanal irrigation once daily, with instructions to instill between 500 mL and 1000 mL of lukewarm water per session, titrate to resident tolerance and clinical response, inflate the balloon catheter with 1-2 pumps of air for retention, not exceed 4 pumps per session, and document irrigation volume, frequency, balloon inflation amount, and any complications. During interview, the ADNS stated that staff on the rehabilitation short stay hallway received in-person education when Resident B was admitted, and that staff who might care for the resident after transfer to the LTC section also received in-person education, step-by-step paper instructions, and a video link. The ADNS also stated that a binder with information about the resident’s specific transanal irrigation device had been available at the nursing station and later moved to the long-term nursing station. However, documentation of these in-services could not be located. The ED also stated the in-services for the transanal irrigation device could not be located and indicated the facility did not have a specific policy regarding in-services.
MDS Assessment Incorrectly Coded PASRR Level II Status
Penalty
Summary
The facility failed to ensure the MDS assessment accurately reflected one resident’s status. Resident 8 had diagnoses including Parkinson’s disease, psychotic disorder, and dementia. A review of the PASARR notice dated 2/2/22 showed a Level I outcome of Dementia/MI Exclusion and stated that a PASRR Level II evaluation was not required at that time. However, the Annual MDS assessment dated 7/1/25 indicated the resident had a current PASARR Level II. During interviews, the Social Services Director stated the resident did not have a PASARR Level II, and the MDS assistant stated section A1500 on the Annual MDS was marked yes in error and should have been marked no for PASARR Level II. The Administrator stated the facility did not have an MDS policy and followed the RAI manual for coding the MDS assessment.
Failure to Complete Self-Medication Assessment
Penalty
Summary
The facility failed to complete a self-medication administration assessment for a resident who was observed with a medication cup containing a large white tablet on her bedside table. The resident identified the tablet as her stomach medication, which she was instructed to take after meals. A review of the resident's clinical record revealed a diagnosis of gastroesophageal reflux disease, but there was no documentation of a self-medication administration assessment. The current physician orders included simethicone tablets to be taken four times a day. The Director of Nursing Services acknowledged that no assessment had been completed, justifying that the medication was a gas pill and the resident needed to take it after meals. The facility's policy on medication administration explicitly stated that medications should not be left at the bedside.
Inaccurate MDS Assessment for Resident with Serious Mental Illness
Penalty
Summary
The facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for a resident with a Level II PASARR and a serious mental illness. The resident's clinical record, reviewed on March 18, 2025, included diagnoses such as anxiety, psychotic disorder with delusions, and anorexia nervosa. A Level II PASARR completed in January 2023 indicated the resident had a serious mental illness. However, the Significant Change MDS assessment dated February 23, 2025, incorrectly indicated that the resident did not have a Level II PASARR or a serious mental illness. During an interview, the Social Services Assistant acknowledged that the MDS assessment should have been coded to reflect the resident's Level II PASARR and serious mental illness status. The facility provided a copy of the RAI Version 3.0 Manual, but it did not indicate the correct coding for the Level II PASARR.
Failure to Revise Care Plan for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident experiencing significant weight loss. Resident 47, who has diagnoses including hemiplegia, adult failure to thrive, and unspecified protein-calorie malnutrition, was observed on two separate occasions with uneaten breakfast trays and no staff present to assist. The resident's clinical records indicated a significant weight loss of over 20% in six months, yet the nutrition care plan had not been updated with new interventions since August 2023. The facility's policy on weight monitoring requires that any significant unexplained weight loss be addressed by the Interdisciplinary Team. Despite this policy, the Director of Nursing acknowledged that the resident's care plan had not been updated with new interventions to address the weight loss. The lack of action in revising the care plan represents a deficiency in the facility's responsibility to provide adequate nutritional care and monitoring for the resident.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with Activities of Daily Living (ADLs) for a dependent resident, specifically in grooming and personal hygiene. Resident 48, who required substantial or maximal assistance for personal hygiene due to conditions such as hemiplegia, adult failure to thrive, and unspecified protein-calorie malnutrition, was observed on multiple occasions with half-inch long whiskers on her chin. The resident expressed sadness about her appearance and indicated that staff used to shave her whiskers more frequently, which she preferred. Despite the care plan indicating the need for assistance with grooming and hygiene, the resident did not receive the necessary care, as confirmed by an RN during an interview.
Inadequate Assistance Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate assistance was provided to prevent a fall for a resident who required two staff members for transfers. On the morning of November 28, 2024, a CNA in Training attempted to transfer Resident C from her wheelchair to her bed without the required assistance of a second staff member. Despite being informed by Resident E, the roommate, that Resident C needed two staff for transfers, the CNA in Training proceeded alone, resulting in both the CNA and Resident C sliding to the floor. Resident C, who has cerebral infarction and hemiparesis, was not injured in the incident. Resident C's clinical records indicated she had impaired upper and lower extremities on one side and required extensive assistance from two people for transfers. The Fall Event Record confirmed the resident was in her wheelchair before the fall and on the floor afterward. A Fall Care Plan intervention had been in place since November 5, 2021, specifying the need for two staff members for transfers. The incident was reported to LPN 1 by the CNA in Training, who acknowledged the resident's need for two-person assistance due to her impairments.
Failure to Provide Written Notification for Transfers
Penalty
Summary
The facility failed to provide the required written notification for transfer and discharge to residents and their representatives for four out of ten residents reviewed for hospitalization. Resident 20, diagnosed with nontraumatic intracerebral hemorrhage and dementia, was sent to the hospital on March 13, 2024, without documentation of written notification to the resident representative. Similarly, Resident 90, with sepsis and vascular dementia, was hospitalized on May 5, 2024, without the necessary written notice being documented. Resident 93, suffering from congestive heart failure and unspecified dementia, was transferred to the hospital on April 12, 2024, without written notification to both the resident and their representative. Resident 74, diagnosed with Alzheimer's disease and depression, was transferred to the hospital on three occasions in March 2024, yet there was no documentation of written notification to the resident or their representative. The Director of Nursing Services confirmed that while the facility contacted representatives by phone, they failed to provide written notices. The facility's policy, dated November 2015, mandates that a copy of the discharge or transfer notice must be included in the resident's clinical record and sent to the resident and responsible party, which was not adhered to in these cases.
Infection Control Deficiency: Urinary Drainage Bag on Floor
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were in place for a resident with a urinary catheter. Specifically, the urinary drainage bag for a resident diagnosed with obstructive and reflux uropathy due to neurogenic bladder was repeatedly observed touching the floor on multiple occasions. These observations occurred over several days, indicating a consistent failure to maintain the drainage bag off the floor as required by the resident's care plan. The care plan for the resident, which was current through a target date in 2025, explicitly stated that the tubing or any part of the drainage system should not touch the floor to prevent infections. Despite this, the facility's policy on indwelling urinary catheter care, which was last reviewed in 2012, did not include instructions to keep the drainage bag off the floor. This oversight was confirmed during an interview with a CNA, who acknowledged the requirement to keep the drainage bag elevated, and by the Director of Nursing Services, who provided the outdated policy.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mooresville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Springs Of Mooresville, The | 1.1 mi | ★★★★★ | 3 | 0 |
| Miller's Merry Manor | 1.6 mi | ★★★★★ | 1 | 0 |
| Cumberland Trace Health & Living Community | 4.2 mi | ★★★★★ | 0 | 0 |
| Plainfield Health Care Center | 5.9 mi | ★★★★★ | 32 | 1 |
| Chalet Rehabilitation And Healthcare Center | 7.2 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.