Meadow Lakes: MDS Record Error Found in Inspection - IN
A federal inspection completed May 27 at Meadow Lakes nursing home found that the facility recorded a resident with Parkinson's disease, dementia, and a psychotic disorder as having undergone a PASARR Level II evaluation, a specialized mental health screening required for certain nursing home residents with serious psychiatric conditions. The resident had never had one.
PASARR, which stands for Preadmission Screening and Resident Review, is a federal process designed to ensure that people with serious mental illness or intellectual disabilities placed in nursing homes actually need to be there and are getting appropriate care. A Level II evaluation goes deeper, triggered when an initial screening suggests a resident may require specialized services. The PASARR notice in this resident's file, dated February 2, 2022, said clearly that a Level II was not required.
The Annual MDS assessment completed July 1, 2025 said otherwise. Section A1500, which asks whether a resident has a current PASARR Level II, was marked yes.
It was wrong.
When inspectors sat down with the Social Services Director on May 26, she told them the resident did not have a PASARR Level II. One minute later, the MDS assistant confirmed the same thing: the yes marking in section A1500 was an error. It should have been no. She said the facility followed the Resident Assessment Instrument manual when coding assessments.
The RAI manual, as inspectors noted in their review of the October 2025 version, is explicit on this point. For section A1500, facilities are instructed to review the Level I PASARR form and code no if the Level I screening did not result in a referral for Level II. The Level I screening for this resident, completed years earlier, did exactly that. No referral. No Level II.
The administrator, interviewed the following morning, said the facility did not have an MDS policy of its own. They followed the RAI manual, he said, the same manual that contradicted what his staff had entered into the record.
The MDS, or Minimum Data Set, is the standardized assessment that nursing homes complete for every resident and submit to the federal government. It drives care planning, staffing decisions, and Medicare reimbursement. An error in one field does not always mean a resident was harmed, and inspectors here rated the deficiency at the lowest level of harm. But the MDS is also the document that is supposed to give regulators, families, and clinicians an accurate picture of who a resident is and what they need.
This resident carried a heavy clinical profile. Parkinson's disease is progressive, steadily eroding the body's ability to control movement. Dementia strips away memory and reasoning. A psychotic disorder compounds both, bringing with it abnormal thinking and perceptions that can be difficult to manage even under close clinical supervision. For a person with that combination of diagnoses, accurate documentation is not a bureaucratic formality. It shapes what services get ordered, what specialists get involved, and whether anyone flags that something more might be needed.
The PASARR system exists precisely because nursing homes have historically placed residents with serious mental illness without adequate psychiatric support. A false Level II designation in the record does not mean the resident received services they did not need. But it also means anyone reading that file, including a new clinician, a family member, or a state reviewer, would believe a mental health evaluation had been completed when it had not been done in over three years, and when the most recent formal determination said it was not required at all.
The MDS assistant said the yes should have been a no. The Social Services Director agreed. The administrator confirmed the facility had no internal policy to catch the mistake.
The resident's file, as of the inspection date, still reflected a screening that never happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Meadow Lakes from 2026-05-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 12, 2026 · Our methodology
MEADOW LAKES in MOORESVILLE, IN was cited for violations during a health inspection on May 27, 2026.
The resident had never had one.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.