Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
SERENITY SPRING SENIOR LIVING AT NORTHWOOD
JASPER, IN · 107 certified beds · Last Life Safety survey June 13, 2025
CMS Certification Number 155282 · first certified June 1986
Ownership
Operated by CONTINUUM HEALTHCARE · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IN
34 citations — more than 92% of the 507 certified nursing homes in IN. Compared within IN rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 14.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (May 2026 to August 2026), and past the point by which nine in ten IN facilities have been surveyed. This facility’s last Life Safety survey was June 2025. Facilities in IN are typically surveyed 11–14 months after the last one (median 13), measured over 883 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
14 of the 34 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
8 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 34 Life Safety citations above. The Physical Environment Index
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
How that compares
Compared with the median facility in IN, and nationally. Surveyors differ markedly between states, so the IN figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 34 |
| Median facility in IN | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 9, 2023 | 15 |
| May 22, 2024 | 14 |
| June 13, 2025 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0037 | Establish staff and initial training requirements. | 2 | 2024-05-22 |
| E-0039 | Conduct testing and exercise requirements. | 2 | 2024-05-22 |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | 2 | 2024-05-22 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2025-06-13 |
| K-0923 | Have proper medical gas storage and administration areas. | 2 | 2025-06-13 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2024-05-22 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2023-02-09 |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | 1 | 2023-02-09 |
What the citations cover
- Emergency Preparedness Deficiencies 14
- Smoke Deficiencies 8
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Miscellaneous Deficiencies 3
- Other 3
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 14 |
| Smoke Deficiencies | 8 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Miscellaneous Deficiencies | 3 |
| Egress Deficiencies | 2 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
June 13, 2025 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (August 1, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (August 1, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (September 6, 2025) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (August 1, 2025) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (August 1, 2025) |
May 22, 2024 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (June 28, 2024) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (September 4, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (July 15, 2024) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (July 15, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (July 15, 2024) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (July 15, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 15, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 15, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (July 15, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (June 28, 2024) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (September 4, 2024) |
February 9, 2023 — 15 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (March 8, 2023) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (March 8, 2023) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (March 8, 2023) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (March 8, 2023) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (March 8, 2023) |
| E-0023 | Establish policies and procedures for medical documentation. | Deficient, Provider has date of correction (March 8, 2023) |
| E-0025 | Create arrangements with other facilities to receive patients. | Deficient, Provider has date of correction (March 8, 2023) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (March 8, 2023) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (March 8, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (March 8, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (March 8, 2023) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (March 8, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (March 8, 2023) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (March 8, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (March 8, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.