Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
CEDARS THE
LEO, IN · 65 certified beds · Last Life Safety survey September 2, 2025
CMS Certification Number 155796 · first certified March 2012
Ownership
Operated by ADAMS COUNTY MEMORIAL HOSPITAL · Non profit - Other
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within IN
24 citations — more than 75% 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 1 citation; the earlier surveys in the window averaged 11.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: August 2026 to October 2026. This facility’s last Life Safety survey was September 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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Emergency preparedness
4 of the 24 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)
2 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 24 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 | 24 |
| Median facility in IN | 15 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 8, 2023 | 12 |
| September 13, 2024 | 11 |
| September 2, 2025 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | 2 | 2024-09-13 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2024-09-13 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2024-09-13 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2023-09-08 |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | 1 | 2024-09-13 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2024-09-13 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2023-09-08 |
| K-0711 | Provide a written emergency evacuation plan. | 1 | 2024-09-13 |
What the citations cover
- Smoke Deficiencies 7
- Egress Deficiencies 5
- Emergency Preparedness Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 3
- Other 5
| Category | Citations |
|---|---|
| Smoke Deficiencies | 7 |
| Egress Deficiencies | 5 |
| Emergency Preparedness Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
| Construction Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
September 2, 2025 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0921 | Ensure that testing and maintenance of electrical equipment is performed. | Deficient, Provider has date of correction (November 7, 2025) |
September 13, 2024 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Deficient, Provider has date of correction (November 10, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (November 10, 2024) |
| K-0271 | Have exits that are accessible at all times. | Deficient, Provider has date of correction (November 10, 2024) |
| K-0311 | Have an enclosure around a vertical opening shaft. | Deficient, Provider has date of correction (November 10, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 10, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 10, 2024) |
| K-0361 | Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Deficient, Provider has date of correction (November 10, 2024) |
| K-0711 | Provide a written emergency evacuation plan. | Deficient, Provider has date of correction (November 10, 2024) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (November 10, 2024) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (November 10, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 10, 2024) |
September 8, 2023 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (November 20, 2023) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (November 20, 2023) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (November 20, 2023) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (November 20, 2023) |
| K-0131 | Meet requirements for sections of health care facilities separated by fire resistive construction. | Waiver has been granted (February 4, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (November 20, 2023) |
| K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Deficient, Provider has date of correction (November 20, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (November 20, 2023) |
| 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 (November 20, 2023) |
| K-0325 | Have properly installed hallway dispensers for alcohol-based hand rub. | Deficient, Provider has date of correction (November 20, 2023) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (November 20, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 20, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.