Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

AVALON VILLAGE

LIGONIER, IN · 67 certified beds · Last Life Safety survey August 14, 2025

CMS Certification Number 155286 · first certified August 1986

Ownership

Operated by AMERICAN SENIOR COMMUNITIES · For profit - Corporation

No change of ownership on CMS record since January 1, 2016, when the records begin.

20
Citations on file
Rolling three-year window
3
Life Safety surveys
In the same window
4
Tags cited more than once
Across separate surveys
11
Inspection & testing records
Of the citations on file

Position within IN

20 citations — more than 66% 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

Slippingmore citations at the latest survey than at its earlier surveys in the window.

The latest survey found 12 citations; the earlier surveys in the window averaged 4. 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: July 2026 to October 2026. This facility’s last Life Safety survey was August 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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Which alerts

4 inspection-and-testing tags have 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.

Physical environment (health survey)

3 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 20 Life Safety citations above. The Physical Environment Index

  • F-0880 Provide and implement an infection prevention and control program.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  • F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

How that compares

Citations on file over three years

Compared with the median facility in IN, and nationally. Surveyors differ markedly between states, so the IN figure is the meaningful one.

This facility20IN median15National median11
Citations on file over three years, compared
MeasureCitations
This facility20
Median facility in IN15
Median facility nationally11

Survey history

Citations at each Life Safety survey
42023-1142024-11122025-08
Citations at each Life Safety survey
Survey dateCitations
November 16, 20234
November 6, 20244
August 14, 202512

Most-cited tags

Most-cited tags at this facility
K-03722K-03632K-03532K-07612K-03551K-09271K-09211K-03211
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.22024-11-06
K-0363Install corridor and hallway doors that block smoke.22025-08-14
K-0353Inspect, test, and maintain automatic sprinkler systems.22025-08-14
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.22025-08-14
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.12025-08-14
K-0927Have proper fire barriers, ventilation and signs for the transfilling of oxygen.12025-08-14
K-0921Ensure that testing and maintenance of electrical equipment is performed.12025-08-14
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.12023-11-16

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 11
  • Gas, Vacuum, and Electrical Systems Deficiencies 3
  • Egress Deficiencies 2
  • Miscellaneous Deficiencies 2
  • Other 2
Citations by CMS category
CategoryCitations
Smoke Deficiencies11
Gas, Vacuum, and Electrical Systems Deficiencies3
Egress Deficiencies2
Miscellaneous Deficiencies2
Construction Deficiencies1
Services Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

August 14, 2025 — 12 citations

Citations issued on August 14, 2025
TagWhat the surveyor checksStatus
K-0211Keep aisles, corridors, and exits free of obstruction in case of emergency.Deficient, Provider has date of correction (October 6, 2025)
K-0300Meet other general requirements that are deficient.Deficient, Provider has date of correction (October 6, 2025)
K-0324Provide properly protected cooking facilities.Deficient, Provider has date of correction (October 10, 2025)
K-0341Install a fire alarm system that can be heard throughout the facility.Deficient, Provider has date of correction (October 6, 2025)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (October 6, 2025)
K-0355Properly select, install, inspect, or maintain portable fire extinguishes.Deficient, Provider has date of correction (October 6, 2025)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (October 10, 2025)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (October 10, 2025)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (October 6, 2025)
K-0920Ensure proper usage of power strips and extension cords.Deficient, Provider has date of correction (October 6, 2025)
K-0921Ensure that testing and maintenance of electrical equipment is performed.Deficient, Provider has date of correction (October 6, 2025)
K-0927Have proper fire barriers, ventilation and signs for the transfilling of oxygen.Deficient, Provider has date of correction (October 6, 2025)

November 6, 2024 — 4 citations

Citations issued on November 6, 2024
TagWhat the surveyor checksStatus
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (December 10, 2024)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (December 10, 2024)
K-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.Deficient, Provider has date of correction (December 10, 2024)
K-0761To conduct inspection, testing and maintenance of fire doors by qualified individuals.Deficient, Provider has date of correction (December 10, 2024)

November 16, 2023 — 4 citations

Citations issued on November 16, 2023
TagWhat the surveyor checksStatus
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (January 15, 2024)
K-0321Ensure 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 (January 15, 2024)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (January 15, 2024)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (January 15, 2024)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.