Based on observation, record review, and interview, the facility failed to ensure the residents' environment was clean and in good repair related to a dirty shower room, dirty and discolored floor tiles, marred walls, loose baseboards, stained sheets, the storage of bedpans and urinals, and call lights lacking pull cords on 3 of 3 units. (Residents 5, 106, and 1, Rainbow, Reflections, and Memory Units) The facility also failed to ensure the kitchen was clean and in good repair related to the following dirty items: window screens, a fan, vents and ceiling tiles, and walls and floors for 1 of 1 kitchen. (The Main Kitchen) Findings include: 1. During an interview on 8/18/26 at 11:00 a.m., Resident 5 indicated the shower room on the Rainbow Unit smelled and there was feces on the floor. …
F921 citations in Indiana
Safe, clean, comfortable environment · Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
Indiana cites F921 more often than its own record predicts
2.35 times the share F921 takes of citations nationally.
Of every deficiency written in Indiana in 2025, this is the portion that was F921.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What Indiana surveyors wrote
F921 findings written in Indiana, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on observation and interviews, the facility failed to ensure the facility was a sanitary and comfortable environment for the residents, related to cigarette smoking where the residents are taken in and out of the building by the Ambulance (Ambulance Bay), which had the potential to affect any of the 101 residents who reside in the facility if they are transferred by Ambulance. Finding includes: An observation of the Ambulance Bay on 9/11/23 at 2:25 p.m., indicated a No Smoking Sign located directly outside of the entry door. The area had a very strong smell of cigarette smoke and there were more than 10 smoked cigarette butts located on the ground inside the bay. The Administrator indicated on 9/11/23 at 2:30 p.m. that the Ambulance Bay was a no-smoking area. …
The short window
Recent years
| Year | Share of Indiana citations | vs expected |
|---|---|---|
| 2023 | 2.20% | 2.56× |
| 2024 | 2.10% | 2.64× |
| 2025 | 1.99% | 2.35× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else Indiana surveyors cite →
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