Inspection Report Summary
The most recent inspection on June 11, 2025, found Edgewater Woods in compliance with fire safety and licensure requirements, with no deficiencies cited. Earlier inspections showed a pattern of deficiencies primarily related to care planning, transportation, infection control, and life safety code compliance, including issues with electrical equipment and fire barriers. Complaint investigations were mostly unsubstantiated, though one substantiated complaint in June 2025 cited failure to invite resident representatives to care plan meetings, and another in March 2025 involved missed transportation to a medical appointment. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s recent clean inspection suggests improvement in addressing prior deficiencies, particularly in life safety and regulatory compliance.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
74% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
86% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Re-Inspection
Census: 70
Capacity: 81
Deficiencies: 0
Date: Jun 11, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 03/11/25 was performed to verify compliance with fire safety and licensure requirements.
Findings
At this PSR survey, Edgewater Woods was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies, and applicable state regulations.
Report Facts
Facility capacity: 81
Census: 70
Inspection Report
Complaint Investigation
Census: 69
Capacity: 69
Deficiencies: 1
Date: Jun 9, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00459983 regarding allegations related to resident representatives not being invited to participate in care plan processes.
Complaint Details
Complaint IN00459983 was substantiated with federal/state deficiencies cited at F553 related to failure to invite resident representatives to care plan meetings for cognitively impaired residents.
Findings
The facility failed to ensure that resident representatives of cognitively impaired residents were invited to participate in care plan processes for 2 of 3 residents reviewed (Resident B and Resident D). Documentation and invitations to family representatives were lacking for care plan meetings.
Deficiencies (1)
Failed to ensure resident representatives of cognitively impaired residents were invited to participate in care plan processes for 2 of 3 residents reviewed.
Report Facts
Census: 69
Total Capacity: 69
Medicare Census: 2
Medicaid Census: 56
Other Payor Census: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Kinley | Executive Director | Signed the report and referenced in quality assurance oversight |
| Social Services Director | Interviewed regarding care plan meeting invitations and documentation | |
| Director of Nursing | DON | Interviewed regarding notification process for care plan summaries |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 28, 2025
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00455522 completed on March 20, 2025.
Complaint Details
Investigation of Complaint IN00455522 completed on March 20, 2025; facility found in compliance.
Findings
Edgewater Woods was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review of the complaint investigation.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Apr 1, 2025
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure Survey.
Findings
Edgewater Woods was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 72
Capacity: 72
Deficiencies: 1
Date: Mar 20, 2025
Visit Reason
This visit was for the investigation of complaints IN00455522 and IN00454528. Complaint IN00455522 resulted in federal/state deficiencies related to transportation issues, while complaint IN00454528 had no deficiencies cited.
Complaint Details
Complaint IN00455522 was substantiated with federal/state deficiencies cited. Complaint IN00454528 was not substantiated with no deficiencies cited.
Findings
The facility failed to provide transportation to a medical procedure appointment for 1 of 3 residents reviewed, resulting in the resident missing the appointment. The appointment was rescheduled with no negative outcomes. The facility lacked a backup transportation plan and the responsible transport driver was terminated.
Deficiencies (1)
Failed to provide transportation to a medical procedure appointment as previously arranged for 1 of 3 residents reviewed for transportation concerns, resulting in the resident missing the appointment.
Report Facts
Census: 72
Total Capacity: 72
Medicare Census: 3
Medicaid Census: 58
Other Payor Census: 11
Days until rescheduled appointment: 11
Plan of Correction Completion Date: Apr 14, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Kinley | Executive Director | Signed report and oversees corrective action plan |
| LPN 1 | Reported transportation failure and attempts to contact transport driver | |
| RN 2 | Reported concern about missed transportation and informed DON and LPN 1 | |
| Transport Driver 5 | Failed to report for work and transport resident; employment terminated | |
| DON | Director of Nursing | Informed of transportation failure and provided facility policy |
| Administrator | Reported termination of Transport Driver 5 |
Inspection Report
Life Safety
Census: 74
Capacity: 81
Deficiencies: 4
Date: Mar 11, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health on 03/11/2025 to assess compliance with emergency preparedness and life safety code requirements.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements. Deficiencies included an undercharged portable fire extinguisher, therapy room door lacking a positive latching mechanism, improper use of extension cords and power strips in patient care areas, and failure to conduct required testing and maintain documentation for Patient Care Related Electrical Equipment (PCREE).
Deficiencies (4)
Failed to ensure 1 of 25 portable fire extinguishers had pressure gauge readings in the acceptable range.
Failed to ensure 1 of 1 therapy rooms was separated from the corridor by a partition capable of resisting the passage of smoke or met an exception; therapy room door lacked a positive latching mechanism.
Failed to ensure 1 of 1 extension cords including power strips were not used as a substitute for fixed wiring in patient care vicinity.
Failed to conduct required maintenance and maintain complete documentation of inspections for all Patient Care Related Electrical Equipment (PCREE).
Report Facts
Facility capacity: 81
Census: 74
Number of portable fire extinguishers inspected: 25
Number of therapy rooms inspected: 1
Number of extension cords/power strips inspected: 1
Completion date for fire extinguisher correction: Mar 13, 2025
Completion date for therapy room door correction: May 22, 2025
Completion date for extension cord correction: Mar 20, 2025
Completion date for PCREE testing: May 22, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Kinley | Executive Director | Signed report and participated in exit conference |
| Maintenance Director | Interviewed regarding fire extinguisher, therapy room door, extension cords, and PCREE testing deficiencies | |
| Director of Nursing | DON | Interviewed regarding fire extinguisher, therapy room door, extension cords, and PCREE testing deficiencies |
Inspection Report
Annual Inspection
Census: 70
Capacity: 70
Deficiencies: 3
Date: Feb 14, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00448154.
Complaint Details
Complaint IN00448154 was investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in monitoring and documenting urinary catheter output for one resident, and failed to follow infection prevention and control practices related to hand hygiene during laundry delivery and enhanced barrier precautions for residents at higher risk of infection.
Deficiencies (3)
Failed to ensure urinary output was monitored as ordered and abnormalities reported for 1 of 2 residents reviewed for urinary catheters (Resident 8).
Failed to utilize infection prevention and control practices related to hand hygiene during laundry delivery affecting 69 of 70 residents.
Failed to utilize infection prevention and control practices related to enhanced barrier precautions during care for residents at higher risk for infection with an indwelling urinary catheter or feeding tube (Residents 8, 9, and 10).
Report Facts
Census: 70
Total Capacity: 70
Residents with urinary catheters reviewed: 2
Residents reviewed for infection control: 5
Residents affected by infection control deficiency: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Kinley | Executive Director | Signed the report |
| CNA 7 | Observed and interviewed regarding catheter care and infection control practices | |
| Laundry Attendant 8 | Observed and interviewed regarding hand hygiene during laundry delivery | |
| Laundry Attendant 9 | Observed regarding hand hygiene during laundry delivery | |
| LPN 10 | Interviewed regarding urinary catheter output documentation | |
| CNA 11 | Observed providing catheter care and interviewed regarding enhanced barrier precautions | |
| RN 4 | Interviewed regarding catheter dignity cover and infection control | |
| RN 5 | Observed administering feeding tube medication and interviewed regarding enhanced barrier precautions | |
| QMA 3 | Assisted resident with catheter bag positioning and educated on catheter care |
Inspection Report
Complaint Investigation
Census: 74
Capacity: 74
Deficiencies: 0
Date: Oct 24, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00443861.
Complaint Details
Complaint IN00443861 - No deficiencies related to the allegations are cited.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 55
Census Payor Type - Other: 8
Inspection Report
Complaint Investigation
Census: 73
Capacity: 73
Deficiencies: 0
Date: Aug 30, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441016.
Complaint Details
Complaint IN00441016 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00441016 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 73
Total Capacity: 73
Medicare Census: 8
Medicaid Census: 57
Other Payor Census: 8
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Date: Jul 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00437583.
Complaint Details
Complaint IN00437583 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 12
Medicaid residents: 61
Other residents: 3
Inspection Report
Complaint Investigation
Census: 67
Capacity: 67
Deficiencies: 0
Date: Jun 27, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00436110 and IN00436712.
Complaint Details
Complaint IN00436110 and Complaint IN00436712 were investigated; no deficiencies related to the allegations were cited.
Findings
No deficiencies related to the allegations in complaints IN00436110 and IN00436712 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 7
Medicaid census: 55
Other payor census: 5
Inspection Report
Re-Inspection
Census: 75
Capacity: 81
Deficiencies: 0
Date: Jun 17, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/18/24 by the Indiana Department of Health.
Findings
Edgewater Woods was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility was fully sprinklered with a fire alarm system and smoke detection in required areas.
Inspection Report
Complaint Investigation
Census: 65
Capacity: 65
Deficiencies: 0
Date: Jun 4, 2024
Visit Reason
This visit was conducted for the investigation of multiple complaints identified as IN00433401, IN00434175, IN00434381, IN00433523, and IN00435886.
Complaint Details
Complaints IN00433401, IN00434175, IN00434381, IN00433523, and IN00435886 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC.
Report Facts
Census: 65
Total Capacity: 65
Medicare Census: 2
Medicaid Census: 55
Other Payor Census: 8
Inspection Report
Life Safety
Census: 75
Capacity: 81
Deficiencies: 3
Date: Apr 18, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but was found not in compliance with Life Safety Code requirements. Deficiencies included unsealed penetrations in smoke barrier walls, improper use of power strips as substitutes for fixed wiring, and an oxygen trans-filling room not protected with a one-hour fire-resistive construction.
Deficiencies (3)
Failed to ensure penetrations through 2 of 8 smoke barrier walls were protected to maintain smoke resistance.
Failed to ensure 1 of 1 power strips were not used as a substitute for fixed wiring to provide power equipment with a high current draw.
Failed to ensure 1 of 1 oxygen trans-filling rooms were separated from other areas in the facility in a room protected with a one-hour fire-resistive construction.
Report Facts
Facility capacity: 81
Census: 75
Number of smoke barrier penetrations unsealed: 2
Number of power strips misused: 1
Number of oxygen trans-filling rooms not properly protected: 1
Residents potentially affected by smoke barrier deficiency: 50
Residents potentially affected by power strip deficiency: 5
Residents potentially affected by oxygen trans-filling room deficiency: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Doug Lynch | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance Director | Interviewed and acknowledged deficiencies related to smoke barrier penetrations, power strip use, and oxygen trans-filling room fire rating | |
| Administrator | Participated in exit conference reviewing findings |
Inspection Report
Renewal
Census: 69
Capacity: 69
Deficiencies: 1
Date: Mar 25, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the investigation of five complaints (IN00429208, IN00429965, IN00430343, IN00430730, and IN00430721).
Complaint Details
Complaints IN00429208, IN00429965, IN00430343, IN00430730, and IN00430721 were investigated with no deficiencies related to the allegations cited.
Findings
No deficiencies were cited related to the complaints investigated. However, a deficiency was found related to infection prevention and control, specifically staff failing to handle medications in a sanitary manner and not performing hand hygiene during medication administration.
Deficiencies (1)
Facility failed to assure staff handled medications in a sanitary manner and performed hand hygiene during medication administration observation on the Willow Lane Unit.
Report Facts
Census: 69
Total Capacity: 69
Medicare Census: 4
Medicaid Census: 58
Other Payor Census: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Kinley | Executive Director | Signed report as provider/supplier representative |
| RN 2 | Named in deficiency for failing to sanitize hands and handle medications properly during medication administration | |
| LPN 3 | Spoke with RN 2 regarding hand hygiene during medication administration |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 25, 2024
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Edgewater Woods was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Report Facts
Facility number: 26
Provider number: 155066
AIM number: 100274820
Inspection Report
Complaint Investigation
Census: 76
Capacity: 76
Deficiencies: 0
Date: Feb 13, 2024
Visit Reason
This visit was conducted for the investigation of three complaints: IN00428168, IN00427440, and IN00427017.
Complaint Details
Complaints IN00428168, IN00427440, and IN00427017 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with relevant regulations.
Report Facts
Census SNF/NF: 76
Total Capacity: 76
Census Payor Type Medicare: 6
Census Payor Type Medicaid: 62
Census Payor Type Other: 8
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 0
Date: Jan 26, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00423389, IN00425917, and IN00426940.
Complaint Details
Complaints IN00423389, IN00425917, and IN00426940 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00423389, IN00425917, and IN00426940 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census Bed Type: 78
Census Payor Type - Medicare: 6
Census Payor Type - Medicaid: 62
Census Payor Type - Other: 10
Inspection Report
Complaint Investigation
Census: 66
Capacity: 66
Deficiencies: 0
Date: May 26, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00409279 and was conducted in conjunction with the Post Survey Revisit to the Recertification and State Licensure Survey completed on April 5, 2023.
Complaint Details
Complaint IN00409279 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Report Facts
Census SNF/NF beds: 66
Total census: 66
Medicare census: 3
Medicaid census: 53
Other payor census: 10
Inspection Report
Re-Inspection
Census: 66
Capacity: 66
Deficiencies: 0
Date: May 26, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on April 5, 2023, conducted in conjunction with an Investigation of Complaint IN00409279.
Complaint Details
Investigation of Complaint IN00409279 was conducted in conjunction with this visit.
Findings
Edgewater Woods was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Medicare census: 3
Medicaid census: 53
Other payor census: 10
Inspection Report
Re-Inspection
Census: 69
Capacity: 81
Deficiencies: 0
Date: May 15, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/17/23 was performed to verify compliance.
Findings
At this Life Safety Code Survey, Edgewater Woods was found in compliance with the Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.90(a).
Inspection Report
Complaint Investigation
Census: 71
Capacity: 71
Deficiencies: 0
Date: Apr 18, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00406163.
Complaint Details
Complaint IN00406163 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 71
Total Capacity: 71
Medicare Residents: 1
Medicaid Residents: 60
Other Residents: 10
Inspection Report
Life Safety
Census: 72
Capacity: 81
Deficiencies: 3
Date: Apr 17, 2023
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) to assess compliance with life safety and fire protection requirements.
Findings
The facility was found not in compliance with life safety requirements, specifically related to electrical safety issues including improperly maintained ground fault circuit interrupters (GFCI), use of non-compliant power strips, and improper use of extension cords. Corrective actions were implemented promptly.
Deficiencies (3)
Failed to ensure 2 of 2 ground fault circuit interrupters (GFCI) were properly maintained for protection against electric shock.
Failed to ensure 1 of 1 power strip in Resident room 305 met UL 1363 standards.
Failed to ensure 1 of 1 flexible cord was not used as a substitute for fixed wiring (extension cord used improperly).
Report Facts
Deficiencies cited: 3
Facility capacity: 81
Census: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Kinley | Executive Director | Named in relation to review of findings and exit conference. |
Inspection Report
Annual Inspection
Census: 70
Capacity: 70
Deficiencies: 6
Date: Apr 5, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from March 30 to April 5, 2023.
Findings
The facility was found deficient in multiple areas including failure to provide dignity in care for dependent residents, improper management of resident funds, inadequate assistance with activities of daily living, insufficient activity programming for developmentally disabled residents, failure to follow oxygen administration orders, and improper labeling and storage of insulin pens.
Deficiencies (6)
Failure to provide dressing assistance and protect dignity for 4 residents with developmental disabilities while sleeping.
Failure to manage resident funds using acceptable accounting principles for 16 residents with intellectual/developmental disabilities.
Failure to ensure dependent resident received assistance with nail care.
Failure to provide an ongoing activities program to meet interests and support physical, mental, and psychosocial well-being for 3 developmentally disabled residents.
Failure to follow physician's orders related to oxygen administration for a dependent resident.
Failure to ensure insulin pens were labeled with open dates and expiration dates on medication cart.
Report Facts
Census: 70
Total Capacity: 70
Residents with intellectual/developmental disabilities: 16
Social Event withdrawals: 9
Social Event withdrawals: 3
Oxygen liter flow: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Victoria Kinley | Laboratory Director or Provider/Supplier Representative | Signed the report |
| LPN 5 | Interviewed regarding resident activity and dressing practices | |
| CNA 6 | Interviewed regarding resident dressing and activity practices | |
| Life Path Unit Manager | Interviewed regarding resident bed rest orders and dressing | |
| Business Office Manager | Interviewed regarding resident funds management and social event withdrawals | |
| Nurse 4 | Observed providing tracheostomy care | |
| LPN 7 | Observed medication cart and insulin pen labeling | |
| DON | Director of Nursing | Provided policies and interviewed regarding oxygen and activities |
Inspection Report
Complaint Investigation
Census: 68
Capacity: 68
Deficiencies: 0
Date: Mar 9, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00398631.
Complaint Details
Complaint IN00398631 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00398631 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 4
Medicaid census: 55
Other payor census: 9
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Aug 29, 2025
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Jun 10, 2025
Report
Mar 20, 2025
Report
Feb 14, 2025
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Mar 25, 2024
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Apr 5, 2023
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