Inspection Reports for Colonial Oaks Health Care Center
4725 S COLONIAL OAKS DR, IN, 46953
Back to Facility ProfileInspection Report Summary
The most recent inspection on March 25, 2025, found no deficiencies related to complaint investigations. Earlier inspections showed a mixed pattern, with several Life Safety Code deficiencies noted in 2024 related to fire barriers, sprinkler coverage, electrical safety, and smoke barriers, as well as a prior issue with medication documentation in 2023. Complaint investigations were mostly unsubstantiated or found no deficiencies, except for one substantiated neglect case in early 2023 that resulted in a deficiency for failure to provide incontinent care. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed many prior issues, with recent inspections showing compliance and no new deficiencies cited.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
31% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a March 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 101
Capacity: 101
Deficiencies: 0
Mar 25, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00453741 and IN00451810.
Findings
No deficiencies related to the allegations in complaints IN00453741 and IN00451810 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00453741 - No deficiencies related to the allegations are cited. Complaint IN00451810 - No deficiencies related to the allegations are cited.
Report Facts
Census Payor Type - Medicare: 26
Census Payor Type - Medicaid: 62
Census Payor Type - Other: 13
Inspection Report
Complaint Investigation
Census: 102
Capacity: 102
Deficiencies: 0
Dec 2, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00446792 and IN00447114 at Colonial Oaks Health Care Center.
Findings
No deficiencies related to the allegations in complaints IN00446792 and IN00447114 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00446792 and Complaint IN00447114 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census: 102
Total Capacity: 102
Medicare Census: 20
Medicaid Census: 68
Other Payor Census: 14
Inspection Report
Re-Inspection
Census: 94
Capacity: 127
Deficiencies: 0
Sep 30, 2024
Visit Reason
This was a Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 127
Census: 94
Inspection Report
Annual Inspection
Census: 94
Capacity: 127
Deficiencies: 13
Aug 12, 2024
Visit Reason
Annual Life Safety Code Recertification and State Licensure Survey conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and 42 CFR 483.73 Emergency Preparedness Survey.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Multiple deficiencies were identified including fire barrier penetrations, improper exit door signage, sprinkler coverage issues, fire alarm and sprinkler system policy inconsistencies, corridor door latching issues, smoke barrier penetrations, electrical safety issues including GFCI protection and exposed wiring, improper storage of oxygen cylinders, smoking policy enforcement, and power strip usage in resident care areas.
Severity Breakdown
E: 7
C: 3
D: 3
Deficiencies (13)
| Description | Severity |
|---|---|
| Penetration in fire barrier wall separating health care from assisted living was not sealed, compromising fire resistance. | E |
| Exit doors had improper signage indicating delayed egress locks when none were installed. | E |
| Exit sign in front dining room corridor pointed in two directions causing confusion. | E |
| Facility had conflicting fire watch policies for fire alarm system out-of-service procedures. | C |
| Breakroom closet lacked adequate sprinkler coverage due to obstruction by closet doors. | E |
| Sprinkler system out-of-service policies were inconsistent and did not comply with NFPA 25 requirements. | C |
| Corridor door to resident room 317 did not latch properly, failing to resist passage of smoke. | D |
| Penetrations through smoke barrier walls were not sealed to maintain smoke resistance. | E |
| Nine electrical receptacles within 6 feet of sinks or wet locations lacked required GFCI protection; exposed electrical splice in beauty shop. | E |
| Fire safety plan did not correctly address smoke compartment evacuation procedures. | C |
| Smoking was observed on facility property despite non-smoking policy. | E |
| Power strip in resident care area did not meet required UL rating. | D |
| Nonflammable 'E' type oxygen cylinder was not properly secured in patient room. | D |
Report Facts
Deficiencies cited: 13
Residents potentially affected: 94
Facility capacity: 127
Residents affected by fire barrier penetration: 40
Residents affected by exit door signage: 60
Residents affected by sprinkler coverage issue: 20
Residents affected by corridor door latching issue: 2
Residents affected by smoke barrier penetration: 50
Residents affected by electrical GFCI deficiency: 65
Residents affected by exposed electrical splice: 20
Residents affected by smoking policy deficiency: Staff around service and kitchen exit.
Residents affected by power strip deficiency: 2
Residents affected by oxygen cylinder storage deficiency: 2
Inspection Report
Annual Inspection
Census: 94
Capacity: 94
Deficiencies: 0
Jul 26, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and included the Investigation of Complaint IN00439296.
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.
Complaint Details
Complaint IN00439296 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 94
Census total residents: 94
Census Medicare residents: 17
Census Medicaid residents: 58
Census other payor residents: 19
Inspection Report
Complaint Investigation
Census: 103
Capacity: 103
Deficiencies: 0
Jun 18, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00431842.
Findings
No deficiencies related to the allegations in Complaint IN00431842 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00431842 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 103
Total Capacity: 103
Census Payor Type Medicare: 27
Census Payor Type Medicaid: 56
Census Payor Type Private: 19
Census Payor Type Other: 1
Inspection Report
Complaint Investigation
Census: 104
Capacity: 127
Deficiencies: 0
Mar 18, 2024
Visit Reason
An investigation of Complaint Number IN00430304 was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
No Federal or State deficiency related to the complaint allegation was cited. The facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and applicable codes.
Complaint Details
Complaint # IN00430304 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Facility capacity: 127
Census: 104
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 0
Feb 22, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427354.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00427354 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 104
Census Payor Type - Medicare: 34
Census Payor Type - Medicaid: 57
Census Payor Type - Other: 13
Inspection Report
Complaint Investigation
Census: 99
Capacity: 99
Deficiencies: 0
Dec 12, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00422159 and IN00421076.
Findings
No deficiencies related to the allegations in complaints IN00422159 and IN00421076 were cited. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Investigation of Complaints IN00422159 and IN00421076 found no deficiencies related to the allegations; both complaints were not substantiated.
Report Facts
Census: 99
Total Capacity: 99
Medicare Census: 13
Medicaid Census: 59
Other Payor Census: 27
Inspection Report
Re-Inspection
Census: 94
Capacity: 127
Deficiencies: 0
Oct 19, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 09/21/23 was performed to verify compliance with fire safety and licensure requirements.
Findings
Colonial Oaks Health Care Center was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire regulations, and the 2012 NFPA 101 Life Safety Code. The facility was fully sprinklered except for a garage used for maintenance supply storage.
Report Facts
Facility capacity: 127
Census: 94
Inspection Report
Complaint Investigation
Census: 99
Capacity: 99
Deficiencies: 0
Oct 12, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418088.
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.
Complaint Details
Complaint IN00418088 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 99
Census Payor Type - Medicare: 25
Census Payor Type - Medicaid: 64
Census Payor Type - Other: 10
Inspection Report
Life Safety
Census: 94
Capacity: 127
Deficiencies: 1
Sep 21, 2023
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. However, the Life Safety Code survey found the facility not in compliance due to a fire alarm system deficiency where a smoke detector was improperly installed within 3 feet of an air supply vent, potentially affecting 20 residents in one smoke compartment.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure fire alarm system was installed in accordance with NFPA 70 and NFPA 72; a smoke detector was located within 3 feet of an air supply vent preventing proper operation. | SS=E |
Report Facts
Facility capacity: 127
Census: 94
Residents potentially affected: 20
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Sevier | RN | Laboratory Director or Provider/Supplier Representative who signed the report |
| Plant Operations Director | Interviewed regarding the fire alarm system deficiency and responsible for corrective actions | |
| Administrator | Interviewed regarding the fire alarm system deficiency |
Inspection Report
Renewal
Census: 96
Capacity: 96
Deficiencies: 1
Aug 25, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from August 21 to August 25, 2023.
Findings
The facility failed to ensure that nonpharmacological interventions were attempted prior to administering PRN psychoactive medication for one resident with dementia. Documentation of interventions prior to medication administration was lacking, and the facility policy was reviewed with staff to improve compliance.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure nonpharmacological interventions were attempted prior to administration of PRN psychoactive medication for a resident with dementia. | SS=D |
Report Facts
Census: 96
Total Capacity: 96
Survey Dates: 5
Medicare Residents: 28
Medicaid Residents: 54
Other Payor Residents: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Sevier | RN | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Director of Nursing | Director of Nursing | Reinserviced staff on psychoactive medication policy and procedures; provided interview regarding documentation and interventions |
| LPN 51 | Licensed Practical Nurse | Provided interview regarding assessment and documentation of anxiety symptoms and interventions |
| Social Services Assistant | Social Services Assistant | Provided interview regarding behavior reports for resident |
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 25, 2023
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Colonial Oaks Health Care Center 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: 91
Capacity: 91
Deficiencies: 0
Jul 11, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00411756.
Findings
No deficiencies related to the allegations in Complaint IN00411756 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00411756 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare census: 23
Medicaid census: 49
Other payor census: 19
Inspection Report
Complaint Investigation
Census: 101
Capacity: 101
Deficiencies: 0
Apr 20, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00405437.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00405437 - No deficiencies related to the allegations are cited.
Report Facts
Census SNF/NF: 101
Total Capacity: 101
Census Payor Type Medicare: 32
Census Payor Type Medicaid: 50
Census Payor Type Other: 19
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 20, 2023
Visit Reason
Paper compliance review to the Investigation of Complaint IN00401111 completed on February 14, 2023.
Findings
Colonial Oaks Health Care Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00401111 completed on February 14, 2023; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 101
Capacity: 101
Deficiencies: 1
Feb 14, 2023
Visit Reason
This visit was for the investigation of complaints IN00400799 and IN00401111. Complaint IN00400799 was substantiated with no deficiencies cited, and complaint IN00401111 was substantiated with federal/state deficiencies cited.
Findings
The facility failed to prevent neglect of one resident (Resident D) by not providing incontinent care on multiple occasions. The investigation substantiated that CNA 1 did not provide care due to a misunderstanding about caring for residents with wounds, leading to the resident being soiled with stool and wounds being exposed. The facility implemented staff re-education and ongoing monitoring to ensure compliance.
Complaint Details
Complaint IN00400799 was substantiated with no deficiencies cited. Complaint IN00401111 was substantiated with federal/state deficiencies related to neglect cited at F600.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to prevent neglect of Resident D by not providing incontinent care, resulting in the resident being soiled with stool and wounds exposed. | SS=D |
Report Facts
Census: 101
Total Capacity: 101
Medicare residents: 31
Medicaid residents: 53
Other payor residents: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tracey Carter | RN, Director of Nursing | Named as DON who provided statements and oversaw re-education and monitoring |
| CNA 1 | Certified Nursing Aide who failed to provide incontinent care leading to neglect | |
| QMA 2 | Qualified Medication Aide | Provided written statement about the incident and communicated with CNA 1 |
| LPN 4 | Licensed Practical Nurse | Provided statements about care and interactions with CNA 1 and Resident D |
| LPN 5 | Licensed Practical Nurse | Provided statements about wound care and resident condition |
| CNA 8 | Provided statement about assisting with dressing change and resident condition |
Inspection Report
Complaint Investigation
Census: 102
Capacity: 102
Deficiencies: 0
Jan 4, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00398304.
Findings
The complaint was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00398304 was substantiated; however, no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF: 102
Census Medicare: 34
Census Medicaid: 51
Census Other: 17
Inspection Report
Complaint Investigation
Census: 104
Capacity: 104
Deficiencies: 0
Nov 7, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00393508 and IN00393934.
Findings
Complaint IN00393508 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00393934 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00393508 was substantiated with no deficiencies cited. Complaint IN00393934 was unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type: 104
Census Payor Type - Medicare: 36
Census Payor Type - Medicaid: 55
Census Payor Type - Other: 13
Inspection Report
Complaint Investigation
Census: 102
Capacity: 102
Deficiencies: 0
Sep 20, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00390020.
Findings
Complaint IN00390020 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00390020 - Substantiated. No deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF: 102
Total Census: 102
Medicare Census: 34
Medicaid Census: 53
Other Payor Census: 15
Inspection Report
Life Safety
Census: 98
Capacity: 127
Deficiencies: 6
Jul 27, 2022
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 not in compliance with Life Safety Code requirements. Deficiencies included locked egress doors without posted exit codes, lack of self-closing doors in hazardous areas, smoke barrier doors not closing properly, an unsecured electrical junction box, and improper use and installation of power strips and extension cords.
Severity Breakdown
SS=E: 6
Deficiencies (6)
| Description | Severity |
|---|---|
| Means of egress doors (main front exit and therapy exit) were magnetically locked without posted exit codes, affecting over 60 staff and visitors. | SS=E |
| Failed to maintain protection of hazardous area where a hot oil popcorn popper was used; doors lacked self-closing devices. | SS=E |
| Two sets of smoke barrier doors did not close completely and latch, affecting 40 residents. | SS=E |
| One electrical junction box had exposed wires not secured in a junction box, affecting staff and 15 residents. | SS=E |
| Power strip in copy machine area was dangling and unsecured, risking damage to the power cord, affecting 4 staff. | SS=E |
| Power strip in resident room 329 lacked required UL rating labels, affecting 2 staff and 2 residents. | SS=E |
Report Facts
Facility capacity: 127
Census: 98
Residents with COVID-19: 35
Residents potentially affected by locked egress doors: 60
Residents potentially affected by hazardous area deficiency: 15
Residents potentially affected by smoke barrier door deficiency: 40
Residents potentially affected by electrical junction box deficiency: 15
Staff potentially affected by power strip deficiency: 4
Staff and residents potentially affected by power strip UL rating deficiency: 4
Inspection Report
Life Safety
Deficiencies: 0
Jul 27, 2022
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey was conducted on 07/27/22 and completed on 08/25/22.
Findings
Colonial Oaks Health Care Center 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 (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
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