Inspection Report Summary
The most recent inspection on May 8, 2025, found deficiencies related to food storage, kitchen sanitation, and hand hygiene during meal service. Earlier inspections showed a pattern of deficiencies involving medication administration errors, food safety issues, and care planning, with substantiated complaints citing these areas. Prior reports also noted problems with controlled drug records, meal quality, infection control, and safety equipment maintenance. Complaint investigations were mostly unsubstantiated except for those involving medication errors and food safety, which were substantiated with citations but no fines or enforcement actions listed in the available reports. The facility’s inspection history shows ongoing challenges in medication management and food safety, with no clear improvement trend over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
83% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a May 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 27
Capacity: 27
Deficiencies: 1
Date: May 8, 2025
Visit Reason
This visit was conducted for the investigation of complaint IN00458070 regarding food procurement, storage, preparation, and sanitary practices.
Complaint Details
Complaint IN00458070 was substantiated with federal/state deficiencies cited at F812 related to food procurement, storage, preparation, and sanitary practices.
Findings
The facility failed to ensure food was stored and distributed according to professional food safety standards, including unlabeled and undated food items stored open to air in the kitchen freezer, and staff failed to perform proper hand hygiene during meal service. The kitchen environment had dust and debris buildup, and cleaning was not documented.
Deficiencies (1)
Food was stored in a reach-in freezer open to air, undated, and unlabeled; kitchen equipment and spaces contained dust and debris; staff failed to complete hand hygiene during meal service.
Report Facts
Census: 27
Total Capacity: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jodi Sanders | Administrator | Signed report and plan of correction |
| Dietary Manager | Interviewed regarding food storage and cleaning practices; responsible for staff re-education and monitoring | |
| RN 3 | Registered Nurse | Interviewed about kitchen cleaning and provided facility policies |
| Cook 4 | Observed during meal service failing to perform hand hygiene | |
| CNA 7 | Certified Nursing Assistant | Interviewed about hand hygiene expectations during meal service |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 8, 2025
Visit Reason
Paper compliance review for the Investigation of Complaints IN00458070 survey ending on May 8, 2025.
Complaint Details
Investigation of Complaints IN00458070; facility found in compliance.
Findings
Oak Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review for the Investigation of Complaints IN00458070 survey.
Inspection Report
Complaint Investigation
Census: 24
Capacity: 24
Deficiencies: 0
Date: Apr 21, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00457077.
Complaint Details
Complaint IN00457077 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: 2
Medicaid residents: 19
Other residents: 3
Inspection Report
Complaint Investigation
Census: 29
Capacity: 29
Deficiencies: 1
Date: Apr 1, 2025
Visit Reason
This visit was conducted as an investigation of complaint IN00456371 regarding federal and state deficiencies related to medication administration practices at the facility.
Complaint Details
Complaint IN00456371 was substantiated with federal and state deficiencies cited at F755 related to medication administration errors involving Resident C.
Findings
The facility failed to ensure accurate and appropriate medication administration for one resident, who received another resident's medications after the nurse preset medications prior to the medication pass. The resident required hospital treatment due to hypotension after receiving incorrect medications. The facility implemented a corrective action plan including staff inservice and monitoring of medication passes.
Deficiencies (1)
Failure to ensure accurate and appropriate medication administration practices, resulting in a resident receiving another resident's medications.
Report Facts
Census: 29
Total Capacity: 29
Medicare Residents: 2
Medicaid Residents: 23
Other Payor Residents: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 4 | Registered Nurse | Named in medication administration error involving Resident C |
| Director of Nursing | Director of Nursing | Provided interview and facility policy related to medication administration |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 20, 2025
Visit Reason
Paper compliance review for the Investigation of Complaints IN00447927, IN00445195, and IN00445197 survey ending on December 31, 2024.
Complaint Details
Investigation of Complaints IN00447927, IN00445195, and IN00445197; facility found in compliance.
Findings
Oak Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review of the Investigation of Complaints IN00447927, IN00445195, and IN00445197 survey.
Inspection Report
Complaint Investigation
Census: 28
Capacity: 28
Deficiencies: 3
Date: Dec 30, 2024
Visit Reason
This visit was for the investigation of complaints IN00447927, IN00445195, and IN00445197 related to federal and state deficiencies.
Complaint Details
The investigation was triggered by complaints IN00447927, IN00445195, and IN00445197. Deficiencies related to these complaints were substantiated with citations at F804, F812, and F755.
Findings
The facility was found deficient in maintaining accurate controlled drug records, providing appetizing and palatable meals at proper temperatures, and ensuring food was stored and distributed according to professional food safety standards.
Deficiencies (3)
Failed to ensure accurate controlled drug records were maintained regarding the dispensing and administration of controlled drugs for 1 of 3 residents reviewed.
Failed to provide appetizing and palatable meals; residents complained of cold food temperatures and unappetizing food during meals.
Failed to ensure food was stored and distributed in accordance with professional standards for food service safety; food was stored open to air and not labeled or dated.
Report Facts
Census: 28
Total Capacity: 28
Controlled substance count discrepancies: 1
Resident complaints: 3
Food temperature measurements: 80
Food temperature measurements: 90
Food temperature measurements: 70
Food temperature measurements: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jodi Sanders | Administrator | Signed report and involved in facility administration |
| Director of Nursing | Interviewed regarding controlled substance count discrepancies | |
| LPN 4 | Interviewed about controlled substance count sheet usage | |
| LPN 8 | Interviewed about medication administration and documentation | |
| Dietary Manager/Designee | Provided education and corrective action plans related to food service deficiencies | |
| Dietary Aide 11 | Interviewed about food labeling and storage practices |
Inspection Report
Re-Inspection
Census: 29
Capacity: 50
Deficiencies: 0
Date: Nov 25, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 10/08/24 was performed to verify compliance with life safety and state licensure requirements.
Findings
At this PSR to the Life Safety Code survey, Oak Village was found in compliance with Medicare/Medicaid participation requirements, 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.
Inspection Report
Life Safety
Census: 30
Capacity: 50
Deficiencies: 1
Date: Oct 8, 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. However, the Life Safety Code survey found the facility not in compliance due to failure to maintain one laundry chute door to be fully self-closing and positively latching, which could affect over 10 residents, staff, and visitors.
Deficiencies (1)
Failed to maintain 1 of 1 laundry chute door to be fully self-closing and positive latching as required by NFPA 82.
Report Facts
Certified beds: 50
Census: 30
Laundry chute door test failures: 4
Audit frequency: 2
Audit duration weeks: 4
Audit duration months: 5
Total audit duration months: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Tina Garrett | Administrator | Named in observation and exit conference regarding laundry chute door deficiency |
| Maintenance Director | Named in observation and exit conference regarding laundry chute door deficiency and staff in-services |
Inspection Report
Renewal
Deficiencies: 0
Date: Sep 20, 2024
Visit Reason
Paper compliance review for the Recertification and State Licensure survey ending on September 20, 2024.
Findings
Oak Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1, in regard to the paper compliance review to the Recertification and State Licensure survey.
Inspection Report
Annual Inspection
Census: 27
Capacity: 27
Deficiencies: 8
Date: Sep 20, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00433301.
Complaint Details
Complaint IN00433301 was investigated with no deficiencies related to the allegations cited.
Findings
The facility had deficiencies related to care planning for dementia, failure to conduct quarterly care plan meetings, inadequate activities programming, delay in treatment after a fall, pain management during wound care, expired medications, facial hair restraints in the kitchen, and incomplete documentation of post dialysis vital signs and medication administration.
Deficiencies (8)
Failed to ensure a care plan was created for dementia and person-centered dementia care plan interventions were in place.
Failed to ensure care plan meetings were conducted quarterly for 3 of 16 residents reviewed.
Failed to provide activities when the Activity Director was out of the building for 6 of 7 residents reviewed.
Failed to ensure there was not a delay in treatment for a resident who had a fall with complaints of pain and discomfort.
Failed to ensure a resident had adequate pain control during a pressure ulcer dressing change.
Failed to ensure expired medications were disposed of properly for 1 of 2 medication carts and 1 medication storage room.
Failed to ensure facial hair restraints were used for kitchen staff with facial hair.
Failed to ensure post dialysis vital signs were documented for 1 resident and medication administration was documented for 4 residents.
Report Facts
Survey dates: 5
Census SNF/NF: 27
Medicare census: 3
Medicaid census: 17
Other payor census: 7
Pain assessment score: 8
Medication administration missing documentation: 5
Expired insulin open date: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jason Keller | Laboratory Director or Provider/Supplier Representative | Signed the report on 10/15/2024 |
| Licensed Practical Nurse 14 | LPN | Mentioned in relation to expired medication and medication documentation |
| Registered Nurse 13 | RN | Mentioned in relation to pain management during wound care |
| Registered Nurse 24 | RN | Mentioned in relation to pain management during wound care |
| Certified Nursing Assistant 11 | CNA | Mentioned in relation to activities coverage |
| Certified Nursing Assistant 12 | CNA | Mentioned in relation to activities coverage |
| Dietary Manager | DM | Mentioned in relation to facial hair restraint deficiency |
| Regional Director of Clinical Services | RDCS | Interviewed regarding multiple deficiencies and policies |
| Director of Nursing | DON | Interviewed and mentioned in relation to multiple deficiencies and corrective actions |
| Social Service Director | SSD | Interviewed regarding care plan meetings |
| Activity Director | Activity Director | Interviewed regarding activities deficiency |
Inspection Report
Complaint Investigation
Census: 29
Capacity: 29
Deficiencies: 0
Date: Feb 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00422898.
Complaint Details
Complaint IN00422898 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: 4
Medicaid residents: 21
Other payor residents: 4
Inspection Report
Life Safety
Census: 28
Capacity: 50
Deficiencies: 4
Date: Sep 14, 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 identified multiple deficiencies including incorrect time and date on the fire alarm control panel, improper maintenance of the sprinkler system, unprotected smoke barrier wall penetrations, and fire/smoke barrier doors that did not close properly.
Deficiencies (4)
Fire alarm system had incorrect time and date information on the main control panel.
Sprinkler system was not maintained with spare sprinklers properly stored in protective slots in the sprinkler cabinet.
Smoke barrier wall in the attic had penetrations that were not properly firestopped.
Two sets of fire/smoke barrier doors did not close completely and latch, leaving gaps larger than allowed.
Report Facts
Certified beds: 50
Census: 28
Deficiencies cited: 4
Spare sprinklers in cabinet: 5
Sprinkler cabinet slots: 12
Fire/smoke barrier doors not closing properly: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to fire alarm system time/date discrepancy, sprinkler cabinet maintenance, smoke barrier wall firestop, and fire/smoke barrier door deficiencies | |
| Administrator | Present during exit conference reviewing findings |
Inspection Report
Life Safety
Deficiencies: 0
Date: Sep 14, 2023
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 09/14/23 was completed on 10/24/23.
Findings
Oak Village was found in compliance with Requirements for Participation in Medicare/Medicaid, 42 CFR Subpart 483.90(a), 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.
Inspection Report
Annual Inspection
Census: 27
Capacity: 27
Deficiencies: 5
Date: Aug 25, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaint IN00415424. No deficiencies related to the complaint were cited.
Complaint Details
Complaint IN00415424 was investigated during the visit and no deficiencies related to the allegations were cited.
Findings
The facility was found to have multiple deficiencies including inaccurate Minimum Data Set (MDS) assessments, failure to prevent falls related to improper use of mechanical lifts, incomplete nutritional assessments by the Registered Dietitian, medication administration errors, and infection control issues such as improper storage of personal hygiene items and inadequate water system management for Legionella prevention.
Deficiencies (5)
Failed to ensure accurate Minimum Data Set (MDS) assessments for residents, including medication and alarm usage errors.
Failed to properly assist a resident with a mechanical lift causing a fall and injury.
Failed to ensure nutritional assessments were completed regularly for residents, and Registered Dietitian did not complete evaluations quarterly or with changes in condition.
Medication error rate exceeded 5%, with errors in dosage administration for two residents.
Failed to maintain a safe and sanitary environment to prevent infections, including unlabeled toothbrushes and denture cups, uncovered bedpans on the floor, and inadequate Legionella water management.
Report Facts
Census: 27
Total Capacity: 27
Medication error rate: 7.41
Medication administration opportunities: 27
Medication errors observed: 2
Legionella CFU: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Michael Meadows | Administrator | Signed report and provided information during interviews |
| Licensed Practical Nurse 8 | LPN | Provided information about lift incident |
| Certified Nurse Aide 4 | CNA | Provided information about lift use and bathroom hygiene |
| Certified Nurse Aide 36 | CNA | Provided information about toothbrush and denture cup labeling |
| Director of Nursing | DON | Provided information about medication errors, bathroom hygiene, and infection control |
| Maintenance Director | Maintenance Director | Provided information about water system testing and Legionella management |
| Registered Dietitian | Registered Dietitian/Kitchen Manager | Provided information about nutritional assessments and facility dietary management |
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 25, 2023
Visit Reason
Paper compliance review for the Recertification and State Licensure survey ending on August 25, 2023.
Findings
Oak Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the paper compliance review for the Recertification and State Licensure survey.
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