Inspection Report Summary
The most recent inspection on May 15, 2025, found the facility in compliance with all applicable regulations and confirmed that prior complaint-related deficiencies were corrected. Earlier inspections showed a pattern of deficiencies primarily related to nursing staff levels, assistance with activities of daily living, catheter and infection control, medication management, and care plan implementation. Complaint investigations were mostly unsubstantiated, with the exception of one substantiated case in July 2023 involving medication storage, disposal, and staff qualifications. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows improvement over time, with recent inspections indicating resolution of earlier issues.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
64% occupied
Based on a May 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Census: 52
Capacity: 81
Deficiencies: 0
May 15, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 2025-04-02, including a PSR to the Investigation of Complaints IN00456575 and IN00456619 completed on 2025-04-02.
Findings
The Villages of Oak Ridge 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 and the PSR to the Investigation of Complaints IN00456575 and IN00456619. Both complaints were corrected.
Complaint Details
Complaint IN00456619 and Complaint IN00456575 were investigated and found to be corrected.
Report Facts
Census Bed Type - SNF/NF: 33
Census Bed Type - SNF: 19
Census Bed Type - Residential: 29
Census Bed Type - Total: 81
Census Payor Type - Medicare: 16
Census Payor Type - Medicaid: 25
Census Payor Type - Other: 7
Census Payor Type - Total: 52
Inspection Report
Life Safety
Census: 43
Capacity: 55
Deficiencies: 0
Apr 23, 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 in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The Villages at Oak Ridge was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is fully sprinklered with a fire alarm system and had no deficiencies noted.
Report Facts
Certified beds: 55
Census: 43
Inspection Report
Recertification
Census: 30
Deficiencies: 5
Apr 2, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Nursing Home Complaints IN00456575 and IN00456619. This visit included a State Residential Licensure Survey.
Findings
The facility was found to have deficiencies related to insufficient nursing staff, failure to provide adequate ADL care including bathing, improper catheter care, inappropriate antibiotic use, oxygen order noncompliance, and infection control lapses. Several residents were affected but no ill effects were reported. The facility submitted plans of correction and requested a desk review for substantial compliance.
Complaint Details
Complaint IN00456575 cited deficiencies at F725 and F690 related to allegations of insufficient nursing staff, bathing, catheter care, antibiotic use, and oxygen order compliance. Complaint IN00456619 cited deficiencies at F677 and F690 related to bathing and catheter care.
Severity Breakdown
SS=D: 2
SS=E: 3
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure residents requiring assistance with ADLs received adequate assistance with bathing for 2 of 2 residents reviewed. | SS=D |
| Failure to ensure appropriate care and services were provided to prevent urinary tract infections for residents with urinary catheters or bladder incontinence for 4 of 4 residents reviewed. | SS=E |
| Failure to provide respiratory care consistent with professional standards for 1 of 2 residents reviewed; oxygen order not followed. | SS=D |
| Failure to ensure sufficient nursing staff was provided for 7 of 7 days reviewed and 1 of 1 Resident Council meeting; resulted in multiple care deficiencies. | SS=E |
| Failure to ensure infection control practices were implemented for a safe, sanitary, and comfortable environment to prevent disease transmission for 2 of 2 random observations. | SS=E |
Report Facts
Survey dates: March 25, 26, 27, 28, 31, April 1, 2, 2025
Resident census: 30
Resident census bed type: 80
Residents reviewed for ADL care: 2
Residents reviewed for catheter care: 4
Residents reviewed for respiratory care: 2
Days of survey: 9
Deficiency counts: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Sarah Wall | RN HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| LPN 5 | Licensed Practical Nurse | Interviewed regarding catheter care and oxygen order compliance |
| CNA 23 | Certified Nurse Aide | Interviewed regarding catheter care and oxygen use |
| QMA 14 | Qualified Medication Aide | Observed assisting with catheter care |
| PTA 32 | Physical Therapy Assistant | Observed assisting with catheter care |
| Interim Director of Nursing | Interim DON | Provided policies and interviews regarding bathing, catheter care, infection control, and oxygen administration |
| Infection Preventionist | IP | Interviewed regarding infection control practices |
| Certified Nurse Aide 42 | CNA | Interviewed regarding bathing schedules |
| Certified Nurse Aide 28 | CNA | Interviewed regarding bathing schedules |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 78
Deficiencies: 0
Mar 20, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454742.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00454742 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 78
Census Present: 48
Medicare Census: 11
Medicaid Census: 22
Other Payor Census: 15
Inspection Report
Complaint Investigation
Census: 47
Capacity: 75
Deficiencies: 0
Jan 17, 2025
Visit Reason
This visit was conducted for the investigation of Nursing Home Complaint IN00450800, which included the investigation of Residential Complaint IN00450800.
Findings
No deficiencies were cited related to the complaint allegations. The facility was found to be in compliance with applicable regulations regarding the complaint investigation.
Complaint Details
Complaint IN00450800 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census bed type total: 75
Census residents present: 47
Census by payor type: 8
Census by payor type: 24
Census by payor type: 15
Inspection Report
Complaint Investigation
Census: 47
Capacity: 77
Deficiencies: 0
Jan 8, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00446457.
Findings
No deficiencies were cited related to the complaint allegations. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00446457 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF beds: 16
Census SNF/NF beds: 31
Census Residential beds: 30
Total census: 47
Total capacity: 77
Medicare census: 8
Medicaid census: 25
Other payor census: 14
Inspection Report
Complaint Investigation
Census: 48
Capacity: 78
Deficiencies: 1
Sep 20, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00441261 and IN00442088, including a residential complaint investigation.
Findings
No deficiencies were cited related to the allegations of the complaints. However, an unrelated deficiency was cited regarding failure to ensure appropriate treatment and services to prevent UTIs for a resident with a nephrostomy tube, including inaccurate MDS coding, lack of resident-centered care plan, medication administration errors, and missed specialist follow-ups.
Complaint Details
Complaint IN00441261 and IN00442088 were investigated with no deficiencies related to the allegations cited. The unrelated deficiency cited was at F-690.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure appropriate treatment and services to prevent UTIs for a resident with a nephrostomy tube, including inaccurate MDS coding, lack of resident-centered care plan, antibiotic given for longer than ordered, and missed specialist follow-ups. | SS=D |
Report Facts
Census Bed Type - SNF/NF: 33
Census Bed Type - SNF: 15
Census Bed Type - Residential: 30
Total Licensed Capacity: 78
Census Payor Type - Medicare: 8
Census Payor Type - Medicaid: 32
Census Payor Type - Other: 8
Total Census: 48
Antibiotic administration duration error: 1
UTIs documented for Resident B: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Emily Farris | RN | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Clinical Support RN 1 | Registered Nurse | Interviewed regarding antibiotic administration, orders, and discharge instructions related to Resident B |
| LPN 3 | Licensed Practical Nurse | Interviewed regarding nephrostomy tube care and dressing changes for Resident B |
| MDS Coordinator | Interviewed regarding MDS assessments and care plan updates for Resident B | |
| Clinical Support RN 2 | Provided current Urinary Catheter Care policy |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 20, 2024
Visit Reason
Paper compliance survey conducted for the investigation of Complaints IN00441261 and IN00442088, with the survey ending on September 20, 2024.
Findings
The Villages of Oak Ridge 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 related to the investigation of the complaints and an unrelated deficiency cited on the survey.
Complaint Details
Investigation of Complaints IN00441261 and IN00442088; facility found in compliance.
Inspection Report
Life Safety
Census: 49
Capacity: 58
Deficiencies: 0
Apr 24, 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 on 04/24/2024.
Findings
The Villages at Oak Ridge was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements for Participation in Medicare/Medicaid. The facility is a one-story, fully sprinklered Type V (111) construction with a fire alarm system covering all resident areas.
Report Facts
Certified beds: 58
Census: 49
Inspection Report
Complaint Investigation
Census: 53
Capacity: 83
Deficiencies: 0
Mar 27, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00430875 and was conducted in conjunction with a Recertification and State Licensure Survey with Investigation of Complaint IN00429428, and a State Residential Licensure Survey.
Findings
No deficiencies related to Complaint IN00430875 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 IN00430875 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF: 20
Census Bed Type - SNF/NF: 33
Census Bed Type - Residential: 30
Total Capacity: 83
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 23
Census Payor Type - Other: 17
Total Census: 53
Inspection Report
Recertification
Census: 30
Deficiencies: 6
Mar 27, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaint IN00429428, including a State Residential Licensure Survey, conducted March 19-27, 2024.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident dignity during feeding, incomplete assessments for self-administered medications, failure to implement care plans, inadequate ADL care, unsafe medication storage, improper infection control during medication administration, missing signed service plans, lack of prior authorization for PRN medications administered by QMAs, and missing annual health statements for residents.
Complaint Details
Complaint IN00429428 was investigated with no deficiencies related to the allegations cited.
Severity Breakdown
SS=D: 5
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Resident was fed at the nurse's station, violating dignity rights. | SS=D |
| Failed to ensure assessments were completed for residents self-administering medications. | SS=D |
| Failed to implement care plans for residents, including oxygen humidification and medication administration. | SS=D |
| Failed to provide ADL care including showers at least twice per week for dependent residents. | SS=E |
| Failed to maintain safe and secure storage of medications; loose pills found in medication cart. | SS=D |
| Failed to ensure infection control practices during medication administration and insulin administration. | SS=D |
Report Facts
Survey dates: March 19-27, 2024
Census: 30
Medication administration without prior authorization: 20
Showers documented: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lori Hess | Laboratory Director or Provider/Supplier Representative | Signed the report |
| QMA 23 | Qualified Medication Aide | Responsible for cleaning medication carts and involved in medication administration |
| RN 3 | Registered Nurse | Observed administering medications with bare hands |
| QMA 5 | Qualified Medication Aide | Observed administering insulin improperly |
| CNA 45 | Certified Nursing Assistant | Provided information about resident bathing and shower refusals |
| DON | Director of Nursing | Provided policies and interview information |
| Regional Support | Regional Support Staff | Provided policy information and interviews |
| IP | Infection Preventionist | Provided infection control interview and observations |
Inspection Report
Renewal
Deficiencies: 0
Mar 27, 2024
Visit Reason
Paper compliance survey for the Recertification and State Licensure Survey ending on March 27, 2024.
Findings
The Villages of Oak Ridge was found to be in compliance with 42 CFR Part 483 subpart B and 410 IAC 16.2-3.1 in regards to the paper compliance review to the Recertification and State Licensure Survey.
Inspection Report
Complaint Investigation
Census: 45
Capacity: 75
Deficiencies: 0
Dec 13, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00422633.
Findings
No deficiencies were cited related to the allegations. 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 IN00422633-No deficiencies cited related to allegations.
Report Facts
Census bed type total: 75
Census present: 45
Census by payor type - Medicare: 7
Census by payor type - Medicaid: 26
Census by payor type - Other: 12
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 19, 2023
Visit Reason
Paper compliance survey conducted for the Investigation of Nursing Home Complaint IN00405855.
Findings
The Villages of Oak Ridge 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 for the complaint investigation.
Complaint Details
Investigation of Nursing Home Complaint IN00405855; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 48
Capacity: 78
Deficiencies: 3
Jul 18, 2023
Visit Reason
This visit was for the Investigation of Nursing Home Complaint IN00405855, which included the Investigation of Residential Complaint IN00405855.
Findings
The facility was found deficient in ensuring resident environments were free of accident hazards, proper medication storage and disposal, and that the Director of the Alzheimer's and dementia special care unit met state qualifications. Specific issues included unlocked medication and treatment carts, improper disposal of expired medications, and the dementia care unit director lacking required educational qualifications.
Complaint Details
Complaint IN00405855 was investigated, with federal and state deficiencies cited related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Facility failed to ensure resident environments remained free of accident hazards; medication and treatment carts were observed unlocked. | SS=D |
| Facility failed to ensure medications were disposed of properly; an expired resident's medication was thrown in an open trash container in a common area. | SS=D |
| Facility failed to ensure the Director of the Alzheimer's Unit met the qualifications for the position; job description did not address required educational experience as required by the State of Indiana. | — |
Report Facts
Census Bed Type - SNF/NF: 32
Census Bed Type - SNF: 16
Census Bed Type - Residential: 30
Total Capacity: 78
Census Payor Type - Medicare: 9
Census Payor Type - Medicaid: 26
Census Payor Type - Other: 13
Total Census: 48
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Emily Farris | RN, Clinical Support | Signed the report as Laboratory Director's or Provider/Supplier Representative |
| LPN 15 | Dementia Care Coordinator | Identified as the dementia coordinator for both locked units; lacked required educational qualifications |
| RN 9 | Observed and interviewed regarding unlocked treatment carts and medication disposal | |
| QMA 7 | Qualified Nurse Aide | Observed improper disposal of medication and unlocked treatment cart |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 83
Deficiencies: 0
Dec 27, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00382544.
Findings
The complaint was found to be unsubstantiated due to lack of evidence, and the facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00382544 was investigated and found to be unsubstantiated due to lack of evidence.
Report Facts
Census: 51
Total Capacity: 83
Medicare Census: 18
Medicaid Census: 17
Other Payor Census: 16
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