01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-07-26 | 0 | 2024-07-26 | 13 |
| Cycle 2 | 2023-08-25 | 1 | 2023-08-25 | 1 |
| Cycle 3 | 2022-06-17 | 3 | 2022-06-17 | 5 |
CMS CCN 1552892026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Colonial Oaks Health Care Center
1725 S Colonial Oaks Dr · Marion, IN 46953 · Grant County
Certified beds127CMS provider file
Recent citation rows23current CMS citation release
Penalty rows0current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
23 rows in the current release
0 rows carry G–L scope/severity codes; 0 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2024-07-26 · FIREK0131Severity E · pattern; potential for more than minimal harm
Construction Deficiencies
Meet requirements for sections of health care facilities separated by fire resistive construction.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-07-26 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-07-26 · FIREK0293Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-07-26 · FIREK0346Severity C · widespread; potential for minimal harm
Smoke Deficiencies
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-07-26 · FIREK0351Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install an approved automatic sprinkler system.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-07-26 · FIREK0354Severity C · widespread; potential for minimal harm
Smoke Deficiencies
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-07-26 · FIREK0363Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Install corridor and hallway doors that block smoke.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-07-26 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-07-26 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-07-26 · FIREK0711Severity C · widespread; potential for minimal harm
Miscellaneous Deficiencies
Provide a written emergency evacuation plan.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-07-26 · FIREK0741Severity E · pattern; potential for more than minimal harm
Miscellaneous Deficiencies
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-07-26 · FIREK0920Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2024-09-122024-07-26 · FIREK0923Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have proper medical gas storage and administration areas.
Correction field: Deficient, Provider has date of correction · 2024-09-122023-08-25 · HEALTHF0744Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Correction field: Deficient, Provider has date of correction · 2023-09-082023-08-25 · FIREK0341Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Correction field: Deficient, Provider has date of correction · 2023-09-262022-06-17 · HEALTHF0623Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Correction field: Deficient, Provider has date of correction · 2022-07-142022-06-17 · HEALTHF0758Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Correction field: Deficient, Provider has date of correction · 2022-07-142022-06-17 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2022-07-142022-06-17 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Correction field: Deficient, Provider has date of correction · 2022-08-112022-06-17 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2022-08-112022-06-17 · FIREK0374Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Correction field: Deficient, Provider has date of correction · 2022-08-112022-06-17 · FIREK0511Severity E · pattern; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2022-08-112022-06-17 · FIREK0920Severity E · pattern; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Ensure proper usage of power strips and extension cords.
Correction field: Deficient, Provider has date of correction · 2022-08-1103 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| No penalty row appeared in the August 2026 penalties file. | |||
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- RIVERVIEW HOSPITALOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 08/01/2012
- FRIEND, JAYNAIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 06/03/2021
- HYATT, DAVIDIndividual · MANAGING CONTROL - GOVERNING BODYNOT APPLICABLE · since 01/28/2022
- COLONIAL OAKS HEALTH CARE LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/01/2012
- TENDER LOVING CARE MANAGEMENT INCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/01/2012
- FRIEND, JAYNAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 06/03/2021
- HYATT, DAVIDIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/01/2012
- LIVINGSTON, CHRISTIANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/01/2012
- SRIKANTH, SHANKARANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 08/01/2012
- GIBSON, CULLENIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 07/11/2025
- OTT, CONNIEIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 07/25/2025
- OTT, DWIGHTIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 07/25/2025
- OTT, GARYIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 07/25/2025
- OTT, JESSEIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 07/11/2025
- OTT, RYANIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 07/11/2025
- DWIGHT A. OTT AND GLORIA OTTOrganization · TRUSTEE OF THE SNFNOT APPLICABLE · since 08/01/2012
- OTT FAMILY TRUSTOrganization · TRUSTEE OF THE SNFNOT APPLICABLE · since 08/01/2012
- COLONIAL OAKS HEALTH CARE LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 09/24/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.40per resident day
RN hours0.37per resident day
Weekend nurse hours2.92per resident day
Staff turnover26.6%CMS reported field