Inspection Report Summary
The most recent inspection on April 8, 2025, found no deficiencies related to the investigation of three complaints. Earlier inspections showed a pattern of deficiencies primarily involving medication management, infection control, and failure to notify physicians timely, including a prior report citing medication errors that contributed to a resident’s death. Complaint investigations often resulted in substantiated issues related to resident grievances, abuse investigations, and pest control, though several complaints were found unsubstantiated. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows some improvement with recent complaint investigations and follow-up visits indicating correction of previously cited deficiencies.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
15.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
274% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
85 residents
Based on a April 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 85
Deficiencies: 0
Date: Apr 8, 2025
Visit Reason
This visit was conducted for the investigation of three complaints: IN00456931, IN00456679, and IN00455843.
Complaint Details
Complaints IN00456931, IN00456679, and IN00455843 were investigated and no deficiencies related to the allegations were found.
Findings
No deficiencies related to the allegations in any of the three complaints were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the investigation of these complaints.
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 9
Date: Feb 12, 2025
Visit Reason
This visit was for a State Residential Licensure Survey including investigation of complaints IN00452887, IN00451356, and IN00452295.
Complaint Details
This visit included investigation of complaints IN00452887, IN00451356, and IN00452295. Deficiencies were cited related to complaints IN00451356 and IN00452887.
Findings
The facility was found deficient in multiple areas including failure to notify physician/legal representative after a resident fall, lack of dementia training for some staff, unclean resident rooms and common areas, failure to complete medication self-administration evaluations, medication administration errors, untimely pharmacy review responses, improper disposal of medications after resident death, and infection control breaches during medication administration.
Deficiencies (9)
Failed to ensure immediate consultation of a resident's physician and legal representative after a fall.
Failed to provide dementia training upon hire for some employees.
Failed to ensure resident rooms and common areas were clean and free of odor.
Failed to complete self-administration medication evaluations for residents self-administering medications.
Failed to ensure vital signs and weights were obtained as ordered; improper insulin pen priming; lack of orders for continuous glucose monitor; and untimely response to call lights.
Failed to dispose of refrigerated foods timely.
Failed to timely address pharmacy reviews for residents.
Failed to record disposition of medications upon resident death.
Failed to maintain infection control during medication administration including glove use, water pitcher cleanliness, and glucometer disinfection.
Report Facts
Residents present: 90
Survey dates: February 12, 13, and 14, 2025
Deficiency completion date: 2025
Call light response times: 87
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lily Price | Executive Director | Signed report and involved in interviews |
| Qualified Medication Aide 1 | QMA | Observed medication administration and infection control breaches |
| Qualified Medication Aide 2 | QMA | Observed medication administration and water pitcher use |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies and corrective actions |
| Business Office Manager | Interviewed regarding dementia training | |
| Maintenance Supervisor | Interviewed regarding cleanliness and call light system |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 0
Date: Dec 3, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00446418 and was conducted in conjunction with a Post Survey Revisit to the Investigation of Complaints IN00437068 and IN00440703 completed on September 4, 2024.
Complaint Details
Complaint IN00446418 was investigated and found to have no deficiencies related to the allegations; the facility was in compliance.
Findings
No deficiencies related to the allegations in Complaint IN00446418 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding this complaint.
Report Facts
Residential Census: 96
Inspection Report
Follow-Up
Census: 96
Deficiencies: 0
Date: Dec 3, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00437068 and IN00440703 completed on September 4, 2024, and was conducted in conjunction with the Investigation of Complaint IN00446418.
Complaint Details
Complaint IN00437068 and Complaint IN00440703 were investigated and found to be corrected. The visit was related to these complaints and an additional complaint IN00446418.
Findings
Oasis at 56th was found to be in compliance with 410 IAC 16.2-5 regarding the PSR to Investigation of Complaints IN00437068 and IN00440703. Both complaints IN00437068 and IN00440703 were corrected.
Report Facts
Residential Census: 96
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 2
Date: Sep 3, 2024
Visit Reason
This visit was for the investigation of multiple complaints (IN00441440, IN00441014, IN00440703, IN00438918, IN00437068, and IN00435224) regarding the facility.
Complaint Details
Complaint IN00437068 cited deficiencies related to failure to obtain weights. Complaint IN00440703 cited deficiencies related to medication administration failures leading to resident death. Other complaints had no deficiencies related to allegations.
Findings
The investigation found deficiencies related to failure to obtain semiannual weights for residents, and failure to administer medications according to physician orders resulting in a resident's adrenal crisis and death. Several complaints had no deficiencies related to the allegations. The facility failed to notify the physician timely about medication refusals, which contributed to a resident's decline and death.
Deficiencies (2)
Failure to obtain semiannual weights for 2 of 3 residents reviewed for weight loss.
Failure to ensure medications were administered according to physician's orders and failure to alert physician when a resident refused medications, resulting in adrenal crisis and death.
Report Facts
Residential Census: 100
Medication refusal counts: 10
Medication refusal counts: 20
Medication refusal counts: 19
Medication refusal counts: 28
Medication refusal counts: 27
Medication refusal counts: 10
Medication refusal counts: 3
Medication refusal counts: 6
Medication refusal counts: 6
Medication refusal counts: 5
Medication refusal counts: 4
Medication refusal counts: 5
Medication refusal counts: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lily Price | Executive Director | Signed the report and provided facility information |
| Resident B's nurse practitioner 1 | Nurse Practitioner | Interviewed; stated he was not notified of medication refusals and would have taken action |
Inspection Report
Complaint Investigation
Census: 108
Deficiencies: 13
Date: Mar 15, 2024
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of multiple complaints (IN00425925, IN00425552, IN00429132, IN00427955, IN00429127, IN00428535).
Complaint Details
This visit included investigation of complaints IN00425925, IN00425552, IN00429132, IN00427955, IN00429127, and IN00428535 with multiple deficiencies cited related to these complaints.
Findings
The facility was cited for multiple deficiencies including failure to notify physicians of medication refusals and falls, failure to address resident grievances, failure to prevent physical abuse, inadequate investigation of abuse incidents, failure to implement bed bug policies, incomplete tuberculosis screening for employees, missing resident signatures on service plans, delayed medication delivery, improper medication labeling and storage, unsecured clinical records, incomplete transfer documentation, lack of cooperation with mental health providers in care planning, and failure to follow infection control protocols including hand hygiene.
Deficiencies (13)
Failed to notify resident's physician and psychiatric provider of medication refusals and resident fall.
Failed to ensure resident grievance was addressed with follow-up.
Failed to ensure resident's right to be free from physical abuse; inadequate investigation of resident-to-resident abuse.
Failed to implement bed bug policy including laundering, vacuuming, PPE use, mattress encasements, and signage.
Failed to ensure employees had proper tuberculosis screening using two-step Mantoux test.
Failed to ensure resident signed service plan.
Failed to timely address resident's change of condition, ensure timely medication delivery, and implement service plan follow-up.
Failed to ensure prescription drug labels included all required information and medications were stored properly.
Failed to ensure expired medications were disposed timely and medication room was secured.
Failed to store clinical records in a secure location.
Failed to provide transfer form for resident transferred to hospital.
Failed to develop resident's comprehensive care plan in cooperation with mental health provider.
Failed to implement infection control program including hand hygiene and scrubbing insulin pen hub prior to use.
Report Facts
Residential Census: 108
Survey dates: 4
Medication disposal box size: 10
Expired medication dates: 2021
Bed bug treatment dates: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lily Price | Executive Director | Signed report and provided policies |
| Psych 35 | Psychiatric Service Provider | Interviewed regarding Resident B's refusal of medications and mental health services |
| Pharm 14 | Pharmacist | Interviewed regarding medication refusals and pharmacy services for Resident B |
| LPN 8 | Licensed Practical Nurse | Interviewed regarding Resident B medication refusals and Resident D fall notifications |
| NP 29 | Nurse Practitioner | Notified of Resident D falls; contact number found invalid |
| NP 26 | Nurse Practitioner | Interviewed and indicated no record of Resident D as patient |
| DOM | Director of Marketing | Witnessed resident altercation and separation |
| BOM | Business Office Manager | Witnessed resident altercation and separation |
| Resident S | Resident who filed grievance not followed up | |
| QMA 10 | Qualified Medication Aide | Observed administering insulin without proper hand hygiene or scrubbing pen hub |
| LPN 7 | Licensed Practical Nurse | Interviewed regarding medication delays and falls |
| Pharmacist 31 | Pharmacist | Interviewed regarding medication prior authorization |
| Pharmacy Staff Person 40 | Interviewed regarding medication delivery | |
| Pharmacy Staff Person 27 | Interviewed regarding medication shipment | |
| Housekeeper 28 | Reported resident fall and bed bug cleaning practices | |
| Case Manager 36 | Received complaints about bed bugs | |
| PCT 33 | Pest Control Technician | Interviewed regarding bed bug treatments and recommendations |
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 0
Date: Nov 13, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints identified as IN00418567, IN00418862, IN00420078, IN00420805, IN00420833, and IN00421072.
Complaint Details
Complaints IN00418567, IN00418862, IN00420078, IN00420805, IN00420833, and IN00421072 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 the applicable regulations regarding the investigation of these complaints.
Report Facts
Residential census: 115
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 1
Date: Sep 19, 2023
Visit Reason
This visit was for the investigation of Complaint IN00417452 related to allegations concerning the facility's implementation of the Elopement Risk and Missing Resident Policy.
Complaint Details
Complaint IN00417452 was substantiated with state deficiencies cited related to the allegations of failure to implement the Elopement Risk and Missing Resident Policy.
Findings
The facility failed to ensure the Elopement Risk and Missing Resident Policy was implemented when Resident B was not located in their apartment, medications were left unattended, and the resident was later found at a friend's house without staff notification. The investigation included interviews and record reviews confirming the resident left overnight without staff awareness and medication administration was not properly confirmed.
Deficiencies (1)
Failure to implement the Elopement Risk and Missing Resident Policy when Resident B was missing from the facility and medications were left unattended.
Report Facts
Residential Census: 123
Date of Incident: Jul 10, 2023
Date of Incident: Jul 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lily Price | Executive Director | Signed the report and involved in corrective action plan |
| QMA 4 | Qualified Medication Assistant | Attempted to administer medications to Resident B and signed off medication records |
| QMA 5 | Qualified Medication Assistant | Worked evening shift on 7/10/23 and did not recall the events |
| Director of Nursing | Director of Nursing | Interviewed regarding the incident and facility response |
| Guardian 3 | Guardian of Resident B who reported the resident missing and found her at a friend's house | |
| Resident F | Companion of Resident B who was present in Resident B's apartment during the incident |
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 0
Date: Jul 20, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00411483 and IN00412677.
Complaint Details
Investigation of Complaints IN00411483 and IN00412677 found no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in complaints IN00411483 and IN00412677 were cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding these complaints.
Inspection Report
Complaint Investigation
Census: 114
Deficiencies: 1
Date: May 30, 2023
Visit Reason
The visit was conducted for the investigation of multiple complaints (IN00406978, IN00408715, IN00408977, IN00409101, IN00409503, and IN00409553) regarding the facility's compliance with regulations.
Complaint Details
Complaints IN00408715, IN00409101, and IN00409503 were substantiated with state deficiencies cited at R0149. Complaints IN00406978, IN00408977, and IN00409553 had no deficiencies related to the allegations.
Findings
The facility was found deficient in maintaining an effective pest control program, specifically failing to ensure drying residents' clothing on high heat to kill bed bugs and eggs, affecting 7 out of 114 residents. The facility used 'smart dryers' that do not meet the required temperature, resulting in clothing being taken to a laundry mat. There was no policy related to bed bugs, and a significant infestation was found on a resident's wheelchair.
Deficiencies (1)
Failed to ensure an effective pest control program including drying residents' clothing on high heat to kill bed bugs and eggs.
Report Facts
Residents affected: 7
Residential Census: 114
Apartments treated for bed bugs: 6
Apartments treated for bed bugs: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim Executive Director | Interim Executive Director | Interviewed regarding pest control and laundry procedures |
| Director of Nursing | Director of Nursing | Interviewed regarding laundry procedures and staffing |
| Maintenance Director | Maintenance Director | Provided bed bug log and information about pest control and laundry mat usage |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 12
Date: Apr 20, 2023
Visit Reason
This visit was for a State Residential Licensure Survey including the Investigation of Complaints IN00406211 and IN00406266.
Complaint Details
Complaint IN00406211 had no deficiencies related to the allegations. Complaint IN00406266 had a state deficiency cited at R0240 related to laboratory services.
Findings
The facility was cited for failure to make complaint survey results available to residents, medication management deficiencies including controlled substance reconciliation and storage, staffing issues related to CPR and First Aid certification, incomplete staff orientation training, failure to discuss and sign service plans with residents, delayed laboratory services, improper food storage and hygiene practices in the kitchen, pharmacy recommendation follow-up failures, medication labeling issues, improper storage of narcotics, lack of comprehensive care plans developed with mental health providers, and failure to perform hand hygiene during medication administration.
Deficiencies (12)
Failed to ensure complaint survey results and plan of correction were made available to residents for examination.
Failed to implement medication management policy by not reconciling controlled substances and not storing them in controlled binders.
Failed to ensure staff certified in CPR and First Aid were scheduled on each shift.
Failed to assure staff received resident rights and dementia training prior to working independently.
Failed to discuss service plans with residents and ensure service plans were signed and dated by residents.
Failed to timely obtain laboratory services for a resident, resulting in delayed lab draw and possible adverse health outcomes.
Failed to ensure proper food storage, wear beard covers in kitchen, and keep trash covered when not in use.
Failed to timely address pharmacy recommendation to clarify and discontinue duplicate beta-blocker orders.
Failed to assure medications were labeled with required information for residents.
Failed to store schedule II narcotic medication under double lock.
Failed to develop comprehensive care plans in cooperation with mental health service providers for residents with major mental illness.
Failed to assure QMA appropriately performed hand hygiene during medication administration.
Report Facts
Residential Census: 117
Medication refusal counts: 27
Medication refusal counts: 13
Medication refusal counts: 17
Medication refusal counts: 9
Medication refusal counts: 23
Medication refusal counts: 13
Medication refusal counts: 32
Medication refusal counts: 31
Medication refusal counts: 8
Medication count: 12
Medication count: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alberta Taybior | Executive Director | Interviewed regarding survey binder and complaint survey availability |
| QMA 8 | Qualified Medication Aide | Observed administering medications without proper hand hygiene and improper narcotic storage |
| LPN 11 | Licensed Practical Nurse | Interviewed regarding controlled medication binder and narcotic counts |
| RDHS | Regional Director of Health Services | Provided policies and interviewed regarding multiple deficiencies including medication management and mental health care |
| DM | Dietary Manager | Interviewed during kitchen tour regarding food storage and hygiene issues |
| QMA 9 | Qualified Medication Aide | Observed with unlabeled narcotic medications |
| QMA 10 | Qualified Medication Aide | Observed with unlabeled narcotic medications |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 0
Date: Mar 17, 2023
Visit Reason
This visit was for the Investigation of Complaint IN00403870.
Complaint Details
Complaint IN00403870 was investigated and no deficiencies related to the allegations were found.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 410 IAC 16.2-5 regarding the complaint investigation.
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 9
Date: Feb 10, 2023
Visit Reason
Investigation of multiple complaints including IN00389266, IN00389283, IN00387427, IN00389935, IN00392800, IN00393477, IN00395111, IN00392636, IN00395109, and IN00400585. The visit also included a Residential COVID-19 Quality Assurance Walk Through.
Complaint Details
Multiple complaints were substantiated including issues with resident grievances, abuse, medication administration, and clinical record keeping. Specific complaints IN00389266, IN00389283, IN00392800, IN00392636, IN00395109, and IN00400585 had related deficiencies cited.
Findings
The facility was found to have substantiated complaints related to failure to address resident grievances about dryer lint removal and dietary service complaints affecting 47 of 113 residents. Resident to resident abuse was substantiated involving multiple residents with follow-up mental health services offered. Deficiencies were also found in medication administration, documentation of falls, blood sugar monitoring, medication availability, and incomplete transfer documentation.
Deficiencies (9)
Failure to address resident grievances regarding lint removal in dryers and dietary service complaints.
Failure to ensure residents were free from physical and mental abuse involving residents M, N, and O.
Failure to maintain documentation of investigation into resident to resident abuse per policy.
Failure to complete a fall incident report per facility policy for a resident who fell.
Failure to administer ferrous sulfate as ordered and failure to timely reorder medication.
Failure to report blood sugar readings less than 90 or greater than 250 to physician and document notification.
Failure to timely obtain and administer prescribed eye drops for a resident due to medication unavailability.
Failure to maintain complete clinical records with documented blood sugar readings prior to insulin administration.
Failure to utilize a transfer form that included required information such as receiving facility name, resident property, functional and physical limitations, and condition at transfer.
Report Facts
Residents affected by grievance deficiency: 47
Resident census: 113
Days ferrous sulfate not administered: 14
Blood sugar readings below 90 or above 250: 17
Days eye drops unavailable: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Alberta Taybior | Administrator | Named as Administrator during complaint investigation and interviews. |
| LPN 2 | Licensed Practical Nurse | Witnessed resident altercation and provided interview about incident. |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding medication administration, abuse investigations, and clinical record keeping. |
| Dietary Manager | Dietary Manager | Interviewed regarding resident complaints about dining services and food quality. |
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Date: Jan 23, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399578.
Complaint Details
Complaint IN00399578 was substantiated but no deficiencies related to the allegations were cited.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
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