Cycle 1
Health 2024-07-26 · Fire 2024-07-26
0 health deficiencies
No concentrated health issue counts in this cycle.
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Marion, IN
Colonial Oaks Health Care Center
5-star overall rating with 5-star inspections with 13 fire-safety deficiencies in the latest cycle
1725 S Colonial Oaks Dr, Marion, IN
(765) 674-9791
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
127
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Tlc Management
Operator or chain grouping
Approved since
1986-10-31
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.33
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.54
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
2.97
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.30
CMS adjusted RN staffing hours
Adjusted total hours
3.16
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
23%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,045
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.09
Composite VBP score used to determine payment impact.
Payment multiplier
1.0066
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
8.25
Baseline 16.03% · Performance 17.61% · Measure score 8.25 · Achievement 8.25 · Improvement 0
Healthcare-associated infections
2.60
Baseline 6.57% · Performance 7.06% · Measure score 2.60 · Achievement 2.60 · Improvement 0
Total nurse turnover
9.41
Baseline 35.48% · Performance 25.23% · Measure score 9.41 · Achievement 9.41 · Improvement 9
Adjusted total nurse staffing
0.59
Baseline 3.09 hours · Performance 3.24 hours · Measure score 0.59 · Achievement 0.59 · Improvement 0.09
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.33% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 229 · Observed rate 7.42% · Lower 95% interval 6.79% |
| Discharge to community | 57.99% |
50.57%
7.4 pts better
|
Better than the National Rate · Eligible stays 240 · Observed rate 55.42% · Lower 95% interval 51.87% |
| Medicare spending per beneficiary | 1.28 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 142 · Denominator 142 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 142 |
| Discharge self-care score | 70.24% |
53.69%
16.5 pts better
|
Numerator 59 · Denominator 84 |
| Discharge mobility score | 57.14% |
50.94%
6.2 pts better
|
Numerator 48 · Denominator 84 |
| Pressure ulcers or injuries, new or worsened | 2.11% |
2.29%
0.2 pts better
|
Numerator 3 · Denominator 142 · Adjusted rate 2.02% |
| Healthcare-associated infections requiring hospitalization | 7.06% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 149 · Observed rate 6.04% · Lower 95% interval 4.7% |
| Staff COVID-19 vaccination coverage | 0.57% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 175 |
| Staff flu vaccination coverage | 31.87% |
42%
10.1 pts worse
|
Numerator 58 · Denominator 182 |
| Discharge function score | 70.24% |
56.45%
13.8 pts better
|
Numerator 59 · Denominator 84 |
| Transfer of health information to provider | 95.83% |
95.95%
0.1 pts worse
|
Numerator 23 · Denominator 24 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 89 · Denominator 89 |
| Resident COVID-19 vaccinations up to date | 4.62% |
25.2%
20.6 pts worse
|
Numerator 3 · Denominator 65 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.6
0.9 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.9 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.5
1 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.6%
6.4 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.1% |
95.4%
1.3 pts worse
|
95.5%
1.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.4% |
3.8%
1.6 pts worse
|
3.3%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.0% · Q3 4.9% · Q4 7.6% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.2% |
24.6%
11.4 pts better
|
11.4%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 12.3% · Q3 12.0% · Q4 22.4% · 4Q avg 13.2% |
| Percentage of long-stay residents who lose too much weight | 5.9% |
5.6%
0.3 pts worse
|
5.4%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 4.1% · Q3 5.4% · Q4 9.3% · 4Q avg 5.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
23.5%
2.3 pts better
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 23.3% · Q3 18.7% · Q4 18.4% · 4Q avg 21.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.4% |
14.8%
9.4 pts better
|
16.7%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 6.9% · Q3 4.6% · Q4 4.8% · 4Q avg 5.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.7% |
13.3%
3.4 pts worse
|
16.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q2 12.6% · Q3 20.6% · Q4 14.8% · 4Q avg 16.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.9% |
11.7%
0.8 pts better
|
14.9%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 11.8% · Q3 11.3% · Q4 9.9% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.4%
0.1 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.2%
0.9 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.6% |
24.2%
4.4 pts worse
|
19.8%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 32.4% · Q3 33.2% · Q4 27.5% · 4Q avg 28.6% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
4.1%
0.4 pts worse
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 9.5% · Q3 0.0% · Q4 2.1% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
81.6%
16.7 pts better
|
81.7%
16.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 99.4% · Q3 100.0% · Q4 94.3% · 4Q avg 98.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.6% |
10.5%
6.9 pts better
|
12.0%
8.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.6% · Observed 3.3% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.7% |
79.0%
5.7 pts better
|
79.7%
5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.2% |
22.4%
5.2 pts better
|
23.9%
6.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 16.5% · Expected 22.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-25 · Fire 2023-08-25
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Cycle 3
Health 2022-06-17 · Fire 2022-06-17
3 health deficiencies
Top issue: Infection Control (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-07-26
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-07-26
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-07-26
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-07-26
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-07-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-07-26
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-07-26
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-07-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-07-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-07-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-12
C · Minimal harm
2024-07-26
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-09-12
C · Minimal harm
2024-07-26
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-09-12
C · Minimal harm
2024-07-26
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-09-12
E · Potential for more than minimal harm
2023-08-25
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-09-26
E · Potential for more than minimal harm
2022-06-17
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2022-08-11
E · Potential for more than minimal harm
2022-06-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-08-11
E · Potential for more than minimal harm
2022-06-17
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-08-11
E · Potential for more than minimal harm
2022-06-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-08-11
E · Potential for more than minimal harm
2022-06-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-08-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-08-25
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-09-08
D · Potential for more than minimal harm
2022-06-17
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-17
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2022-07-14
D · Potential for more than minimal harm
2022-06-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-14
Penalties and ownership
What sits behind the stars
Ownership
Riverview Hospital
5% Or Greater Direct Ownership Interest · Organization
Colonial Oaks Health Care LLC
Operational/Managerial Control · Organization
Friend, Jayna
Operational/Managerial Control · Individual
Hyatt, David
Operational/Managerial Control · Individual
Livingston, Christian
Operational/Managerial Control · Individual
Srikanth, Shankaran
Operational/Managerial Control · Individual
Tender Loving Care Management Inc
Operational/Managerial Control · Organization
Nearby options
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3-star overall rating with 2-star inspections with $8,824 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Aperion Care Marion LLC
Marion, IN
1-star overall rating with 1-star inspections with abuse icon flag with $15,593 in total fines with 17 recent health deficiencies
#3
Twin City Health Care
Gas City, IN
3-star overall rating with 4-star inspections with 2 recent health deficiencies
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