Silver Oak Nursing And Rehabilitation Center Llc
Silver Oak Nursing and Rehabilitation Center LLC in Marion, IA — inspection on September 15, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
documented the incident.
The facility Abuse Policy implemented March, 2022 and revised 9/2025 included: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations.
Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being.
Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.VII.
Reporting/ResponseA.
The facility will have written procedures that include:1.
Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a.
Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb.
Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/15/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Silver Oak Nursing and Rehabilitation Center LLC
455 31st Street Marion, IA 52302
SUMMARY STATEMENT OF DEFICIENCIES
Based on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies form, the facility Quality Assurance and Performance Improvement (QAPI) Plan, and staff interviews the facility failed to carry out Quality Assurance activities to ensure effective measures had been taken to correct deficiencies and prevent their ongoing prevalence.
The facility reported a census of 76 residents.
Findings include:The CMS 2567, dated 4/9/2025 reflected deficiencies identified for failure to report an allegation of abuse.
The current complaint survey, conducted 9/8/2025 - 9/15/2025 also identified the above concern.
During an interview on 9/15/2025 at 11:31 a.m. with Staff D, Administrator and Staff C, DON, Staff D explained the QAPI team met at least quarterly to discuss Performance Improvement Projects (PIP).
The next committee meeting is scheduled for October 6 with administration, heads of departments and the medical director.
Issues are discussed in the morning meetings, and those issues are carried over to QA (Quality Assurance).
Data is collected via PCC (Point Click Care), grievance forms, and any relevant vender notes such as pharmacy.
Staff can leave notes or texts and they can call the compliance line anonymously.
The committee decides which issues to work on by ranking them in order with which affect the residents first.
Administration held a nurse's meeting regarding the failure to report.
Staff were given an opportunity to voice some of the things they reported to prior administration.
Things they felt should have been reported but were not.
Staff were told they could put notes under the administrator's door if they had a concern.
The facility Quality Assurance and Performance Improvement (QAPI) implemented 7/17/2023 included: Policy: It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data drivenQAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides.
The QAPI plan will address the following elements:a.
Design and scope of the facility's QAPI program and QAA Committee responsibilities and actions.b.
Policies and procedures for feedback, data collection systems, and monitoring.c.
Process addressing how the committee will conduct activities necessary to identify and correctquality deficiencies.
Key components of this process include, but are not limited to, the following:i.
Tracking and measuring performance.ii.
Establishing goals and thresholds for performance improvements.iii.
Identifying and prioritizing quality deficiencies.iv.
Systematically analyzing underlying causes of systemic quality deficiencies.v.
Developing and implementing corrective action or performance improvement activities.vi.
Monitoring and evaluating the effectiveness of corrective action/performance improvementactivities and revising as needed.d. A prioritization of program activities that focus on resident safety, health outcomes, autonomy,choice, and quality of care, as well as, high-risk, high-volume, or problem-prone areas as identifiedin the facility assessment that reflects the specific units, programs, departments, and uniquepopulation the facility serves.
The facility must also consider the incidence, prevalence, andseverity of problems or potential problems identified.e. A commitment to quality assessment and performance improvement by the governing body and/orexecutive leaders.f.
Process to ensure care and services delivered meet accepted standards of quality.
The facility QAPI Plan received from the administratoron 8/25/2025
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