Cycle 1
Health 2025-04-09 · Fire 2025-04-09
26 health deficiencies
Top issue: Resident Rights (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Marion, IA
Silver Oak Nursing and Rehabilitation Center LLC
1-star overall rating with 1-star inspections with $29,107 in total fines with 26 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
455 31st Street, Marion, IA
(319) 377-7363
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
91
Certified beds
Average residents
74
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ivy Healthcare Group
Operator or chain grouping
Approved since
1991-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
4 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 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
0.50
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.57 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.53 · national 2.35
Total nurse hours
3.45
All reported nurse hours · state 3.83 · national 3.89
Licensed hours
1.04
RN + LPN hours · state 1.30 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.35 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
4.20
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
91%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,567
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9816
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.60% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 8.17% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
4.41
Baseline 77.36% · Performance 51.56% · Measure score 4.41 · Achievement 2.96 · Improvement 4.41
Adjusted total nurse staffing
2.09
Baseline 3.56 hours · Performance 3.67 hours · Measure score 2.09 · Achievement 2.09 · Improvement 0.02
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.34% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 50 · Observed rate 8% · Lower 95% interval 6.28% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 44 · Denominator 44 |
| Falls with major injury | 2.27% |
0.77%
1.5 pts worse
|
Numerator 1 · Denominator 44 |
| Discharge self-care score | 46.67% |
53.69%
7 pts worse
|
Numerator 14 · Denominator 30 |
| Discharge mobility score | 26.67% |
50.94%
24.3 pts worse
|
Numerator 8 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 2.27% |
2.29%
About the same
|
Numerator 1 · Denominator 44 · Adjusted rate 1.81% |
| Healthcare-associated infections requiring hospitalization | 8.17% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 14.29% · Lower 95% interval 4.7% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 106 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 167 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 18 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 4.17% |
25.2%
21 pts worse
|
Numerator 1 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.5
0.5 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
2.1
0.2 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 70.7% |
94.0%
23.3 pts worse
|
93.4%
22.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 71.4% · Q2 65.3% · Q3 71.4% · Q4 75.0% · 4Q avg 70.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 28.8% |
95.2%
66.4 pts worse
|
95.5%
66.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 28.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
3.7%
2 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.6% · Q3 5.7% · Q4 5.9% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
4.0%
2 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 0.0% · Q4 5.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
4.9%
3 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 1.4% · Q3 1.6% · Q4 0.0% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.5% |
20.6%
2.9 pts worse
|
19.6%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.5% · Q2 21.1% · Q3 22.6% · Q4 22.6% · 4Q avg 23.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.9% |
19.8%
4.1 pts worse
|
16.7%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 21.6% · Q3 26.5% · Q4 21.3% · 4Q avg 23.9% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
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 | 25.3% |
18.5%
6.8 pts worse
|
16.3%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.7% · Q2 31.3% · Q3 21.4% · Q4 27.9% · 4Q avg 25.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.3% |
18.3%
About the same
|
14.9%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 19.1% · Q3 16.4% · Q4 19.7% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 4.4% |
1.7%
2.7 pts worse
|
1.0%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.8% · Q3 6.4% · Q4 5.8% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
2.5%
0.7 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.4% · Q3 2.9% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.3% |
26.0%
1.3 pts worse
|
19.8%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.1% · Q2 25.2% · Q3 26.3% · Q4 28.7% · 4Q avg 27.3% |
| Percentage of long-stay residents with pressure ulcers | 2.0% |
4.3%
2.3 pts better
|
5.1%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.4% · Q3 2.4% · Q4 1.3% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 18.8% |
84.3%
65.5 pts worse
|
81.7%
62.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 15.0% · Q3 16.2% · Q4 13.2% · 4Q avg 18.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.9% |
13.1%
0.8 pts worse
|
12.0%
1.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 16.3% · Expected 13.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.9%
1.9 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 16.7% |
73.3%
56.6 pts worse
|
79.7%
63 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 16.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
21.3%
3 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 25.6% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-22 · Fire 2024-02-22
20 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-12-15 · Fire 2022-12-15
27 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-09
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 2025-05-01
F · Potential for more than minimal harm
2025-04-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-01
E · Potential for more than minimal harm
2025-04-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-01
F · Potential for more than minimal harm
2024-02-22
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 2024-03-27
F · Potential for more than minimal harm
2024-02-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-02-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-03-27
F · Potential for more than minimal harm
2024-02-22
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-02-22
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-03-27
E · Potential for more than minimal harm
2024-02-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-27
D · Potential for more than minimal harm
2024-02-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-03-27
F · Potential for more than minimal harm
2022-12-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-27
F · Potential for more than minimal harm
2022-12-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-22
F · Potential for more than minimal harm
2022-12-15
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-12-26
F · Potential for more than minimal harm
2022-12-15
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2022-12-29
F · Potential for more than minimal harm
2022-12-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-29
F · Potential for more than minimal harm
2022-12-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-01-14
F · Potential for more than minimal harm
2022-12-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-14
F · Potential for more than minimal harm
2022-12-15
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2023-01-14
E · Potential for more than minimal harm
2022-12-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-23
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-12-05
E · Potential for more than minimal harm
2025-09-15
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-10-15
D · Potential for more than minimal harm
2025-09-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-10-15
F · Potential for more than minimal harm
2025-04-09
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-05-09
F · Potential for more than minimal harm
2025-04-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-09
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-09
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-05-09
E · Potential for more than minimal harm
2025-04-09
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-09
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-09
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-04-09
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-04-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-28
D · Potential for more than minimal harm
2025-04-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-09
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-09
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-09
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-09
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-09
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-09
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-04-09
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-05-09
B · Minimal harm
2025-04-09
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 2025-05-09
B · Minimal harm
2025-04-09
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-02-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-05
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-02-05
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-07
E · Potential for more than minimal harm
2024-11-25
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-12-21
D · Potential for more than minimal harm
2024-11-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-21
D · Potential for more than minimal harm
2024-08-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-21
D · Potential for more than minimal harm
2024-04-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-17
J · Immediate jeopardy
2024-02-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-02-22
F · Potential for more than minimal harm
2024-02-22
F843 · Administration Deficiencies
Health
Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-02-22
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-22
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-04-15
D · Potential for more than minimal harm
2024-02-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-22
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-22
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2024-03-22
D · Potential for more than minimal harm
2024-02-22
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-03-22
G · Actual harm
2023-10-05
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-19
G · Actual harm
2023-10-05
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-19
F · Potential for more than minimal harm
2023-10-05
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-11-05
E · Potential for more than minimal harm
2023-10-05
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-11-05
E · Potential for more than minimal harm
2023-10-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-05
E · Potential for more than minimal harm
2023-10-05
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-10-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-05
D · Potential for more than minimal harm
2023-06-08
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-08
D · Potential for more than minimal harm
2023-06-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-07-08
D · Potential for more than minimal harm
2023-06-08
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-08
D · Potential for more than minimal harm
2023-06-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-07-08
D · Potential for more than minimal harm
2023-06-08
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-08
D · Potential for more than minimal harm
2023-06-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-08
D · Potential for more than minimal harm
2023-06-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-08
D · Potential for more than minimal harm
2023-06-08
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-08
D · Potential for more than minimal harm
2023-03-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-31
E · Potential for more than minimal harm
2022-12-15
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-01-19
D · Potential for more than minimal harm
2022-12-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-01-19
D · Potential for more than minimal harm
2022-12-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-01-19
D · Potential for more than minimal harm
2022-12-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-01-19
D · Potential for more than minimal harm
2022-12-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-19
D · Potential for more than minimal harm
2022-12-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-19
D · Potential for more than minimal harm
2022-12-15
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-01-19
D · Potential for more than minimal harm
2022-12-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-01-19
D · Potential for more than minimal harm
2022-12-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-01-19
D · Potential for more than minimal harm
2022-12-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-01-19
B · Minimal harm
2022-12-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-01-19
Penalties and ownership
What sits behind the stars
$16,068
2024-02-22
Fine
Fine · fine $16,068
Fine
$0
2024-02-22
Payment Denial
Payment Denial · denial start 2024-03-22 · 24 days
24 day denial
$13,039
2023-10-05
Fine
Fine · fine $13,039
Fine
$0
2023-10-05
Payment Denial
Payment Denial · denial start 2023-11-03 · 2 days
2 day denial
Ownership
Hyman, Chaim
5% Or Greater Direct Ownership Interest · Individual
De Jong, Alsion
Operational/Managerial Control · Individual
Younger, Clete
Operational/Managerial Control · Individual
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