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Home / Iowa / Marion

Silver Oak Nursing and Rehabilitation Center LLC

455 31st Street, Marion, IA 52302 · Linn County · (319) 377-7363

91 certified beds, about 74 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1991

Certified for Medicaid Certified for Medicare
Overall
1 of 5
Health inspections
1 of 5
Staffing
4 of 5
Quality measures
3 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 165171 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on April 23, 2026, inspectors cited 7 health deficiencies (the Iowa average is 6.5, the national average 9.2).

Of 60 health citations since October 2023, 3 were rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).

CMS lists 2 fines totaling $29,107 in the last three years; the largest was $16,068, and the latest is dated February 22, 2024.

Nurses and nurse aides worked 3.55 hours per resident per day, against 3.82 across Iowa and 3.86 nationally. Registered nurses accounted for 0.65 of those hours.

55.4% of nursing staff left within the year CMS measured (Iowa average 44.0%).

CMS links it to Ivy Healthcare Group, an affiliated group of 4 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 60 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
35D
15E
5F
Potential for minimal harm
0A
2B
0C
April 23, 2026Standard inspection, Complaint inspection · 7 citations
  1. F
    Have a plan that describes the process for conducting QAPI and QAA activities.
    F865 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) May 23, 2026
    Inspectors wroteBased on the Centers for Medicare and Medicaid Services (CMS) Statement of Deficiencies forms, review of the facility Quality Assurance and Performance Improvement (QAPI) documentation, QAPI policy review, and staff interview the facility failed to implement effective quality assurance processes to address deficient practices with F658 Services Provided Meet Professional Standards, F725 Sufficient Nursing Staff, and F880 Infection Prevention and Control, resulting in deficient practices previously identified in 2025 also identified on the facility's current survey. The facility reported a census of 75 residents.
  2. E
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 23, 2026
    Inspectors wroteBased on observation, staff and resident interviews, facility document review and facility policy review the facility failed to answer call lights timely for 4 out of 6 residents reviewed (Resident #1, Resident #26, Resident #50,and Resident #80). The facility reported a census of 75 residents.
  3. D
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    F607 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 7, 2026
    Inspectors wroteBased on staff interviews, employee files, facility document review, and facility policy review the facility failed to check the licensure for 1 of 1 nurse before hire, and failed to obtain clearance from the Department of Criminal Investigation (DCI) before 1 out of 5 staff were hired. The facility reported a census of 75 residents.
  4. D
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    F628 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 23, 2026
    Inspectors wroteBased on resident interview, staff interview, and clinical record review the facility failed to notify the Long-Term Care Ombudsman of discharge and transfers as required for 1 of 1 resident reviewed for hospitalizations (Resident #13). The facility reported a census of 75 residents.
  5. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 23, 2026
    Inspectors wroteBased on observation, record review, staff interviews, resident interviews, and policy review the facility failed to follow Physician's Orders when applying topical medication for 1 of 5 residents reviewed (Resident #50). The facility reported a census of 75 residents.
  6. D
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    F698 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 23, 2026
    Inspectors wroteBased on clinical record review, staff interview, and policy review the facility failed to ensure assessments were completed before and after dialysis and ensure ongoing coordination between the facility and dialysis center for 1 of 1 resident reviewed for dialysis (Resident #1). The facility reported a census of 75 residents.
  7. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 23, 2026
    Inspectors wroteBased on observation, staff interviews, and facility policy review the facility failed to implement Enhanced Barrier Precautions (EBP) for 2 of 3 residents reviewed (Resident #6 and Resident #11). The facility reported a census of 75 residents.
October 23, 2025Complaint inspection · 1 citation
  1. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 5, 2025
    Inspectors wroteBased on clinical record review, resident interviews, staff interviews, training documentation, personnel files, and policy review the facility failed to ensure 2 of 5 residents received respectful dignified care that protected their right to privacy (Residents #2 and #8). An Activity Assistant walked into Resident #2's room while a Certified Nurses Aide (CNA) was providing personal cares, and into Resident #8's room while she was dressing and using the restroom. The facility reported a census of 70 residents.
September 15, 2025Complaint inspection · 2 citations
  1. E
    Have a plan that describes the process for conducting QAPI and QAA activities.
    F865 · Administration · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) October 15, 2025
    Inspectors wroteBased 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.
  2. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 15, 2025
    Inspectors wroteBased on clinical record review, staff interviews and facility policy review, the facility failed to report an allegation of resident to resident abuse,(Resident #3 and Resident #4). The facility reported a census of 76 residents.
April 9, 2025Standard inspection, Complaint inspection · 23 citations
  1. F
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on observation, clinical record review, facility policy review, and staff and resident interviews, the facility failed to ensure sufficient staff in order to provide bathing and/or grooming assistance for 8 of 13 residents reviewed for activities of daily living assistance (Residents #2, #10, #13, #30, #46, #49, #71, & #231). The facility reported a census of 74 residents.
  2. F
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on facility policy and staff interview, the facility failed to carry out a system of surveillance to track and address infections and potential infections in the facility. The facility reported a census of 74 residents.
  3. E
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on observation, record review, resident interviews, staff interviews, and policy review the facility failed to treat 3 of 7 residents reviewed with dignity and respect while providing care and services (Residents #30, #49, and #51). The facility reported a census of 74 residents.
  4. E
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on observation, clinical record review, facility policy review, and staff and resident interviews, the facility failed to provide bathing and/or grooming assistance for 8 of 13 residents reviewed for activities of daily living assistance (Residents #2, #10, #13, #30, #46, #49, #71, #231). The facility reported a census of 74 residents.
  5. E
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on clinical record review, facility policy review, and staff interviews, the facility failed to carry out wound assessments and/or wound treatments for 3 of 6 residents reviewed for non-pressure wounds (Residents #63, #71, and #232). The facility reported a census of 74 residents.
  6. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on observation, facility cleaning schedules, and staff interview, the facility failed to maintain adequate kitchen sanitation for 2 of 2 kitchen observations. The facility reported a census of 74 residents.
  7. E
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on clinical record review, facility policy review, and staff interview, the facility failed to offer influenza vaccines to 4 of 5 residents reviewed for immunizations (Residents #2, #8, #10, and #63). The facility reported a census of 74 residents.
  8. E
    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.
    F887 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on clinical record review, facility policy review, and staff interview, the facility failed to offer a Covid-19 vaccine for 1 of 5 residents reviewed for vaccinations (Resident #2). The facility reported a census of 74 residents.
  9. D
    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.
    F578 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to ensure resident records included advance directive wishes for 2 of 24 residents reviewed for code status (Residents #2 and #10). The facility reported a census of 74 residents.
  10. D
    Protect each resident from the wrongful use of the resident's belongings or money.
    F602 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 28, 2025
    Inspectors wroteBased on observation, clinical record review, pharmacy record review, resident interview, police narrative, staff interviews, and policy review the facility failed to protect 1 of 3 residents reviewed for abuse from misappropriation of property and exploitation (Resident #51). The facility reported a census of 74 residents.
  11. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 28, 2025
    Inspectors wroteBased on observation, clinical record review, pharmacy record review, resident interview, staff interviews, and policy review the facility failed to report potential misappropriation and exploitation for 1 of 3 residents reviewed (Resident #51). Facility staff indicated they were aware of potential incidents as early as July 2024. The facility reported a census of 74 residents.
  12. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 28, 2025
    Inspectors wroteBased on a police narrative, clinical record review, resident interview, staff interviews, and facility policy review the facility failed to prevent further potential misappropriation of property and exploitation and failed to conduct thorough investigations into two incidents for 1 of 3 residents reviewed (Resident #51). The facility reported a census of 74 residents.
  13. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on clinical record review, interview, and facility policy review the facility failed to provide services according to physician orders for 1 of 4 residents reviewed (Residents #49). The facility reported a census of 74 residents.
  14. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on clinical record review, facility policy review, and staff interview, the facility failed to complete regular assessments and treatments to treat a pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident #71). The facility reported a census of 74 residents.
  15. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on observation, clinical record review, and staff interview, the facility failed to ensure safe wheelchair movement for 1 of 1 residents reviewed for wheelchair safety (Resident #41). The facility reported a census of 74 residents.
  16. D
    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.
    F728 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on personnel file review, the Health Facility Database (HFD), and interviews the facility failed to ensure 1 of 4 Certified Nursing Aides (CNAs) was certified prior to employment. The facility reported a census of 74 residents.
  17. D
    Observe each nurse aide's job performance and give regular training.
    F730 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on personnel file review, staff training records, and interviews the facility failed to ensure 1 of 4 Certified Nursing Aides (CNAs) received a performance evaluation, competency evaluation, or training based on performance reviews. The facility reported a census of 74 residents.
  18. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on clinical record review, facility policy review, and staff and resident interviews, the facility failed to ensure the availability of routine medications for 2 of 7 residents reviewed for medications (Resident #17 and #13) The facility reported a census of 74 residents.
  19. D
    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.
    F803 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on observation, facility menus, facility policy review, and staff interview, the facility failed to follow the menu for 2 out of 2 residents on a pureed diet to ensure nutritional needs were met. The facility reported a census of 74 residents.
  20. D
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on observation, facility policy review, and resident and staff interviews, the facility failed to ensure staff served food at palatable hot holding temperatures for 1 of 1 meal observed. The facility reported a census of 74 residents.
  21. D
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    F947 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on personnel file review, staff training records, and interviews the facility failed to ensure 1 of 4 Certified Nursing Aides (CNAs) completed 12 hours of in-services per year that included abuse and dementia training. The facility reported a census of 74 residents.
  22. B
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for minimal harm, pattern · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on clinical record review, interview, and policy review the facility failed to notify the Office of the State Long-Term Care Ombudsman of resident transfers to the hospital for 3 of 3 residents reviewed for hospitalizations (Residents #31, #43, #70). The facility reported a census of 74 residents.
  23. B
    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.
    F625 · Resident Rights · No actual harm, potential for minimal harm, pattern · Corrected (the home has a date of correction) May 9, 2025
    Inspectors wroteBased on clinical record review, Progress Notes, staff interview, and facility policy review the facility failed to notify a resident and their representative of the cost to hold their bed when the resident was transferred out of the facility for 3 of 3 residents reviewed for hospitalization (Residents #31, #43, #70). The facility failed to complete written Bed Hold notices or provide potential costs to the resident or family representative. The facility reported a census of 74 residents.
February 5, 2025Complaint inspection · 3 citations
  1. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 7, 2025
    Inspectors wroteBased on clinical record review, facility policy, provider interview, and staff interviews the facility failed to notify resident's representatives and providers in a timely manner of test results related to changes in clinical conditions for 2 of 3 residents reviewed for notification (Residents #2 and #3). The responsible parties were not notified of x-ray results (Resident #2) or a new urinary tract infection (Resident #3). The facility further failed to provide x-ray and urine culture results to providers in a timely manner (Residents #2 and #3). The facility reported a census of 77 residents.
  2. D
    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.
    F726 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 7, 2025
    Inspectors wroteBased on review of the electronic health record, hospital reports, facility policy, and interviews the facility failed to provide sufficient resident assessments and interventions to maintain resident's highest practical physical and psychosocial well-being for 2 of 3 residents reviewed (Residents #2 and #3). The review revealed staff assessed a resident with new orders for as needed (PRN) oxygen and new complaints of breathing and chest discomfort 1 time during a 56 hour period, and did not assess a resident with pending urine culture results for 8 days. The facility reported a census of 77 residents.
  3. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 7, 2025
    Inspectors wroteBased on clinical record review and staff interviews the facility failed to maintain accurate and complete clinical records for 2 of 3 residents reviewed for records (Residents #2 and #3). The medical records for Resident #2 and Resident #3 failed to reflect the resident's current health conditions and the services provided to ensure communication throughout the interdisciplinary team. The facility reported a census of 77 residents.
November 25, 2024Complaint inspection · 2 citations
  1. E
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    F800 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 21, 2024
    Inspectors wroteBased on observation, policy review, and staff interview the facility failed to serve hot food at least 135 degrees Fahrenheit and provide a palatable meal for 2 of 2 noon meal trays tested. The facility reported a census of 78 residents.
  2. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 21, 2024
    Inspectors wroteBased on observation, clinical record review, policy review, and resident and staff interview the facility failed to complete pre-dialysis and post-dialysis assessments for 1 of 1 resident on dialysis (Resident #2), and the facility failed to routinely assess a resident's skin condition for 1 of 1 resident reviewed for skin impairments (Resident #4). The facility reported a census of 78 residents.
August 21, 2024Complaint inspection · 1 citation
  1. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) September 21, 2024
    Inspectors wroteBased on clinical record review, staff and resident interviews, policy review, and observations the facility failed to provide adequate assessment and timely interventions for 1 of 4 residents reviewed (Resident #2). The facility reported a census of 73 residents.
April 30, 2024Complaint inspection · 2 citations
  1. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 17, 2024
    Inspectors wroteBased on clinical record review, facility policy and staff interview, the facility failed to follow physician orders for 1 of 3 residents reviewed. (Resident #2). The facility reported a census of 70 residents.
  2. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) May 17, 2024
    Inspectors wroteBased on clinical record review and staff interviews, the facility failed to provide appropriate assessment and interventions for 1 of 3 residents reviewed. (Resident #1). The facility reported a census of 70 residents.
February 22, 2024Standard inspection, Complaint inspection · 12 citations
  1. J
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Immediate jeopardy to resident health or safety, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on observations, clinical record review, staff interviews and facility policy review, the facility failed to complete accurate evaluation, failed to implement interventions and failed to prevent a staff member from allowing an exit seeking cognitively impaired resident from leaving the facility at 5:40 AM, walking down the street around the corner, down a main road 0.3 miles (1584 feet) and being outside in below freezing temperatures for 20 minutes. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The Facility reported a census of 67 Residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began on February 19, 2024 on February 20, 2024 at 10:45 a.m. Facility staff corrected the Immediate Jeopardy on February 20, 2024 through the following actions: a. [...]
  2. F
    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.
    F843 · Administration · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) March 22, 2024
    Inspectors wroteBased on record review and staff interview, the facility failed to attempt to enter into a transfer agreement with a hospital in an effort to ensure that the transfer of residents was safe and orderly. The deficient practice had the potential to affect all residents who resided in the facility. The facility identified a census of 67 residents.
  3. E
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 22, 2024
    Inspectors wroteBased on observations, clinical record review, staff and resident interviews and facility policy review the facility failed to treat 4 out of 4 resident reviewed with dignity for cares and meals (Resident #32, 34, 52, and 56). The facility reported a census of 67 residents.
  4. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 22, 2024
    Inspectors wroteBased on observation, interview, and facility policy review the facility failed to cover resident drinks during transportation through the hallways in 2 of 3 hallways observed for resident room tray delivery. The facility reported a census of 67 residents.
  5. E
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    F883 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) March 22, 2024
    Inspectors wroteBased on record review, interviews, and policy review the facility failed to document education and/or administration of flu and pneumococcal immunizations for 4 of 5 residents reviewed for immunizations (Residents #1, #4, #31, and #267). The facility reported a census of 67 residents.
  6. D
    Allow residents to self-administer drugs if determined clinically appropriate.
    F554 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) April 15, 2024
    Inspectors wroteBased on observation, resident and staff interviews and clinical record review, the facility failed to complete a resident assessment for 1 of 1 residents reviewed for self-administration of medications, (Resident #19). A resident's medication was left in their possession without a completed assessment to determine if self-administration was clinically appropriate. The facility reported a census of 67 residents.
  7. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 22, 2024
    Inspectors wroteBased on observation, manufacturer's recommendations and staff interviews, the facility failed to follow manufacturer ' s recommendations while administering insulin utilizing a KwikPen, for 1 of 1 residents reviewed for insulin administration (Resident #167). The facility reported a census of 67 residents.
  8. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 22, 2024
    Inspectors wroteBased on observation, interview, clinical record review, and facility policy review, the facility failed to assess and document an open ulcerated wound and further failed to perform hand hygiene at appropriate times during wound care to prevent infection for 1 of 2 residents reviewed for skin conditions, (Resident #267). The facility reported a census of 67 residents.
  9. D
    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.
    F726 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) March 22, 2024
    Inspectors wroteBased on observation, clinical record review, document review and staff interview the facility failed to ensure licensed and certified nursing staff had documented competency skills to show skill proficiency for 2 of 2 employees sampled (Staff B and C). The facility identified a census of 67 residents.
  10. D
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 22, 2024
    Inspectors wroteBased on observation, clinical record review and staff interviews, the facility failed to follow physician ' s orders for 1 of 1 residents reviewed for insulin administration (Resident #167). The facility reported a census of 67 residents.
  11. D
    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.
    F887 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 22, 2024
    Inspectors wroteBased on record review, interviews, and policy review the facility failed to document education and/or administration of COVID-19 immunizations for 3 of 5 residents reviewed for immunizations (Residents #4, #31, and #267). The facility reported a census of 67 residents.
  12. D
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    F943 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) March 22, 2024
    Inspectors wroteBased on personnel record review and staff interview, the facility failed to ensure mandatory Dependent Adult Abuse training had been completed within 6 months of employment for 1 of 5 staff reviewed (Staff F). The facility reported a census of 67 residents.
October 5, 2023Complaint inspection · 7 citations
  1. G
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 19, 2023
    Inspectors wroteBased on clinical record review, observation, and staff interviews, the facility failed to adequately provide supervision to keep one of three residents safe from an accident with injury (Resident #6). While providing care to a resident in bed who required extensive assistance of two persons with bed mobility, they completed the task with only one person. As they rolled Resident #6, he fell out of bed, and received a hip fracture. In addition, the facility failed to lock the medication cart while unsupervised. During the time the lock remained unlock, at least one resident sat need the medication cart.
  2. G
    Provide safe, appropriate pain management for a resident who requires such services.
    F697 · Quality of Life and Care · Actual harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) October 19, 2023
    Inspectors wroteBased on clinical record review, observations, staff and resident interviews the facility failed to provide pain medications for 1 of 10 residents reviewed (Resident #3). Resident #3 missed 14 doses of fentanyl (pain medication) patch. The documented assessments revealed that she had an increase in pain from not every day and mild to everyday and moderate.
  3. F
    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.
    F727 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) November 5, 2023
    Inspectors wroteBased on record review, staffing assignment sheets, and staff interviews the facility failed to have eight hours of continuous Registered Nurse (RN) coverage in 24-hours in the month of September. The facility reported a census of 56.
  4. E
    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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) November 5, 2023
    Inspectors wroteBased on observation and staff interview, the facility failed to provide housekeeping services in a manner to maintain a safe, clean, comfortable, and homelike environment. The facility reported a census of 55 residents.
  5. E
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) November 5, 2023
    Inspectors wroteBased on clinical record review, observations, staff, and resident interviews the facility failed to provide 4 of 4 residents reviewed with two baths a week (Residents #1, #3, #7, and #9).
  6. E
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) November 5, 2023
    Inspectors wroteBased on clinical record review, observations, staff, and resident interviews the facility failed to complete a shift to shift narcotic count. The facility reported a census of 56.
  7. D
    Ensure services provided by the nursing facility meet professional standards of quality.
    F658 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) November 5, 2023
    Inspectors wroteBased on clinical record review, staff and resident interviews and observations the facility failed to follow physician's orders for 1 of 10 residents reviewed (Resident #9).

Fire safety inspections

14 fire safety citations on file: 4 on April 23, 2026, 3 on April 9, 2025, 7 on February 22, 2024.

Every fire safety citation14 citations
  1. F
    Install emergency lighting that can last at least 1 1/2 hours.
    K 291 · April 23, 2026 · Corrected (the home has a date of correction)
  2. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · April 23, 2026 · Corrected (the home has a date of correction)
  3. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · April 23, 2026 · Corrected (the home has a date of correction)
  4. F
    Ensure proper usage of power strips and extension cords.
    K 920 · April 23, 2026 · Corrected (the home has a date of correction)
  5. F
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · April 9, 2025 · Corrected (the home has a date of correction)
  6. F
    Ensure proper usage of power strips and extension cords.
    K 920 · April 9, 2025 · Corrected (the home has a date of correction)
  7. E
    Install corridor and hallway doors that block smoke.
    K 363 · April 9, 2025 · Corrected (the home has a date of correction)
  8. F
    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.
    K 222 · February 22, 2024 · Corrected (the home has a date of correction)
  9. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · February 22, 2024 · Corrected (the home has a date of correction)
  10. F
    Have simulated fire drills held at unexpected times.
    K 712 · February 22, 2024 · Corrected (the home has a date of correction)
  11. F
    Ensure that testing and maintenance of electrical equipment is performed.
    K 921 · February 22, 2024 · Corrected (the home has a date of correction)
  12. E
    Use approved construction type or materials.
    K 161 · February 22, 2024 · Corrected (the home has a date of correction)
  13. E
    Install corridor and hallway doors that block smoke.
    K 363 · February 22, 2024 · Corrected (the home has a date of correction)
  14. D
    Properly select, install, inspect, or maintain portable fire extinguishes.
    K 355 · February 22, 2024 · Corrected (the home has a date of correction)

Fines and payment denials

DatePenaltyAmount or length
February 22, 2024Fine $16,068
February 22, 2024Payment Denial 24 days from March 22, 2024
October 5, 2023Fine $13,039
October 5, 2023Payment Denial 2 days from November 3, 2023

A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeIowaUnited States
All nursing staff (RN, LPN and aides)3.553.823.86
Registered nurses0.650.740.69
All nursing staff on weekends3.023.373.42
Nurse aides2.33
Licensed practical nurses0.57
Nursing staff turnover (share who left in a year)55.4%44.0%45.8%
Registered nurse turnover54.5%42.1%42.9%
Administrators who left1

CMS expects 3.07 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.76 on weekdays and 3.02 on weekends, 20% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.55 in April to June 2025 to 3.55 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.550.653.763.02 0.0%0 of 9074
Oct to Dec 20253.400.603.543.03 0.0%0 of 9272
Jul to Sep 20253.450.503.593.07 0.0%0 of 9274
Apr to Jun 20253.550.413.723.14 0.8%1 of 9174
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Iowa, Jan to Mar 20263.800.713.983.364.7%0.3% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Iowa

JobMedianMiddle halfEmployed
Iowa, all employers
CNAs (nursing assistants)$18.92$17.96 to $21.9522,670
LPNs and LVNs$30.11$27.12 to $34.065,510
Registered nurses$37.80$32.83 to $41.3234,420
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

Work here? Share your pay anonymously

For Silver Oak Nursing and Rehabilitation Center LLC. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

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Optional questions
Mandatory overtime?
How did staffing feel on your usual shift?

Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeIowaUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
23.317.113.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
4.81.50.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.82.41.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
4.83.83.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
1.22.11.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
26.416.614.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
2.54.24.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
21.619.415.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
19.220.923.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
9.113.212.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
2.11.51.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.62.11.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Silver Oak Nursing and Rehabilitation Center LLC's Medicare short-stay residents. How to read these, and what Medicare pays for.

Went home or back to the community

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

US median of homes 51.5% · Iowa: 28 better, 21 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 24 eligible stays.

Potentially preventable readmissions

10.3% this home

No different from the national rate

US median of homes 10.7% · Iowa: 1 better, 1 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 50 eligible stays.

Infections that led to a hospital stay

8.2% this home

No different from the national rate

US median of homes 7.1% · Iowa: 0 better, 0 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 28 eligible stays.

Self-care and mobility at discharge

57.1% this home

Median of homes: Iowa56.7% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 35 residents counted.

Falls with major injury

2.0% this home

Median of homes: Iowa0.0% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 49 residents counted.

New or worsened pressure ulcers

0.0% this home

Median of homes: Iowa1.8% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 49 residents counted.

Medication list given at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Iowa100.0% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 11 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: SILVER OAK NURSING AND REHABILITATION CENTER LLC. CMS links this home to Ivy Healthcare Group, a group of 4 nursing homes averaging 1.8 stars overall.

NameRoleTypeShareSince
De Jong, AlsionOperational/managerial controlIndividual08/15/2025
Younger, CleteOperational/managerial controlIndividual02/01/2016
De Jong, AlsionAdp of the SNFIndividual08/15/2025
Hyman, ChaimAdp of the SNFIndividual05/14/2025
Younger, CleteAdp of the SNFIndividual02/01/2016

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 13 problems in this area, most recently on April 23, 2026: "Provide safe, appropriate dialysis care/services for a resident who requires such services."
  2. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 10 problems in this area, most recently on April 23, 2026: "Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies."
  3. How many nurses and aides work each shift, nights and weekends included?Inspectors cited 8 problems in this area, most recently on April 23, 2026: "Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift."
  4. How are allegations of abuse or neglect reported and investigated, and who tells the family?Inspectors cited 6 problems in this area, most recently on April 23, 2026: "Develop and implement policies and procedures to prevent abuse, neglect, and theft."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.02 hours per resident per day, below the Iowa average of 3.37.
  6. How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.

Other nursing homes nearby

Iowa contacts for a concern about a nursing home

These are the official offices in Iowa. NursingHomeClear cannot take or act on complaints.

Common questions

What is Silver Oak Nursing and Rehabilitation Center LLC's Medicare star rating?
CMS rates Silver Oak Nursing and Rehabilitation Center LLC 1 out of 5 stars overall, with 1 for health inspections, 4 for staffing and 3 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Silver Oak Nursing and Rehabilitation Center LLC get at its last inspection?
7 health deficiencies at the standard inspection on April 23, 2026. The Iowa average is 6.5.
Has Silver Oak Nursing and Rehabilitation Center LLC been fined?
Yes. CMS lists 2 fines totaling $29,107 in the last three years.
Does Silver Oak Nursing and Rehabilitation Center LLC accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Silver Oak Nursing and Rehabilitation Center LLC?
CMS lists 5 owners and managers, and links the home to Ivy Healthcare Group. Legal business name: SILVER OAK NURSING AND REHABILITATION CENTER LLC.

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