Inspection Reports for Oakview Nursing & Rehabilitation
720 Oakbrook Drive, Marion, IA, 52302
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 3, 2025, identified one deficiency related to acceptance of a credible allegation of substantial compliance and the facility’s plan of correction. Earlier inspections showed a pattern of deficiencies involving documentation, resident supervision, and infection control, with some substantiated complaints regarding resident safety and timely communication with physicians. Prior issues included failure to provide updated Medicare notices, inadequate supervision to prevent wandering, and lapses in medication and care plan management. Complaint investigations were mostly unsubstantiated except for one substantiated case involving inadequate supervision that led to unsafe resident interactions. The facility has shown some improvement over time, with accepted plans of correction and certifications of compliance following several inspections.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
14% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
36 residents
Based on a August 2025 inspection.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 3, 2025
Visit Reason
The document is a plan of correction following a credible allegation of substantial compliance.
Findings
Based on acceptance of the credible allegation of substantial compliance and the Plan of Correction, the facility will be certified in compliance effective August 22, 2025.
Deficiencies (1)
Initial comments regarding acceptance of credible allegation of substantial compliance and Plan of Correction.
Report Facts
Certification effective date: Aug 22, 2025
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 1
Date: Aug 21, 2025
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and investigation of complaints and a facility reported incident.
Complaint Details
The visit included investigation of Complaints #1804304-C, #1804307-C and Facility Reported Incident 1084309-I.
Findings
The facility failed to provide residents ending skilled care with current Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) documents for 3 of 3 residents reviewed. The facility was not using the updated CMS forms as required.
Deficiencies (1)
Failure to provide residents ending skilled care with current Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) documents.
Report Facts
Residents reviewed: 3
Census: 36
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed on 08/21/2025 regarding responsibility for completion of ABN and NOMNC forms. | |
| Administrator | Interviewed on 08/21/2025 regarding awareness of updated forms. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 15, 2025
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility will be certified in compliance effective April 11, 2025, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 1
Date: Mar 26, 2025
Visit Reason
The inspection was conducted as a result of complaint #127430-C, which was substantiated after investigation from March 24, 2025 to March 26, 2025.
Complaint Details
Complaint #127430-C was substantiated based on observations, clinical record review, and interviews indicating failure to prevent wandering and unsafe resident interactions.
Findings
The facility failed to prevent one resident from wandering into another resident's room and putting their hand on that resident, indicating inadequate supervision and assistance devices to prevent accidents. The investigation included clinical record review, observations, and staff and resident interviews.
Deficiencies (1)
The facility failed to ensure the resident environment remains free of accident hazards and that each resident receives adequate supervision and assistance devices to prevent accidents.
Report Facts
Census: 29
Dates of complaint investigation: March 24, 2025 to March 26, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aid (CNA) | Mentioned in interviews regarding resident supervision and incidents |
| Staff B | Certified Nurse Aid (CNA) | Reported observations about resident wandering and supervision needs |
| Staff D | Licensed Practical Nurse (LPN) | Reported on resident behavior and supervision |
| Director of Nursing | Director of Nursing (DON) | Reported on resident wandering and care plan knowledge |
| Administrator | Administrator | Reported on facility policies and communication with consulting company |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 7, 2024
Visit Reason
A complaint investigation for facility reported incident #124525-I was conducted from November 05, 2024 to November 07, 2024.
Complaint Details
Complaint investigation for incident #124525-I; facility found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Aug 29, 2024
Visit Reason
The document serves as a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility was found to be in substantial compliance based on the accepted Plan of Correction, and certification in compliance is effective as of August 27, 2024.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Mar 14, 2024
Visit Reason
The document is a Plan of Correction following a prior inspection, indicating acceptance of the facility's credible allegation of substantial compliance.
Findings
The facility will be certified in compliance effective March 5, 2024, based on acceptance of the Plan of Correction and credible allegation of substantial compliance.
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 5
Date: Feb 15, 2024
Visit Reason
The inspection was conducted as the facility's Annual Recertification Survey from February 12, 2024 to February 15, 2024.
Findings
The facility was found deficient in several areas including resident rights related to dignity and respect during dining, care plan revisions for medication management, sufficient nursing staff response times, food safety and sanitation practices, and infection prevention and control procedures.
Deficiencies (5)
Facility failed to serve 2 out of 16 residents meals in a dignified manner in the dining room.
Care plan failed to include anti-depressant and diuretic medications for one resident.
Facility failed to answer resident call lights in a timely manner for 2 of 39 residents.
Facility failed to ensure sanitary conditions in food service area including refrigerator temperature monitoring and hair covering compliance.
Facility failed to cover clean linens during transport and maintain infection control protocols.
Report Facts
Residents in dining room not served meals on trays: 2
Facility census: 39
Residents with delayed call light response: 2
Number of nurses identified in staffing plan: 2
Number of CNAs identified in staffing plan: 4
Call light response times: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dawn Johnson | Director of Nursing | Reported expectations for call light response and nursing staff involvement in findings |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 19, 2023
Visit Reason
An investigation of Complaints #112641-C, #117411-C, #117557-C and facility Self-Reported Incidents #110746-I and #112583-I was conducted from December 11, 2023 to December 19, 2023.
Complaint Details
Investigation involved multiple complaints and self-reported incidents; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance following the investigation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 7, 2022
Visit Reason
The document is a plan of correction submitted following a prior inspection, indicating acceptance of credible allegation of compliance and certification of the facility in compliance effective November 7, 2022.
Findings
The facility was found to be in compliance based on the accepted plan of correction; no specific deficiencies or findings are detailed in this document.
Inspection Report
Annual Inspection
Census: 39
Deficiencies: 5
Date: Oct 11, 2022
Visit Reason
The inspection was conducted as part of the facility's Annual Recertification Survey and investigation of complaints #104909-C and #105641-C, which were not substantiated.
Complaint Details
The investigation of complaints #104909-C and #105641-C was conducted and both complaints were not substantiated.
Findings
The facility was found deficient in multiple areas including failure to implement abuse/neglect policies, failure to report injuries of unknown source timely, failure to investigate alleged violations thoroughly, failure to revise care plans timely, and failure to provide proper catheter care. The facility also failed to include all relevant staff statements in investigations and did not complete mandatory abuse training within required timeframes.
Deficiencies (5)
Failure to implement the facility's Abuse Policy for 1 out of 1 residents reviewed and failure to have 1 out of 4 Certified Nursing Assistants complete required Abuse training in the required timeframe.
Failure to report injuries of unknown source to the State Agency timely for 1 out of 1 residents reviewed.
Failure to thoroughly investigate all alleged abuse violations for 1 out of 1 residents reviewed.
Failure to revise Resident Care Plans with changes in resident needs for 3 of 12 residents reviewed.
Failure to provide proper catheter care to minimize urinary tract infections for 1 of 1 sampled residents.
Report Facts
Census: 39
Certified Nursing Assistants: 4
Residents reviewed for care plan revisions: 12
Residents reviewed for abuse policy implementation: 1
Residents reviewed for injury reporting: 1
Residents reviewed for catheter care: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Registered Nurse (RN) | Completed Confidential Incident Report and reported Resident #2's wife presence |
| Staff D | Certified Nursing Assistant (CNA) | Failed to complete mandatory abuse training and worked 19 shifts during review period |
| Staff E | Assistant Director of Nursing (ADON)/MDS Nurse | Reviewed falls and interventions for Resident #27 |
| Director of Nursing | Acknowledged staff did not complete catheter care to expectations |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 2, 2022
Visit Reason
An onsite revisit of a complaint survey ending on 2022-05-12 was conducted from June 1, 2022 to June 2, 2022 at the facility.
Complaint Details
This visit was a follow-up to a complaint survey. All deficiencies identified in the complaint survey were corrected.
Findings
All deficiencies were corrected and the facility was found to be in substantial compliance effective May 13, 2022.
Inspection Report
Complaint Investigation
Census: 36
Deficiencies: 3
Date: May 12, 2022
Visit Reason
Investigation of Complaint #104403-C and a Facility Self-Reported Incident #104404-I conducted from May 2, 2022 to May 12, 2022.
Complaint Details
Complaint #104403-C was substantiated. Facility Self-Reported Incident #104404-I was substantiated.
Findings
The complaint and incident were substantiated. Deficiencies were found related to failure to notify physician and responsible party timely about resident changes and injuries, failure to obtain treatment orders timely, and failure to ensure hot liquid safety in the dining room. The facility reported a census of 36 residents.
Deficiencies (3)
Failure to notify resident's physician and responsible party timely of an accident or significant change in condition.
Failure to obtain appropriate treatment orders prior to initiating treatment.
Failure to ensure hot liquid safety; serving hot liquids to residents without nursing staff present.
Report Facts
Resident census: 36
Temperature: 195
Temperature: 140
Temperature: 145.4
Temperature: 155
Temperature: 189
Temperature: 136.4
Temperature: 138.7
Pressure sore size: 0.5
Pressure sore size: 0.5
Pressure sore size: 17
Pressure sore size: 2.5
Pressure sore size: 17
Pressure sore size: 2.5
Burn wound size: 8
Burn wound size: 12
Burn wound size: 4
Burn wound size: 6
Deficiency count: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff D | Licensed Practical Nurse (LPN) | Recorded nursing progress notes and involved in resident care and injury assessment. |
| Staff B | Certified Nursing Assistant (CNA) | Witnessed coffee spill and assisted in resident care. |
| Staff C | Certified Nursing Assistant (CNA) | Witnessed coffee spill and assisted in resident care. |
| Staff E | Licensed Practical Nurse (LPN) | Assisted with resident injury assessment and nursing care. |
| Staff F | Certified Nursing Assistant (CNA) | Reported observations related to coffee spill and resident condition. |
| Staff G | Licensed Practical Nurse (LPN) | Reported resident injury and coffee spill. |
| Staff H | Registered Nurse (RN)/Facility Wound and Restorative Nurse | Assessed resident's wound and directed treatment. |
| Staff I | Assistant Director of Nursing (ADON) | Reported on notification policy and fax communication issues. |
| Staff J | Registered Nurse (RN) | Ensured treatment was provided after delivery and educated staff. |
| Staff K | Dietary Aide (DA) | Reported on coffee serving and hot liquid safety. |
| Director of Nursing (DON) | Director of Nursing | Oversaw nursing staff education and compliance monitoring. |
Inspection Report
Renewal
Census: 40
Deficiencies: 7
Date: Jul 15, 2021
Visit Reason
The inspection was conducted as a Recertification Survey and investigation of a Facility Self Reported Incident #97783 completed 7/12-15/2021.
Findings
The facility was found to have multiple deficiencies including failure to meet professional standards in medication administration, inadequate catheter care, failure to post correct nurse staffing information, improper food portioning and preparation, inadequate infection prevention and control practices, and failure to ensure proper use of personal protective equipment.
Deficiencies (7)
Nurse failed to follow professional standards by having 2 residents' medication in medication cups on top of the medication cart.
Facility failed to provide proper care of catheters for 2 residents observed with catheters.
Facility failed to post the correct Daily Staff Posting for 3 out of 4 days observed.
Facility staff failed to ensure residents on pureed and general texture diets received proper portion sizes based on the planned menu.
Facility failed to ensure dietary staff properly restrained their hair under hairnets during food preparation and serving.
Facility failed to maintain infection control standards including catheter drainage bags on the floor and improper catheter care for residents.
Facility staff failed to wear proper face masks when working near residents.
Report Facts
Census: 40
Deficiencies cited: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Samantha Gaspar | Director of Nursing | Named in multiple deficiency findings and plans of correction related to medication administration, catheter care, and staff postings |
| Josh Bargman | Culinary Manager | Named in deficiency related to food preparation and portioning |
| Morgan Brunscheen | Administrator | Named in infection control deficiency and plan of correction |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 23, 2020
Visit Reason
Complaints #91476 and #92150 and a Facility Self-Reported Incident #922812 were investigated on 7/20-23/2020.
Complaint Details
Complaints #91476 and #92150 and a Facility Self-Reported Incident #922812 were investigated and found not substantiated.
Findings
The complaints and self-reported incident were investigated and found to be not substantiated.
Inspection Report
Routine
Census: 25
Deficiencies: 0
Date: Jun 22, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 6/22/20 to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with the CMS and CDC recommended practices to prepare for COVID-19.
Report
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