Inspection Reports for
Silver Oak Nursing and Rehabilitation LLC

The facility failed to ensure that two residents received respectful and dignified care protecting their privacy, as an Activity Assistant entered their rooms without knocking during personal care activities, causing distress. The staff member was educated and disciplined for repeated incidents.

The complaint investigation involved substantiated allegations that Staff D, an Activity Assistant, entered Resident #2's and Resident #8's rooms without knocking, violating their privacy rights. The facility confirmed multiple incidents and took disciplinary action against Staff D.

The facility failed to ensure that 2 of 5 residents received respectful and dignified care protecting their right to privacy. An Activity Assistant entered residents' rooms without knocking while they were receiving personal care or dressing, causing distress and discomfort to the residents. The facility acknowledged prior similar incidents involving the same staff member.

The complaint investigation found that the facility failed to report an allegation of resident-to-resident abuse that occurred on 6/21/2025 involving Resident #3 and Resident #4. The incident involved physical aggression resulting in injury and infection. The facility's abuse policy required immediate reporting, which was not followed. The complaint was substantiated based on interviews and documentation.

The facility failed to report an incident where Resident #4 slapped Resident #3, causing injury and an infected abscess. The incident was not reported to the state as required by the facility's abuse policy. Additionally, the facility failed to carry out effective Quality Assurance and Performance Improvement activities to correct and prevent ongoing deficiencies related to reporting abuse.

The complaint investigation was substantiated. The facility reported an incident between Resident #3 and Resident #4 involving physical abuse that was not reported timely to the state survey agency as required. The facility failed to notify staff and state officials within mandated timeframes. The facility reported a census of 76 residents during the investigation period.

The facility failed to report an allegation of resident-to-resident abuse within the required timeframe. Resident #4 slapped Resident #3, causing injury and requiring antibiotic treatment. Staff failed to notify appropriate personnel at the time of the incident. The facility also failed to implement effective Quality Assurance and Performance Improvement (QAPI) activities to prevent recurrence.

The complaint investigation involved allegations of dignity and respect violations, abuse and exploitation including inappropriate staff-resident relationships and medication misappropriation, failure to provide adequate care including bathing and medication administration, and failure to maintain safe and sanitary conditions.

The facility failed to treat residents with dignity and respect, protect residents from abuse and exploitation, provide timely medication administration, ensure adequate bathing and grooming assistance, provide appropriate wound care, maintain safe wheelchair practices, ensure sufficient staffing, serve food at safe temperatures, and implement an effective infection control program.

The complaint investigation was triggered by allegations of resident dignity violations, abuse and exploitation involving staff and residents, medication misappropriation, failure to provide adequate care, and failure to follow regulatory requirements for notifications and vaccinations.

The facility failed to treat residents with dignity and respect, ensure advance directive documentation, protect residents from abuse and exploitation, notify ombudsman of hospital transfers, provide timely bed hold notices, administer medications as ordered, provide adequate bathing and grooming assistance, maintain wound care, ensure safe wheelchair use, maintain sufficient staffing, provide proper CNA certification and training, ensure medication availability, serve food at proper temperatures, maintain kitchen sanitation, implement infection control surveillance, offer influenza and COVID-19 vaccinations, and provide adequate dietary services.

Complaints #126563-C, #127121-C, #127196-C, #127475-C, and #127628-C were substantiated. Facility reported incident #127679-I/M information will be sent separately.

The facility was found deficient in multiple areas including resident rights and dignity, advance directives, abuse prevention and reporting, medication administration, nursing staff sufficiency, infection control, and quality of care related to skin and wound management. Several residents were affected by these deficiencies.

The complaint investigation found that the facility failed to notify responsible parties and providers timely of test results for Residents #2 and #3, failed to conduct timely assessments during changes in condition, and failed to maintain accurate clinical records. The responsible parties were not notified of chest x-ray results or new urinary tract infection. The facility reported a census of 77 residents.

The facility failed to notify responsible parties and providers in a timely manner of chest x-ray and urine culture results for two residents, failed to conduct timely and sufficient resident assessments related to changes in condition, and failed to maintain accurate and complete clinical records reflecting residents' current health conditions and services provided.

Complaint #126237-C was substantiated.

The facility failed to promptly notify residents' representatives and providers of test results related to changes in clinical conditions for 2 of 3 residents reviewed. The facility also failed to maintain sufficient resident assessments and interventions to ensure resident safety and well-being.

Complaints #124910-C and #125055-C were substantiated. Facility reported incident #124696-I was not substantiated.

The facility was found deficient in quality of care related to failure to complete pre- and post-dialysis assessments for a resident on dialysis, failure to routinely assess a resident's skin condition, and failure to serve hot food at appropriate temperatures and provide palatable meals. Complaints #124910-C and #125055-C were substantiated, while the facility reported incident #124696-I was not substantiated.

The facility failed to complete pre- and post-dialysis assessments for one resident on dialysis and failed to routinely assess skin condition for another resident. Additionally, the facility failed to serve hot food at the required temperature and provide palatable meals for two tested noon meal trays.

Complaints #120982-C and #122656-C were substantiated. Complaint #122218-C and incidents #122804-I and #122827-I were not substantiated.

The facility failed to provide adequate assessment and timely interventions for one of four residents reviewed (Resident #2), who experienced critically low blood sugar and did not receive timely glucagon injection as ordered. Staff re-education and corrective actions were planned to prevent recurrence.

The facility failed to provide adequate assessment and timely intervention for Resident #2 who experienced a critically low blood sugar and was unresponsive. Staff delayed administration of Glucagon injection as ordered, instead calling the primary care provider, resulting in delayed treatment. Re-education was provided to the involved nurse and plans for further staff training were noted.

The facility failed to follow physician orders for medication administration for Resident #2, including failure to administer Suboxone and incorrect dosing of Fluoxetine. Additionally, the facility failed to provide appropriate assessment and interventions for Resident #1 related to PICC line management and flushing, resulting in complications and hospital readmission.

Complaints #120314-C and #120414-C were substantiated based on investigation findings.

The facility failed to follow physician orders for medication administration for Resident #2 and failed to provide appropriate assessment and interventions for Resident #1. Issues included missed medication orders, incorrect medication dosages, failure to arrange treatment, and inadequate care related to PICC line management and quality of care.

Complaint #119984-C was unsubstantiated.

The facility failed to complete a resident assessment for self-administration of medications for one of three residents reviewed, with the complaint found unsubstantiated. The facility reported a census of 68 residents and lacked a self-administration medication assessment in the electronic health record.

The facility was found deficient in multiple areas including failure to treat residents with dignity, incomplete resident assessments for medication self-administration, failure to follow manufacturer recommendations for insulin administration, inadequate wound care and hand hygiene, failure to prevent resident elopement resulting in immediate jeopardy, lack of documented nursing competencies, medication administration errors, uncovered resident drinks during transport, absence of hospital transfer agreements, incomplete immunization documentation and education, and failure to ensure mandatory dependent adult abuse training for staff.

Complaint #118859 was substantiated. Incident #118928 was substantiated.

The facility was found to have multiple deficiencies including failure to treat residents with dignity, incomplete resident assessments for self-administration of medications, failure to follow manufacturer recommendations for insulin administration, inadequate wound care and documentation, lack of accurate transfer agreements, and insufficient staff competency documentation. Several residents were found at risk due to these deficiencies.

The complaint investigation was triggered by allegations of improper insulin administration, inadequate wound care and hand hygiene, failure to prevent elopement of a cognitively impaired resident, and lack of competency documentation for nursing staff. The elopement incident involved Resident #67 who left the facility unsupervised and was outside in below freezing temperatures for 20 minutes before being found and returned safely. Immediate Jeopardy was identified and corrected during the survey.

The facility failed to follow manufacturer instructions for insulin administration, failed to properly assess and document wounds and perform hand hygiene during wound care, allowed a cognitively impaired resident to elope causing immediate jeopardy, and lacked documented competency training for nursing staff.

The investigation involved complaints #114902, #114904, #114935, #115229, #115618, #115757 and facility reported incidents #114951 and #115734. Most complaints were substantiated except complaint #115618 which was not substantiated.

The facility was found not in compliance with several requirements including maintaining a safe, clean, and homelike environment, following physician's orders for care, providing adequate assistance with activities of daily living, ensuring resident safety to prevent accidents, securing medication carts, and providing pain management. Specific deficiencies included mold in shower rooms, failure to follow physician orders for a resident's feeding tube care, inadequate bathing assistance for multiple residents, a resident falling from bed resulting in a hip fracture, unlocked medication carts, and missed doses of pain medication.

The facility was found deficient in maintaining a safe and clean environment, following physician orders for resident care, providing adequate bathing assistance, securing medication carts, preventing resident falls, managing pain medications, ensuring adequate RN coverage, and completing shift-to-shift narcotic counts.

The investigation was triggered by complaints #112691-C, #112805-C, #112986-C, #113177-C and facility self-reported incidents #112163-I and #113362-I. Complaints #112691-C, #112805-C, #112986-C and #113177-C were substantiated. Facility Self-Reported Incident #112163-I was substantiated.

The facility failed to provide translator services for a non-English speaking resident, did not update care plans timely or comprehensively for residents with new medical devices or after falls, failed to obtain and transcribe physician orders for wound care, did not follow proper infection control during incontinence care, failed to document physical assessments after abuse allegations, and did not prevent or properly respond to falls including incomplete neurological assessments. Additionally, tracheostomy care was not performed according to professional standards.

The facility was found deficient in multiple areas including failure to provide translator services for a non-English speaking resident, incomplete care plans addressing medical devices and falls, failure to obtain and transcribe physician orders for wound care, improper incontinence care technique, lack of documented physical assessments after abuse allegations, inadequate fall prevention and post-fall assessments, and improper tracheostomy care technique.

Complaint #110839-C was substantiated.

The facility failed to complete appropriate vital signs and neurological assessments post unwitnessed resident falls for 3 of 5 residents reviewed, despite documented care plans and protocols. Staff did not consistently follow the Neuro Checks protocol, especially when residents were asleep, and neurological assessments were incomplete or missing. The complaint #110839-C was substantiated.

The facility failed to complete appropriate vital signs and neurological assessments post unwitnessed falls for 3 of 5 residents reviewed, despite established care plans and protocols. Staff interviews confirmed expectations to complete these assessments even if residents were asleep, but documentation showed missed assessments.

Complaints #110417, #110440, #110549, and #110633 were substantiated. Complaint #110438 was not substantiated. Facility reported incidents #110504, #110641, and #110639 were not substantiated.

The facility failed to report a resident elopement and fall injury to the Department of Inspections and Appeals, failed to provide adequate nursing assessments for two residents, and failed to provide adequate pain management for a resident with burn injuries. The facility also failed to adequately supervise a resident to prevent elopement and subsequent injury.

The facility was found deficient in multiple areas including failure to maintain resident dignity and respect, inadequate call light accessibility, missing advanced directives for some residents, failure to provide required CMS forms, failure to follow physician orders especially regarding oxygen therapy and medication administration, incomplete assessments for dialysis patients, failure to arrange transportation for physician appointments, inadequate care for feeding tubes, failure to prevent accidents during resident transfers, and improper medication storage and labeling.

Complaint #109340-C was substantiated based on findings related to resident dignity, call light response, and missing property.

The facility was found deficient in multiple areas including resident rights and dignity, call light accessibility, advanced directives, medication administration, quality of care, accident prevention, tube feeding management, dialysis care, pharmacy services, and medication storage. Specific issues included delayed staff response to call lights, missing resident property, inconsistent advanced directive documentation, failure to follow physician orders, inadequate supervision during transfers, improper tube feeding management, incomplete dialysis assessments, delayed medication delivery, and unsecured medications.

Complaints #106613-C, #107188-C, and #107286-C were substantiated. Facility Self-Reported Incidents #106615-I, #106616-I, and #107290-I were substantiated.

The facility was found deficient in multiple areas including failure to treat residents with dignity and respect due to staffing shortages, failure to maintain a clean and safe environment, failure to protect residents from abuse including resident-to-resident altercations, failure to report alleged abuse in a timely manner, failure to thoroughly investigate abuse allegations, failure to follow physician orders for a resident with bleeding, insufficient nursing staff to meet resident needs, and failure to provide adequate staff to prevent behaviors in a cognitively impaired resident.

Complaints #105228-C and Facility Self-Reported Incident #105472-I were substantiated. The deficiencies from the Complaint Survey conducted May 4, 2022 to May 17, 2022 were corrected.

The facility was found to have multiple deficiencies including failure to respect residents' dignity, failure to maintain a clean and homelike environment, failure to thoroughly investigate alleged abuse, neglect, exploitation, or mistreatment, and failure to provide adequate ADL care and restorative services. Several residents required extensive assistance and the facility failed to provide scheduled baths/showers and restorative programs as required.

The Facility Self-Reported Incident #104003-I was substantiated. The complaint investigation revealed failure to conduct required background checks and medication management deficiencies.

The facility was found to have failed to conduct a criminal background check for one of six employees prior to hire, and deficiencies were found in the management and reconciliation of controlled medications, including missing morphine and inadequate narcotic count documentation.

The facility was found deficient in multiple areas including abuse prevention and reporting, transfer and discharge requirements, resident assessments, care planning, medication administration, infection control, staffing, and quality assurance. Specific issues included failure to report abuse allegations timely, incomplete transfer documentation, inadequate care plans, medication errors, and insufficient infection control practices.

The survey was complaint-driven, investigating multiple complaints identified by Iowa Department of Inspections and Appeals. The complaints included issues with advance directives, Medicaid/Medicare notices, transfer/discharge notices, comprehensive assessments, pressure ulcer treatment, accident hazards, drug storage, infection control, and antibiotic stewardship. The report includes substantiation of these complaints through record reviews, interviews, and policy reviews.

The facility was found deficient in multiple areas including failure to determine and inform residents about advance directives, failure to provide proper Medicaid/Medicare notices, failure to provide transfer/discharge notices, incomplete comprehensive assessments and baseline care plans, inadequate treatment and documentation for pressure ulcers, failure to maintain a safe environment free of accident hazards, improper labeling and storage of drugs and biologicals, incomplete facility assessments, and deficiencies in infection prevention and control programs. The facility also failed to provide proper documentation and notifications related to transfers, bed hold policies, and infection control. Systemic measures and plans of correction were outlined for each deficiency.