Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oakview Nursing & Rehablitation - Marion during CMS and state inspections, most recent first.
A resident with MS and intact cognition reported that staff flipped her too hard during care, causing her head to hit a side rail and her glasses to break, and that a staff member swatted her shoulder when she held onto the rail because she felt like she was falling. She shared these concerns with a CNA and an activities assistant, who in turn relayed them to management and nursing. Documentation and staff statements showed that the resident had reported in a prior month that someone had done something to her, but the staff member who received this information did not report it, and another nurse who later learned of the allegations did not notify the DON or Administrator. The Administrator acknowledged not reporting the abuse allegation to the state agency when first aware, believing it was a medical issue, and the facility’s self-report log lacked a timely report, contrary to policy requiring immediate internal reporting and external reporting within 24 hours.
Outdated ABN and NOMNC forms were used for 3 residents whose skilled care was ending. The DON said she completed the forms using the versions she had been given and was unaware updated forms were needed, and the Administrator said she did not know the forms had been updated. The record review showed the facility used older CMS-10055 and CMS 10123-NOMNC versions instead of current forms.
A resident with severe cognitive impairments wandered into another resident's room multiple times, engaging in inappropriate behavior. Despite a care plan addressing the resident's wandering and aggressive behaviors, staff struggled to provide constant supervision due to other responsibilities. The facility lacked a specific policy for resident-to-resident incidents, contributing to the failure to prevent the resident from causing distress.
The facility failed to maintain hot foods at the required minimum temperature during a meal service. The Dietary Policies and Procedures specify that hot foods should be held at a minimum temperature of 135°F. However, during the meal service, various food items were recorded below this standard, with temperatures ranging from 90°F to 130°F. The Dietary Manager confirmed the required temperature standard and acknowledged witnessing the temperature readings.
The facility failed to maintain sanitary conditions in three kitchen areas, with issues such as dust and food debris on surfaces, improper dishwasher temperatures, and staff not wearing hair nets. The Dietary Manager acknowledged these problems, including a kink in the dishwasher hose and unfulfilled cleaning duties.
The facility failed to conduct effective QA activities to gather feedback, use data, and take action for systematic investigations of problems affecting facility-wide processes, impacting quality of care, quality of life, and resident safety. Despite having QAPI meetings, the facility did not adequately address dietary issues, focusing more on nursing. The QAPI Plan indicated prioritization of problem-prone areas, but this was not effectively implemented.
The facility failed to ensure dignity for two residents with catheters by not placing catheter bags in dignity bags. One resident, with intact cognition, was observed multiple times with her catheter bag visibly hanging from her bed and recliner. Another resident, who used an electric wheelchair, had his catheter bag visibly hanging from his wheelchair in both his room and the dining room. The DON stated that dignity bags were expected in community environments, but staff were only educated to use them in public areas.
A resident with severe cognitive impairment was physically abused by a CNA during a transfer. The resident, who required substantial assistance, attempted to hit the CNA, who retaliated by punching the resident in the shoulder. This incident violated the facility's abuse prevention policy, which mandates that residents be free from physical abuse.
Failure to Timely Report Resident’s Abuse Allegations and Suspected Crime
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime and allegations of abuse in accordance with section 1150B of the Act. A cognitively intact resident with multiple sclerosis, dysarthria, anarthria, and chronic pain reported that during care a CNA flipped her too hard, causing her head to bump the side rail and her glasses to break. She also stated that staff wore ear devices for music, talked about their boyfriends, did not listen to her, and that one staff member swatted her shoulder when she held onto the rail because she felt like she was falling. The resident believed she had to “go with the flow” because she could not move or get up, and she reported these concerns to a CNA and later to an activities staff member. Documentation of one-on-one activity visits showed that on multiple occasions in January the resident shared concerns with an activities assistant, who reported them to management, nursing, the Life Enrichment Director, and the MDS Coordinator. A facility summary indicated that on one date the ADON met with the resident about a CNA spilling urine on her nightgown and causing pain when changing it, and on another date the resident reported that staff were rude, that when they rolled her she felt like she would fall, and that staff would “smack” her for holding on. The resident stated staff still did this and that the person still worked at the facility, although she did not identify who the person was or when it occurred. The Administrator later reported that the resident denied saying she was hit and attributed her arm movements to her disease. Despite these reports, the facility did not notify the state agency within the required timeframe. An incident report later documented that a CNA reported the resident had said someone hit her arm in December. A written statement from a staff member confirmed that the resident had told her in December that someone had done something to her and that the staff member did not report it. Another nurse learned of the allegation during report and, after speaking with the resident about broken glasses and being upset with named CNAs, did not follow up with the CNAs, the DON, or the Administrator. The Administrator acknowledged that the abuse allegation was not reported to the department when first known because she believed it was more of a medical and health issue, and the facility’s self-report log did not show a report submitted at the time of the initial allegation, contrary to the facility’s abuse reporting policy requiring immediate internal reporting and external reporting within 24 hours.
Outdated Medicare Non-Coverage Notices Used
Penalty
Summary
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on record review and interviews, the facility failed to provide current Advanced Beneficiary Notice (ABN) and Notice of Medicare Non-Coverage (NOMNC) documents for 3 of 3 residents reviewed. Resident #22’s MDS documented an admission date of 4/17/25 and a Medicare end date of 5/5/25, but the NOMNC signed by the representative on 5/2/25 used Form CMS 10123-NOMNC (approved 12/31/2011) and the SNFABN signed on 5/2/25 used Form CMS-10055 (2018). Resident #41’s MDS documented an admission date of 5/5/25 and a discharge date of 6/3/25, and the NOMNC signed by the resident on 5/29/25 used Form CMS 10123-NOMNC (approved 12/31/2011). Resident #42’s MDS documented a Medicare start date of 2/25/25 and a Medicare end date of 3/7/25, and the NOMNC and SNFABN signed by the representative on 3/5/25 used Form CMS 10123-NOMNC (approved 12/31/2011) and Form CMS-10055 (2018), respectively. During interview, the DON stated she was responsible for completing ABNs and NOMNCs and that the forms currently used were given to her, with filling them out being the standard process unless residents used an Advantage Plan. She stated she had not thought about needing updated forms and did not know the process for getting new ones. The Administrator stated she was not aware the forms had been updated and said she would look to CMS or the consulting company for guidance. The Medicare Claims Processing Manual cited in the report states ABNs are effective only through the OMB approval or expiration date and that providers must exclusively use the current version of the ABN and the OMB-approved NOMNC (CMS-10123).
Inadequate Supervision Leads to Resident Wandering and Inappropriate Behavior
Penalty
Summary
The facility failed to prevent a resident with severe cognitive impairments from wandering into another resident's room and engaging in inappropriate behavior. Resident #1, diagnosed with non-Alzheimer's dementia and stroke, exhibited verbal and physical behaviors towards others and was known to wander. Despite having a care plan in place to manage these behaviors, Resident #1 entered Resident #3's room multiple times, touching her belongings and tapping her inappropriately. Staff interviews revealed that Resident #1's wandering and aggressive behaviors were known to the staff, but they struggled to provide constant supervision due to other responsibilities. Staff A and Staff B reported that Resident #1 frequently got up on his own and wandered, and they were unable to monitor him at all times. The Director of Nursing acknowledged the wandering behavior but did not express concern over Resident #1 entering Resident #3's room, despite Resident #3's distress. The facility lacked a specific policy for resident-to-resident incidents, relying instead on a general incident report policy. This deficiency in supervision and policy contributed to the failure to prevent Resident #1 from entering Resident #3's room and causing distress. The facility's incident report policy did not adequately address the specific needs for managing resident-to-resident interactions, particularly in cases involving residents with severe cognitive impairments.
Failure to Maintain Adequate Food Temperatures
Penalty
Summary
The facility failed to maintain hot foods at the required minimum temperature during a meal service, as observed by surveyors. The Dietary Policies and Procedures of the facility, dated February 24, specify that hot foods should be held at a minimum temperature of 135 degrees Fahrenheit. However, during the meal service on August 13, the temperatures of various food items were recorded below this standard. Specifically, sweet potatoes were at 119 degrees Fahrenheit, green beans at 120 degrees Fahrenheit, pork at 130 degrees Fahrenheit, pureed meatballs at 96 degrees Fahrenheit, pureed sweet potatoes at 99 degrees Fahrenheit, gravy at 90 degrees Fahrenheit, and pureed green beans at 108 degrees Fahrenheit. The Dietary Manager confirmed that hot food should be held at a minimum of 135 degrees Fahrenheit and acknowledged witnessing the temperature readings taken by Staff D, the Dietary Aide, during the meal service. The facility reported a census of 39 residents at the time of the observation.
Sanitation Deficiencies in Kitchen Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in its food storage and preparation areas across three kitchen areas. During an initial tour of the main kitchen, surveyors observed a thick brown substance on the dishwasher, dust particles on a vent above clean dishes, and dust on the fire suppression system spigots. The walk-in freezer contained multiple boxes covered with thick ice, indicating a recent malfunction. The Dietary Manager acknowledged the issue but did not discard the ice-covered boxes. Further observations revealed dust and food debris on various kitchen surfaces, including spice shelves, microwaves, and toasters. In the B Wing kitchenette, surveyors found a spilled red liquid, onion skins, crumbs, and an eyelash in cupboards. The dishwasher had a significant white build-up, and clean dishes were stored nearby. Staff members were observed without hair nets, and the dishwasher's temperature was below the required 160 degrees Fahrenheit. The Dietary Manager admitted to a kink in the dishwasher hose and acknowledged that staff failed to report low temperatures. The kitchen was not maintained according to the facility's cleaning guidelines. The C Wing kitchenette also exhibited unsanitary conditions, with brown build-up on the dishwasher, crumbs in dish racks, and food debris in microwaves. Wet plastic cup lids and crumbs were found in drawers, and brown splatters covered cabinet doors. The facility's records showed multiple instances of the dishwasher not reaching the required temperature, and the Dietary Manager confirmed that staff did not fulfill their cleaning duties. The facility's policies and procedures for food safety and sanitation were not followed, leading to these deficiencies.
Deficiency in Conducting Effective QA Activities
Penalty
Summary
The facility failed to effectively conduct Quality Assurance (QA) activities to gather feedback, utilize data, and take action for structured and systematic investigations and analysis of underlying causes or contributing factors of problems affecting facility-wide processes. This deficiency impacted the quality of care, quality of life, and resident safety. The facility, with a census of 39 residents, had documented QAPI meetings on two occasions, 4/19/24 and 7/26/24, as per the QAPI Sign-In Sheets. However, during the survey conducted from 8/12/24 to 8/15/24, it was identified that the facility had not adequately addressed issues in dietary services, as stated by the Administrator, who acknowledged a greater focus on nursing after the last survey. The undated facility QAPI Plan indicated that the QAA committee would prioritize problem-prone areas, yet this was not effectively implemented.
Failure to Ensure Dignity for Residents with Catheters
Penalty
Summary
The facility failed to ensure dignity for residents with catheters by not placing catheter bags in dignity bags for two residents. Resident #8, who had intact cognition and required assistance for various activities, was observed multiple times with her catheter bag hanging visibly from her bed frame and recliner without a dignity bag. This was noted on several occasions, making the catheter bag visible to staff, residents, and visitors passing by. Similarly, Resident #143, who was alert and oriented and used an electric wheelchair, was observed with his catheter bag hanging visibly from his wheelchair without a dignity bag. This occurred both in his room and in the dining room, where the bag was visible to others. The Director of Nursing stated that dignity bags were expected to be used in community environments, but staff were only educated to use them in public areas. The facility's policy required catheter bags to be covered with a dignity cover in public areas.
Resident Suffers Physical Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse when a staff member hit the resident on the shoulder. The incident involved a resident with severe cognitive impairment, as indicated by a Brief Interview for Mental Status Score of 6 out of 15, and diagnoses including diabetes, non-Alzheimer's dementia, and morbid obesity. The resident required substantial assistance for daily activities and had a history of verbal behavioral symptoms. During an interaction, the resident attempted to hit a CNA, who then retaliated by punching the resident in the shoulder, as reported by another staff member. The incident was corroborated by a statement from Staff C, who witnessed the altercation and confirmed that the CNA used a closed fist to hit the resident. The facility's policy on abuse prevention clearly stated that residents have the right to be free from abuse, including physical abuse such as hitting and slapping. Despite this policy, the incident occurred during a transfer with a mechanical lift, where the resident and the CNA engaged in an argument. The CNA's response to the resident's attempted hit was inappropriate and escalated the situation, resulting in physical abuse. The facility's administrator emphasized the expectation for staff to treat residents with respect and dignity, highlighting a failure in adhering to these standards during the incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Marion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Winslow House Care Center | 0.8 mi | ★★★★★ | 10 | 0 |
| Silver Oak Nursing And Rehabilitation Center Llc | 1.1 mi | ★★★★★ | 14 | 0 |
| Terrace Glen Village | 1.3 mi | ★★★★★ | 5 | 0 |
| Linn Manor Care Center | 1.7 mi | ★★★★★ | 10 | 0 |
| Hallmar Village | 2.6 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.