116 3rd St SE
Cedar Rapids, Iowa 52401
Home / Marion nursing home cited in wake of death, abuse, short-staffing allegations
A Marion nursing home has been cited for more than two dozen health care violations and is accused of being so short-staffed the residents have not received food or medicine as scheduled.
One resident of the Silver Oak Nursing and Rehabilitation Center in Marion died at the home after a fall last Thanksgiving.
The alleged physical abuse of another resident wasn’t reported to the state as required by law, and some temporary employees have reportedly arrived for work and immediately walked out after seeing how short-staffed the facility was.
The facility has been cited for 25 separate federal regulatory violations. It is now facing a state fine of $12,500, which could be cut to $8,125 if the owners agree to forgo an appeal.
Inspectors allege the home has failed to meet minimum standards related to resident abuse, professional standards of care, cardiopulmonary resuscitation, bed sores, accident hazards, incontinence care, dialysis, frequency of physician visits, maintaining a sufficient number of nursing staff, dietary issues, frequency of meals and snacks, storage and preparation of food, and infection prevention.
After fielding several complaints about the quality of care at the home, inspectors visited the facility in December, resulting in 25 separate findings of deficient care and the $12,500 fine.
At that time, the home also was cited for failing to provide a safe transfer for a resident who had sustained a hip fracture, failing to report a major injury to the state inspectors, and failing to document the possible causes and interventions for a resident who sustained multiple fractures in a fall.
One resident who fell was found on the floor screaming in pain and yelling, “Get me to the hospital, I don’t feel good, I need a doctor, I need a doctor.” The resident was taken to a hospital and then died a short time later.
Inspectors also found that the home failed to employ sufficient staff with the skills necessary to meet residents’ food and nutrition needs.
They reported only three employees — the activities director, a central-supply staff employee and a dietary aide — were working in the kitchen during lunch to serve 52 residents.
The home’s housekeeping supervisor and the activities director told inspectors they expected to be cooking in the kitchen that same evening.
There was no dietary manager on staff, and the head of the maintenance department reported corporate executives had asked him to help out in the kitchen, suggesting he puree food for residents who could not eat solid food.
A nurse told inspectors she’d been forced to withhold residents’ insulin due to meals being served so late. Nine residents ended up with low blood sugar waiting for their meals.
The home was cited for insufficient staffing, with one nurse aide telling inspectors she and one other worker were expected to care for 30 residents during an eight-hour shift. The workload was too great, she said, and residents weren’t getting to the bathroom, to the dining room, or being put to bed on time.
A registered nurse alleged that the company refused, at times, to let the home bring in temporary workers from an agency, which prompted the home’s own workers to quit.
Another nurse said medical treatments for residents were not getting done, and she had found medical orders for residents that had been “sitting there for a week” and not processed.
Another employee said that on some occasions, the home would call in temporary workers from staffing agencies, only to have the temps come into the building, find out they were the only aide working with 52 residents and walk out.
The home’s director of rehabilitation told inspectors that in November, a tearful resident had reported to him that a nurse aide had shoved a wheelchair into her because she needed to use the bathroom, injuring her leg. The director of rehabilitation immediately reported the allegation to the home’s administrator.
The administrator reportedly confirmed the potential abuse but was told by the corporate owner’s vice president of clinical operations to refrain from reporting the matter to the Iowa Department of Inspections and Appeals.
Janet Bryant, the director of clinical operations for the facility’s owner, Ivy Healthcare Group, denied ever giving that directive. “I would never, ever, ever tell anyone not to report an allegation of abuse,” she told the Iowa Capital Dispatch.
Silver Oak also was accused of failing to ensure that residents who rely on Medicaid are seen by a physician every 30 to 60 days.
One resident with paralysis, Parkinson’s disease and schizophrenia had not been seen by a doctor for seven months. Another resident, who suffered from heart failure, end-stage renal disease and diabetes, had not seen a doctor for six months.
Until last year, when the home was sold, it was known as Willow Gardens Care Center and had operated for three years with no fines or citations. Last May, the facility was bought by Ivy Healthcare Group, which is based in Surfside, Fla.
Ivy Healthcare’s president and CEO, Ryan Coane, when asked about non-dietary workers in the kitchen, told the Iowa Capital Dispatch, “There might have been one situation like that, you know, where there was some sort of delay, where other personnel had to go to the kitchen and help out. If I was in the facility myself, I would go into the kitchen and help with what’s needed.”
Coane acknowledged he has never been to Silver Oak. He said that if the facility needs to use agency staff to meet residents’ needs, that’s not something he would ever refuse.
In November, he told Skilled Nursing News his company owned nine facilities and hoped to expand based on the economic opportunities that exist by avoiding the use of agency staff.
“Some (nursing facilities) have still maintained really good margins because we’re operating in small towns and there’s not as much competition,” he said.
He said his company acquired a facility in May 2021 — the same month the company bought the Marion home — after seeing the upside the deal would have if he was able to reduce the use of agency-employed temporary workers who drive up personnel costs.
Coane also told Skilled Nursing News his company had been paying “astronomical rates” for agency-employed nursing staff, with wages reaching $100 an hour for registered nurses and $50 an hour for certified nurse aides.
Bryant, the company’s director of clinical operations, said Thursday that Ivy Healthcare Group had yet to give the state a written plan to address the problems cited by inspectors last month.
She questioned why the media would even have access to the inspectors’ findings at this point. “This is not a public record,” she said.
In addition to Silver Oak, Ivy Healthcare Group also runs The Ivy at Davenport. According to state records, the Davenport home was fined $288,330 in 2021 by the federal Centers for Medicare and Medicaid Services, later reduced to $192,664.
This article first appeared in the Iowa Capital Dispatch.