Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Azria Health Clarinda during CMS and state inspections, most recent first.
Delayed Call Light Response and Inadequate Staffing: Staff did not answer call lights in a timely manner for multiple residents. A resident with severe cognitive impairment waited 19 minutes for transfer assistance after the call light was activated, while other residents reported frequent waits of more than 15 to 30 minutes, and one resident said delays could last up to an hour on PM shift. Residents also reported staff sometimes turned off the call light before their needs were met, and resident council minutes documented ongoing concerns about call light response times.
Staff failed to maintain infection control practices during personal care, wound care, medication administration, and catheter care. A CNA continued personal care without changing gloves or performing hand hygiene, an LPN performing wound care changed gloves without hand hygiene, and medication passes were completed without hand hygiene; one tablet that fell onto the narcotic book/cart was picked up with an ungloved hand and still administered. Staff also failed to use EBP during catheter care for a resident with an MDRO and Foley catheter, despite a gown being available in the room.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
A facility failed to implement a bowel management plan and notify the physician for a resident with severe cognitive impairment and slow transit constipation. The resident did not have a bowel movement for several days, and staff interviews revealed inconsistencies in following the bowel protocol. The physician was not informed of the resident's condition, and the facility's policy on bowel disorders was not consistently adhered to, resulting in a deficiency.
A facility failed to conduct timely care conferences for a resident, as required every 90 days, due to an increase in census and staff oversight. The resident, who had no cognitive impairment, and their Power of Attorney were not invited to participate in the care planning process, contrary to facility policy.
A resident with severely impaired cognition did not receive consistent restorative aid due to staff unavailability, impacting their ability to perform ADLs. Despite being discharged from therapy, the resident was supposed to be ambulated daily, but this was not consistently documented or provided, as revealed by staff interviews and EHR review.
A resident with intact cognition and multiple diagnoses, including GERD, was sent to the hospital with a UTI and C-Diff infection. The resident complained of nausea and was given Ondansetron, but the administration was not documented in the MAR. Staff interviews revealed a lack of documentation, and the DON confirmed the medication was given but not recorded, violating the facility's policy.
A facility failed to implement proper infection control practices by not performing hand hygiene during resident care. A resident with intact cognition and multiple diagnoses required assistance with personal care. During incontinence care, two CNAs did not perform hand hygiene, violating the facility's Standard Precautions policy. The DON confirmed the breach in protocol.
Delayed Call Light Response and Inadequate Staffing
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet resident needs and failed to have a licensed nurse in charge on each shift, as shown by delayed responses to call lights for 4 of 4 residents reviewed. Resident #1 had severe cognitive impairment with a BIMS of 00 and was dependent on staff for toileting hygiene, personal hygiene, and transfers. On 5/4/26, Resident #1's wife activated the call light at 12:35 PM because the resident wanted assistance back to bed. A CNA entered at 12:40 PM, said she needed to get a lift and another staff member, and left. Another CNA then entered, said she needed to get a lift and a second staff member, and left. An LPN entered at 12:46 PM and turned off the call light, but the wife turned it back on at 12:47 PM. The resident remained in the wheelchair until 12:54 PM, when two CNAs returned with a hoyer lift and assisted the transfer, resulting in a 19-minute delay in completing the request. Resident #15 had a BIMS of 15 and was dependent on staff for toileting hygiene, personal hygiene, and transfers. The resident stated the facility was short staffed and that call lights frequently took over 20 minutes to be answered, with staff sometimes turning off the light and not returning. Resident #15 also had a sign stating not to shut the light off until needs were met. Resident #14, who had intact cognitive functioning, stated call lights often took up to 30 minutes to be answered and that he watched the clock to track the delay. Resident #47, who had moderate cognitive impairment, stated that on the PM shift it sometimes took up to an hour and usually longer than 15 minutes for call lights to be answered almost nightly. Resident council minutes documented concerns about call light response times, and the facility policy stated staff were to answer call lights timely and keep the light on until the resident was cared for.
Infection Control and EBP Failures During Resident Care
Penalty
Summary
The facility failed to maintain universal infection control measures during resident care, including hand hygiene during personal care, wound care, medication administration, and catheter care, and failed to ensure Enhanced Barrier Precautions (EBP) were used during catheter care for a resident requiring them. The report documents multiple observations in which staff did not perform hand hygiene at required points during care and, in one instance, did not wear the gown required for EBP. Resident #1 had severe cognitive impairment, was dependent on staff for all ADLs, and was always incontinent. During a transfer and personal care episode, two CNAs used hand hygiene and gloves at the start, but one CNA continued personal care to the resident’s buttocks and groin, applied a clean brief and cream, and repositioned the resident without changing gloves or performing hand hygiene between contaminated and clean tasks. Resident #41 had severe cognitive impairment, diabetes, and an open area requiring dressings and ointments/medications. During wound care, an LPN completed some hand hygiene and glove changes, but after cleansing the wound with washcloths, the nurse removed contaminated gloves and replaced them without hand hygiene. The nurse then completed dressing application and later applied skin prep and heel protectors before removing PPE and performing hand hygiene. Medication administration observations showed an LPN administered medications to six residents in a row without hand hygiene before or after gathering and giving medications, and a CMA administered medications without hand hygiene before administration. In another observation, an LPN dropped a tablet onto the narcotic book and medication cart, picked it up with an ungloved hand, placed it in the medication cup, and administered it without replacing the medication or performing hand hygiene before, during, or after administration. Resident #5, who had severe cognitive impairment and was dependent on staff for toileting, was observed during catheter emptying and peri-care when staff removed gloves and did not perform hand hygiene before moving from catheter care to buttocks care and again before returning to catheter-related tasks. Resident #37 had obstructive uropathy, MDRO history, and a Foley catheter with care instructions for EBP. Although an EBP sign was posted and gowns were available in the room, a CNA performed catheter drainage and related care wearing gloves only and did not wear a gown. The Infection Preventionist stated she expected a gown to be worn whenever staff performed catheter care and wound care, and the DON acknowledged concerns with hand hygiene during catheter care, medication administration, personal care, wound care, and with EBP not being worn during catheter care.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Implement Bowel Management Protocol and Notify Physician
Penalty
Summary
The facility failed to provide appropriate assessments, implementation of the bowel management plan, and physician notification for a resident with severely impaired cognitive skills and a history of traumatic brain injury, profound intellectual disabilities, and slow transit constipation. The resident did not have a bowel movement from December 1st through the morning shift of December 9th, despite having multiple physician orders for laxatives and other bowel management interventions. The Medication Administration Record indicated that suppositories were given on December 5th and 9th but were ineffective, and no other PRN medications were administered during this period. Interviews with facility staff revealed inconsistencies in the implementation of the bowel management protocol. Staff A, an LPN, indicated that nightshift nurses were responsible for identifying residents needing medication and passing this information to the day shift. However, there was uncertainty about the facility's policy on physician notification when medications were ineffective. Staff B, another LPN, mentioned a new bowel protocol that required assessments and physician notification if a resident had not had a bowel movement in three days, but admitted to not consistently documenting bowel assessments. The Director of Nursing confirmed that the protocol was changed due to discrepancies in bowel movement tracking and acknowledged that eight days without a bowel movement was excessive. The physician, Staff D, was unaware of the facility's bowel protocol and confirmed that the resident had not had a bowel movement for almost nine days without being notified. The Assistant Director of Nursing stated that the bowel protocol was revised in December and emphasized the importance of following the protocol and notifying the physician when residents have not had a bowel movement. The facility's policy on bowel disorders required comprehensive assessments and documentation, which were not consistently followed, leading to the deficiency.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to provide an opportunity for a comprehensive care plan to be reviewed and revised by an interdisciplinary team, including the resident and/or their representative, for one of the five residents reviewed. This deficiency was identified during a review of electronic health records, resident interviews, staff interviews, and facility policy. Specifically, a resident with a BIMS score indicating no cognitive impairment reported not having attended a care plan meeting, nor had their Power of Attorney been invited. The last documented care conference for this resident was several months prior, indicating a lapse in the required quarterly care conference schedule. Staff interviews revealed that the staff member responsible for care conferences had been overwhelmed due to a recent doubling of the facility's census, which contributed to the oversight. The Director of Nursing confirmed that the facility's expectation was for care conferences to be completed every 90 days with resident and/or resident representative participation. The facility's policy on care planning emphasized the importance of comprehensive, person-centered care plans developed by an interdisciplinary team, which should include the resident and/or their representative.
Failure to Provide Restorative Aid for Resident with Impaired Cognition
Penalty
Summary
The facility failed to maintain the Activities of Daily Living (ADLs) for a resident with severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 0 out of 15. The resident required varying levels of assistance with daily activities, including eating, oral hygiene, toileting, and dressing. Despite being discharged from occupational and physical therapy in early April, the resident was supposed to receive restorative therapy, specifically ambulation to the dining room for one meal daily. However, due to a lack of available staff, this restorative aid was not consistently provided. Observations and staff interviews revealed that the resident had difficulty eating and required assistance with ambulation, which was not adequately documented or provided. The Electronic Health Record (EHR) showed that the resident was ambulated only 11 times since early April, with only three instances in May. Staff members indicated that changes in shower schedules and staff availability contributed to the lack of restorative therapy. The Director of Nursing acknowledged that the resident's refusal to participate in therapy should have been documented, but it was not consistently done.
Failure to Document Medication Administration
Penalty
Summary
The facility failed to document the administration of a medication for a resident, leading to a deficiency in pharmaceutical services. The resident, who had intact cognition and a history of diabetes, hypertension, anxiety, depression, and GERD, was sent to the hospital with a UTI and C-Diff infection. On the day of the incident, the resident complained of nausea and vomited, prompting the administration of Ondansetron, a medication prescribed for nausea. However, the administration of this medication was not documented in the resident's MAR, as required by the facility's policy. Staff interviews revealed that the LPN on duty was informed during the shift report that the resident had already received medication for nausea. The RN on duty did not recall any complaints from the resident during her shift and noted that PRN medications should be documented on the MAR with a progress note. Despite the hospital record indicating the resident received Zofran, the MAR lacked documentation of this administration. The DON confirmed that the LPN had administered the medication but failed to document it, which was against the facility's medication administration policy.
Infection Control Deficiency Due to Lack of Hand Hygiene
Penalty
Summary
The facility failed to implement appropriate infection control practices, specifically in performing hand hygiene during resident care, which led to a deficiency. A resident with intact cognition, diagnosed with Diabetes Mellitus, anxiety, and depression, required assistance with personal care, including toileting hygiene. The care plan indicated the need for two staff members to assist with toileting and to observe enhanced barrier precautions for infection control. However, during an observation of incontinence care, it was noted that the staff did not perform hand hygiene while providing care to the resident. The incident involved two Certified Nurse Aides (CNAs) who were observed performing incontinence care for the resident. One CNA, already wearing gloves, repositioned the resident's clothing and performed urinary incontinence care without performing hand hygiene. The facility's policy on Standard Precautions, revised in October 2022, required staff to perform hand hygiene after contact with items in the resident's room and to change gloves as necessary to prevent cross-contamination. The Director of Nursing confirmed that staff should not have touched anything else after gloving their hands, indicating a breach in protocol.
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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 Clarinda
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Villisca | 14.4 mi | ★★★★★ | 10 | 0 |
| Bedford Specialty Care | 17.3 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Shenandoah | 17.3 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Stanton | 17.4 mi | ★★★★★ | 1 | 0 |
| Garden View Care Center | 17.7 mi | — | 63 | 2 |
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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 August 2026) and official state health department websites.