Below 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 Clarion Wellness And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with HTN was ordered a change in amlodipine from 5 mg daily to 2.5 mg BID, but the updated order was not faxed to the pharmacy because the pharmacy was not integrated with the EHR. As a result, the med cart still contained the old dose, the resident received the ordered dose for several days, and the evening dose was later held after staff discovered the discrepancy; the resident’s BP was 157/96 at that time.
Failure to Follow Fall-Prevention Care Plan: A resident with severely impaired cognition, multiple fractures/trauma, COPD, muscle weakness, repeated falls, and substantial to maximal assistance needs was found on the floor with a skin tear, abrasion, and other minor injuries. The care plan directed staff to keep the bed in the low position after an actual fall, but later observations found the bed was not in the lowest position, and staff acknowledged the care plan direction.
A resident with anxiety, depression, schizophrenia, bipolar disorder, and schizoaffective disorder repeatedly voiced suicidal intent and engaged in self-harm gestures, including using his fingernails and a pen against his arm. After ER visits and a brief period of 1:1 supervision, the facility discontinued monitoring without adding suicide precautions, a formal prevention plan, line-of-sight supervision, or removal of sharp objects, despite psychiatric recommendations and ongoing suicidal statements.
Missed and undocumented psychotropic medication administration. A resident with schizoaffective disorder, schizophrenia, depression, and anxiety had multiple missed doses of fluphenazine on the MAR, no documentation that ordered Geodon IM was offered or given when fluphenazine was refused, and a missed monthly Haldol Decanoate IM injection. The DON acknowledged the medication error and staff confirmed the missed injection and documentation gaps.
A resident with intact cognition and diagnoses including anxiety, depression, and schizophrenia had a physician order for Cogentin 1 mg at bedtime. The MAR showed doses documented as administered even though the facility did not have the medication in stock for part of the month, and the pharmacist reported the refill was delayed because the prior auth had expired and notices of noncoverage had been sent. The DON acknowledged staff signed off the MAR as if the medication had been given when it was not available.
Repeated Infection Prevention and Control Deficiency: The facility failed to correct an infection prevention and control deficiency across the current recertification survey and the previous 2 recertification surveys. The QAPI plan described monitoring care and services, using feedback from staff, residents, families, and others, tracking performance indicators, and addressing adverse events through the PDSA cycle, but the Administrator acknowledged the F880 deficiency remained present on all 3 surveys.
The facility failed to document the required IP presence at a quarterly QAPI meeting. Review of the sign-in sheet for the meeting showed no IP signature, and the DON’s email stated attendees signed the forms the day of the meeting. The Administrator acknowledged the IP did not sign to show attendance and said QAPI meetings would be held monthly instead of quarterly.
Infection control was deficient during wound care for a resident with diabetes, COPD, a coccyx pressure ulcer, and a diabetic/venous leg ulcer. An LPN placed wound supplies on a table without a barrier and performed dressing changes while changing gloves without hand hygiene, then washed hands only briefly and turned off the faucet with a bare hand. The same hand hygiene lapses occurred during care of the coccyx wound, despite the facility hand hygiene policy requiring hand hygiene before and after resident contact, before handling dressings, after glove removal, and after PPE removal.
Two residents experienced repeated delays in call light response, with documented waits of 15 minutes or more, including several instances exceeding 30 minutes. Both residents had cognitive impairments and reported or were observed waiting extended periods for assistance, contrary to facility policy requiring call lights to be answered within 10-15 minutes. The administrator acknowledged staff shortages during the period in question.
Three residents in an LTC facility experienced verbal abuse and disrespect from CNAs. One resident, with no memory impairments, was verbally abused when requesting assistance with bed-making. Another resident, dependent on staff for personal care, was rudely questioned by a CNA when feeling unwell. A third resident, requiring substantial assistance, was rudely treated and physically poked by an agency CNA. Despite these incidents, the residents generally felt safe and satisfied with the care from other staff members.
The facility failed to report two separate abuse allegations to the Department of Inspections, Appeals, and Licensing (DIAL) within the required 24-hour timeframe. In one case, a resident reported alleged physical abuse to a CNA, but it was not reported to the DON until days later. In another case, a CNA witnessed alleged verbal abuse but delayed reporting it to the DON. Both incidents involved residents with specific medical conditions and cognitive assessments.
The facility failed to promptly separate staff accused of abuse from residents. In one case, a resident reported physical abuse to a CNA, who did not report it, allowing the alleged abuser to continue working. In another case, a CNA witnessed verbal abuse but delayed reporting, allowing the alleged abuser to work multiple shifts. The facility's policy on immediate reporting and separation was not followed.
Two residents in a LTC facility were not protected from abuse, leading to a deficiency. One resident reported physical abuse by a staff member, who continued to work and enter her room alone, causing fear and discomfort. Another resident experienced verbal abuse, which was not reported promptly, allowing the staff member to continue working with vulnerable residents. The facility failed to adhere to its abuse prevention and reporting policies.
Two residents in a long-term care facility experienced significant medication errors. One resident did not receive their prescribed Revlimid medication for over a month, while another resident received medications not prescribed to her due to a mix-up by a CMA. The facility failed to follow its policies on medication administration and physician orders, leading to these errors.
The facility failed to ensure proper food handling procedures during lunch service, as uncovered food items were delivered to residents in multiple hallways. A cook admitted to not covering desserts, chips, and crackers, despite the expectation to do so for infection control. The Administrator confirmed this expectation, although the facility lacked a specific policy on food service safety.
A resident with an indwelling urinary catheter experienced improper handling of their catheter drainage bag, which was observed lying on the floor and hanging on a trash can. This was against the facility's policy, which required the bag to be covered and properly positioned to prevent infection. Staff actions did not align with these guidelines, leading to a deficiency in maintaining a sanitary environment.
A CNA failed to report an alleged abuse incident involving a resident due to lacking a valid Dependent Adult Abuse Mandatory Reporter Certificate at the time of the incident. The facility's policies require immediate reporting of abuse, but the CNA did not comply, and the necessary certification was only obtained after the incident.
A facility failed to maintain consistent code status documentation for a resident, resulting in a mismatch between the IPOST, Care Plan, and EHR. The Care Plan and physician orders indicated CPR/Full Code, while the IPOST reflected a DNR status. The facility's policy required written submissions for changes, which were not properly communicated, leading to this discrepancy. The DON acknowledged the inconsistency.
The dietary staff at a facility failed to properly prepare pureed food for three residents, as observed during a survey. A cook, lacking formal training, prepared a turkey and wild rice casserole without measuring ingredients or using a puree graph to determine portion sizes. The administrator acknowledged the absence of a specific puree policy but expected staff to follow therapeutic diets and use the graph for portion control.
Medication Order Change Not Transmitted to Pharmacy
Penalty
Summary
The facility failed to administer medications as ordered by the physician for 1 of 3 residents reviewed. Resident #1 had a diagnosis of hypertension, and a physician order dated 10/22/25 changed amlodipine from 5 mg daily to 2.5 mg twice daily beginning 10/23/25. The EMAR showed the resident received 2.5 mg twice daily from 10/23/25 through the morning dose on 10/27/25, and the evening dose on 10/27/25 was held. The EHR documented that on 10/27/25 a CMA told an LPN that the medication cart still contained amlodipine 5 mg daily instead of the ordered 2.5 mg twice daily. The LPN contacted the provider and received an order to hold the evening dose and resume 2.5 mg twice daily on 10/28/25. At that time, Resident #1 had a blood pressure of 157/96, with an average blood pressure of 120/80 noted in the record. The DON stated the order change was not faxed to the pharmacy because the pharmacy was not integrated into the EHR, and the medication cards for the new dose were not in the cart until the error was discovered. The facility notified the resident's sister and the DON of the medication error.
Failure to Follow Fall-Prevention Care Plan
Penalty
Summary
The facility failed to implement care plan interventions to reduce the risk for falls for Resident #19. The resident’s MDS assessment dated [DATE] identified a BIMS score of 4, indicating severely impaired cognition, and documented substantial to maximal assistance needed with bed mobility and all transfers. The MDS also listed diagnoses including fractures and other multiple traumas, depression, COPD, muscle weakness, a wedge compression fracture of the second lumbar vertebrae, COVID-19, cognitive communication deficits, limitation of activities due to disabilities, other reduced mobility, and repeated falls. The care plan focus initiated 7/28/25 identified an actual fall with no injury, and an intervention created 8/10/25 and initiated 8/8/25 directed staff to place the resident’s bed in a low position. On 8/8/25 at 8:38 AM, two CNAs summoned the nurse to the resident’s room after the resident was found lying on his right side on the floor facing the bed, with his feet near the dresser next to the bed below the TV. He was wearing his brief but not his gown, his oxygen concentrator was on but the oxygen cannula was lying on the bedside table, and he sustained a 2.7 cm by 2.7 cm skin tear to the right elbow with minimal bleeding, an abrasion to the right knee, and a small red area to the right shoulder blade. The note stated three staff assisted him from sitting to standing with a gait belt and into a wheelchair, and that he could bear his own weight on both lower legs. Later observations on 8/25/25 and 8/27/25 found the resident lying in bed without the bed in the low position, and on 8/27/25 a CNA reviewed the care plan and lowered the bed after observing it was not in the lowest position. The DON stated staff were expected to follow the care plan, and the Administrator stated the standard of practice was for staff to follow the care plan.
Failure to Provide Suicide Supervision and Safety Measures
Penalty
Summary
The facility failed to provide adequate nursing supervision to prevent an accident and injuries for one resident who had repeated suicidal statements and gestures. The resident had diagnoses including anxiety, depression, schizophrenia, bipolar disorder, and schizoaffective disorder, and his MDS showed intact cognition with a BIMS score of 13. His care plan addressed psychotropic medications and auditory hallucinations, but it did not include suicide precautions or a suicide prevention plan. The resident had escalating behavioral and self-harm-related events. After threatening staff and assaulting an RN with a walker, he was sent to the hospital. He later told EMS and hospital staff that he was suicidal, had tried to dig out a vein with his fingernails, and would kill himself if he had to return to the facility. He returned to the facility with new psychiatric medication orders, but the record lacked documentation of a formal suicidal prevention plan, suicide precautions, or other interventions after his return. The resident again told staff he was suicidal and used a pen against his wrist and inner arm area while refusing medications. He was sent back to the ER, where psychiatric evaluation documented a positive suicide risk screen and that he would try again if returned to the facility. The reassessment directed the facility to remove sharp objects and keep him in line of sight, but the record lacked documentation that these measures were implemented. Staff and leadership interviews confirmed that 1:1 supervision was started after one ER return and discontinued the same evening, and no additional safety precautions were put in place. The DON also stated the facility did not complete suicide assessments and did not provide line-of-sight supervision.
Missed and Undocumented Psychotropic Medication Administration
Penalty
Summary
The facility failed to administer medications according to physician orders for Resident #23, who had diagnoses of anxiety, depression, schizophrenia, and schizoaffective disorder, with a BIMS score of 13 indicating intact cognition. The care plan directed staff to administer psychotropic medications as ordered, including Haldol Decanoate IM monthly. Review of the MAR showed missed doses of fluphenazine HCL 5 mg on multiple occasions, including missed AM and HS administrations, and the MAR did not document administration of Geodon 20 mg IM when the resident refused fluphenazine as ordered. The resident also missed the ordered monthly Haldol Decanoate IM injection. The MAR showed the injection was not given on the scheduled date, and the progress notes did not document that staff offered or attempted to administer it later. The DON acknowledged the medication was not given per the physician order and stated the nurse made an error. Staff interviews confirmed the missed injection and the lack of documentation for the ordered Geodon IM when fluphenazine was refused.
Incomplete MAR Documentation for Cogentin
Penalty
Summary
The facility failed to maintain a complete and accurately documented medical record for Resident #23. The resident’s MDS assessment identified a BIMS score of 13, indicating intact cognition, and listed diagnoses of anxiety, depression, and schizophrenia. A physician order dated 4/9/24 directed staff to administer benztropine mesylate (Cogentin) 1 mg at bedtime related to schizoaffective disorder, bipolar type. The record showed inconsistencies in the administration of Cogentin in May 2025. A secured conversation note dated 5/10/25 documented that nursing staff told the PCP the facility did not have the resident’s Cogentin in stock since the beginning of the month. The May 2025 MAR documented doses as given from 5/1/25 through 5/5/25 and on 5/9/25, while the pharmacist reported the pharmacy had only sent 27 tablets on 4/4/25 to cover through the end of April and did not send more until 5/20/25 after the order was reinstated. The pharmacist also stated the prior authorization had expired, the pharmacy had sent a notice of noncoverage on 4/17/25 and again on 5/8/25, and the facility later received a discontinuation order on 5/12/25. The DON acknowledged staff signed off the MAR as if the medication had been administered in May when the facility did not have the medication.
Repeated Infection Prevention and Control Deficiency
Penalty
Summary
The facility failed to correct its own deficiency related to infection prevention and control across 1 of 1 areas of concern. The facility had a census of 62 residents. Review of the facility's undated QAPI plan showed it documented a process for monitoring care and services using data from multiple sources, incorporating feedback from staff, residents, families, and others, tracking performance indicators, reviewing findings against benchmarks or goals, and tracking, investigating, and monitoring adverse events with action plans implemented through the PDSA cycle. Despite this plan, the survey identified the same infection prevention and control concern at the current recertification survey and during the previous 2 recertification surveys. During interview, the Administrator acknowledged the facility received a deficiency at F880 on the current recertification survey and the previous 2 recertification surveys.
QAPI Meeting Lacked Required Member Attendance Documentation
Penalty
Summary
The facility failed to have the minimum required members present at its quarterly QAPI meetings, as required by CMS. Facility record review showed that the sign-in sheet for the 2/18/25 QAPI meeting did not document the presence of the Infection Preventionist (IP). The facility provided sign-in sheets for QAPI meetings, and an email from the DON stated that all people who attended the QAPI meeting signed the forms the day of the meeting. During an interview on 8/28/25 at 9:05 AM, the Administrator acknowledged that the IP did not sign the form to indicate attendance at the February 2025 quarterly QAPI meeting as expected and stated that QAPI meetings would be held monthly instead of quarterly.
Infection Control Lapses During Wound Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when wound care for Resident #3 was observed to be performed without proper infection control practices. Resident #3’s MDS identified diagnoses of diabetes, COPD, and a pressure ulcer of the sacral region, and the care plan documented an actual pressure ulcer to the coccyx, risk for additional pressure ulcers, and a diabetic ulcer of the right front leg with a secondary venous leg ulcer. The care plan goals stated the ulcers would remain free from infection and that the resident would not have complications from the ulcer through the review date. During observed wound care, Staff B, an LPN, placed supplies on the resident’s table without a barrier, donned a gown and gloves, removed the dressing from the lower leg wound, and changed gloves without performing hand hygiene. Staff B then completed wound care, removed gloves, washed hands only for a few seconds, turned off the faucet with a bare hand, and put on new gloves. The same pattern occurred when the coccyx dressing was removed and the wound was cleansed and covered, with hand hygiene not performed between glove changes. The Infection Preventionist stated staff should only take needed dressing supplies into the room, use a barrier, wash hands for 20 seconds, use a paper towel to shut off the faucet, and perform hand hygiene between glove changes. The facility hand hygiene policy required hand hygiene before and after resident contact, before handling dressings, after removing gloves, and after removing PPE.
Failure to Provide Timely Call Light Response Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by prolonged call light response times for two residents. One resident, with moderately impaired cognition, was observed waiting 27 minutes for a response to his call light and reported frequent waits of half an hour or more. Facility records confirmed multiple instances over several days where this resident's call light remained unanswered for 15 minutes or longer, with some instances exceeding 25 minutes. The resident reported having to plan ahead for bathroom needs due to the long wait times and stated that these delays occurred throughout various shifts. Another resident, with severe cognitive impairment, was observed waiting 32 minutes for a response to their call light. Call light reports for this resident also documented numerous occasions where the call light was on for 15 minutes or more, including several instances exceeding 30 minutes and one instance lasting 50 minutes. The facility's policy required staff to answer call lights within 10-15 minutes, and the administrator confirmed the expectation for a 15-minute response time. The administrator also noted that two staff members had called in on one of the days in question.
Failure to Treat Residents with Dignity and Respect
Penalty
Summary
The facility failed to treat three residents with respect and dignity, leading to deficiencies in their care. Resident #1, who had no memory impairments and required supervision for activities of daily living, experienced verbal abuse from a CNA. The resident had requested assistance with making her bed, but the CNA responded rudely and did not fulfill the request. The resident felt scared and upset due to the CNA's behavior, which included yelling and slamming the door shut. Resident #2, with intact cognition and dependent on staff for personal care, also reported verbal abuse from a CNA. The resident, who was not feeling well, requested to go to bed, but the CNA responded rudely and questioned why the resident had not informed the first shift about her condition. This interaction left the resident feeling upset, although she later reported feeling safe at the facility. Resident #4, who required substantial assistance with daily activities and had intact cognition, reported an incident with an agency CNA who was rude and physically poked him in the chest. Although the poking did not cause pain, it was described as annoying. The resident expressed a desire not to be cared for by that particular CNA again, although he generally felt safe and satisfied with the care provided by other staff members.
Delayed Reporting of Abuse Allegations
Penalty
Summary
The facility failed to notify the Department of Inspections, Appeals, and Licensing (DIAL) within the required 24-hour timeframe for two separate allegations of abuse. In the first incident, a resident reported alleged physical abuse to a CNA, but the allegation was not reported to the Director of Nursing (DON) until several days later. The facility began its investigation and reported the incident to DIAL on the same day the DON was informed, but this was beyond the 24-hour requirement. In the second incident, a CNA documented witnessing alleged verbal abuse towards another resident but did not report it to the DON until four days later. The DON then reported the incident to DIAL, but the facility failed to provide the completed investigation findings and results within the required five days. The facility eventually filed their Self-Report with DIAL, but this was also delayed. Both residents involved had specific medical conditions and cognitive assessments that were documented in their Minimum Data Set (MDS) assessments. The first resident had moderately impaired cognition and was receiving hospice services, while the second resident had intact cognition but was diagnosed with a neurocognitive disorder and other related conditions. The facility's failure to report these allegations in a timely manner and to complete the investigation within the required timeframe constituted a deficiency.
Removal Plan
- The facility educated all staff regarding the abuse policy and reporting of alleged abuse to their supervisor immediately. The facility would notify the as needed (PRN) staff prior to them working their next shift.
- The facility terminated the employment of the 2 alleged perpetrators.
Failure to Timely Separate Alleged Abusers from Residents
Penalty
Summary
The facility failed to promptly separate staff members accused of alleged physical and verbal abuse from dependent residents. In the first case, a resident reported an allegation of physical abuse to a CNA, who did not report the incident to the administration, allowing the alleged abuser to continue working for several days. Additionally, a dietary staff member learned of the allegation but delayed reporting it until later in the day, further allowing the staff member to work their entire shift. In the second case, a CNA witnessed another CNA using profanity towards a behavioral resident but did not report the incident until their next scheduled workday. This delay in reporting allowed the alleged abuser to continue working multiple shifts before the administration was informed. The facility's investigation revealed that the alleged abuser continued to work with access to vulnerable residents during this period. The facility's policy on abuse prevention and prohibition was not adhered to, as staff failed to immediately report and separate the alleged abusers from residents. The policy mandates that any suspected abuse should be reported immediately, and the alleged perpetrator should be removed from resident care pending investigation. However, in both cases, the staff did not follow these procedures, resulting in continued exposure of residents to potential harm.
Removal Plan
- The facility educated all staff regarding the abuse policy and reporting of alleged abuse to their supervisor immediately. The facility would notify the as needed (PRN) staff prior to them working their next shift.
- The facility terminated the employment of the 2 alleged perpetrators.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in a deficiency. Resident #47 reported alleged physical abuse by a staff member on multiple occasions, but the facility did not take immediate action. The alleged abuser continued to work and enter Resident #47's room alone, despite the resident expressing fear and discomfort. The facility's investigation revealed that the staff member had inappropriate interactions with the resident, including kissing her on the neck and cheek, which made her uncomfortable and increased her feelings of depression. In another incident, Resident #316 was subjected to verbal abuse by a staff member, which was not reported to the Director of Nursing until several days later. The staff member continued to work with vulnerable residents during this time, creating an immediate jeopardy situation. The facility's lack of timely action and failure to separate the alleged abuser from the resident contributed to the deficiency. Both incidents highlight the facility's failure to adhere to its abuse prevention and reporting policies. The facility did not promptly investigate or address the allegations, allowing the alleged perpetrators to continue working with residents. This inaction compromised the safety and well-being of the residents involved.
Removal Plan
- The facility educated all staff regarding the abuse policy and reporting of alleged abuse to their supervisor immediately.
- The facility would notify the as needed (PRN) staff prior to them working their next shift.
- The facility terminated the employment of the 2 alleged perpetrators.
Significant Medication Errors in LTC Facility
Penalty
Summary
The facility failed to administer medications per physician orders for two residents, leading to significant medication errors. Resident #25, who has a history of cancer, anemia, hypertension, and renal disease, did not receive their prescribed Revlimid medication from April 25, 2024, to June 5, 2024. Despite having a complete cycle of Revlimid available, the facility staff did not administer the medication as ordered, and there was no documentation of notifying the resident's primary care physician or family about the omission. The facility also failed to complete an investigation or medication error form regarding this omission. Resident #2, who has a history of coronary artery disease, hypertension, hyperlipidemia, thyroid disorder, anxiety disorder, depression, schizophrenia, and cognitive communication deficit, received medications not prescribed to her. Instead, she was given her roommate's medications, which included Oxycodone, Baclofen, Gabapentin, Lexapro, Melatonin, and Topamax. This error occurred when a certified medication aide (CMA) mixed up the medication cups for Resident #2 and her roommate, Resident #10, and left the medications unattended in the room. The facility's policies on physician orders and medication administration were not followed, contributing to these errors. The charge nurse or DON is responsible for placing orders for prescribed medications, and medication errors should be reported to the resident's attending physician. Additionally, the policy requires staff to accurately prepare, administer, and document oral medications, ensuring the correct resident receives the correct medication by verifying their identity before administration.
Removal Plan
- The facility educated all nurses and certified medication aides (CMAs) on following the physician orders policy. As needed (PRN) staff members will complete education prior to working the next shift.
- The DNS (Director Nursing Services)/designee will audit all missing/omitted MAR (Medication Administration Records) and TAR (Treatment Administration Record) entries. They will educate nursing when needed on following physician orders, correct order entry, and the process for medication errors.
- Two nurses will double note all orders. This is a permanent systemic change.
- The DNS/designee will run missing entries report in the electronic medical record (EMR) for omissions on the MAR/TAR.
Improper Food Handling Procedures
Penalty
Summary
The facility failed to ensure proper food handling procedures during lunch service, leading to potential contamination of food. Observations revealed that room trays delivered to residents in multiple hallways contained uncovered food items, including desserts, a bowl of chips, and a bowl of crackers. During an interview, a cook acknowledged that food should be covered when transported down hallways but admitted to not covering the desserts, chips, and crackers. The Administrator confirmed the expectation for staff to cover all food during transport for infection control purposes, although the facility lacked a specific policy on food service safety and infection control.
Improper Handling of Catheter Drainage Bag
Penalty
Summary
The facility failed to maintain a safe and sanitary environment to prevent the transmission of infections for a resident with an indwelling urinary catheter. The resident, who was recently admitted and lacked a completed Minimum Data Set (MDS) assessment, had a care plan that directed staff to position the catheter bag and tubing below the bladder level and away from the entrance room door. However, observations revealed that the catheter drainage bag was repeatedly mishandled. On multiple occasions, the bag was found lying on the floor without a privacy cover and hanging on the side of a trash can containing garbage, which is contrary to the facility's policy. Staff actions were inconsistent with the facility's policy, which required daily and as-needed catheter care to promote hygiene, comfort, and reduce infection risk. The policy also instructed staff to cover the drainage bag with a privacy bag to maintain dignity. Despite these guidelines, the catheter bag was observed uncovered and improperly positioned, and the Assistant Director of Nursing was seen discarding garbage in the trash can while the catheter bag was hanging on it. The Nurse Consultant later verified that the catheter drainage bag should not hang on the side of a dirty trash can.
Failure to Ensure Mandatory Reporter Certification for CNA
Penalty
Summary
The facility failed to provide a valid Dependent Adult Abuse Mandatory Reporter Certificate for Staff C, a Certified Nursing Assistant (CNA), at the time of an alleged abuse incident. Resident #47 reported an alleged abuse incident to Staff C, who did not report it to the administrative staff as required. The review of Staff C's employee file revealed that the certificate was completed only after the incident, dated 3/27/24, while the alleged abuse occurred on 3/20/24. The facility's policy mandates immediate reporting of abuse allegations, but Staff C did not comply with this requirement. The facility's policies on abuse prevention and reporting require staff to be trained on recognizing and reporting abuse, neglect, and exploitation. However, the facility could not provide evidence of Staff C's certification prior to the incident. The Director of Nursing stated that Staff C was in the process of obtaining the certification, but it was not provided before the survey exit. The facility's failure to ensure that Staff C had the necessary certification and training contributed to the deficiency in handling the abuse allegation appropriately.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure consistency in the code status documentation for a resident, leading to a discrepancy between the Iowa Physician's for Scope of Treatment (IPOST), the Care Plan, and the Electronic Health Record (EHR). The Care Plan indicated that the resident desired cardiopulmonary resuscitation (CPR) as per the IPOST, and the clinical physician orders also reflected a CPR/Full Code status. However, the resident's IPOST document indicated a do not resuscitate (DNR) status. The facility's Advanced Directives policy required any changes or revocations to be submitted in writing and communicated to the Care Plan team for updates. During an interview, the Director of Nursing acknowledged the inconsistency between the IPOST, Care Plan, and EHR orders for the resident.
Deficiency in Pureed Food Preparation for Residents
Penalty
Summary
The facility's dietary staff failed to properly execute the food and nutrition services for residents requiring a pureed diet. During an observation, a cook was seen preparing a pureed turkey and wild rice casserole for three residents without measuring the ingredients or using the puree graph to determine the appropriate portion size. The cook added unmeasured amounts of thickener and chicken broth to the mixture, altering the original volume, and used a scoop to plate the food without verifying the consistency or portion size. Interviews revealed that the cook had been pureeing food for about a year without receiving any formal training on the process or the required texture for pureed servings. The cook relied on information from the dietitian and online searches, and was unaware of how to use the puree graph in the kitchen. The facility's administrator acknowledged the lack of a specific puree policy but expected staff to follow therapeutic diets and use the graph to ensure appropriate portion sizes. The deficiency affected three residents on a pureed diet in a facility with a census of 61 residents.
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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 Clarion
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rotary Senior Living | 9.1 mi | ★★★★★ | 3 | 1 |
| Rehabilitation Center Of Belmond | 11.2 mi | ★★★★★ | 2 | 0 |
| Kanawha Community Home, Inc. | 15.4 mi | ★★★★★ | 3 | 0 |
| Crestview Nursing And Rehabilitation | 19 mi | ★★★★★ | 13 | 0 |
| Southfield Wellness Community | 19.1 mi | ★★★★★ | 24 | 0 |
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