Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Nursing And Rehab during CMS and state inspections, most recent first.
Expired multi-dose insulin pens and vials were found on A Wing and B Wing med carts, including opened Lantus pens and Humalog vials that had exceeded the facility’s dating requirements. In addition, a B Wing med cart was observed unsecured and out of the RN’s view while the RN was in the dining room with a resident; the RN confirmed the cart should have been locked.
PHI was not kept private during med pass when an RN administered meds in the main dining room and left a computer screen with resident PHI visible to anyone passing in the corridor. Housekeeping and dietary staff passed by the visible screen, and the RN confirmed the PHI was visible.
Incomplete transfer documentation and missing clinical information: The facility failed to ensure that necessary resident information was communicated to the receiving provider when a resident was transferred to the hospital, and the record lacked complete transfer documentation. The resident had diagnoses including partial intestinal obstruction, dysphagia, unsteady gait, weakness, and need for assistance with personal care, and the DON confirmed the missing evidence in the clinical record.
Surveyors found that medications were not administered according to prescriber orders and facility policy, which requires administration within one hour of the scheduled time. Over two evening shifts, many residents had medications scheduled for late afternoon and evening (including 4:30 p.m., 5:00 p.m., 6:30 p.m., 7:00 p.m., and 8:00 p.m.) that were actually given several hours late, in some cases close to or after midnight. These delays involved both single and multiple medications per resident, with some individuals receiving 10 or more medications well outside the required timeframe. The NHA confirmed that the medications identified in the records review were administered late.
A resident with impaired mobility and at risk for skin integrity issues was not repositioned every two hours as required by their care plan. Observations showed the resident remained on their back during multiple checks over two days, despite the care plan's directive. The DON confirmed the care plan was not followed.
A resident with a contracture did not receive the physician-ordered treatment of a washcloth or palm grip in the right hand to prevent further decline in range of motion. Observations on multiple occasions revealed the absence of the required device, and the DON confirmed the deficiency.
A resident with chronic systolic congestive heart failure was observed receiving supplemental oxygen throughout the day, contrary to the physician's order for administration only at night. This was confirmed by the DON, indicating a failure to follow the prescribed respiratory care plan.
The facility failed to properly label and dispose of medications, as observed in the C/B medication room and B-Wing medication cart. An opened vial of Tubersol PPD lacked an open date, and another was expired. An injector pen of Humalog insulin was also expired. These issues were confirmed by LPNs, indicating non-compliance with facility policies and manufacturer's guidelines.
A resident with a known allergy to Keflex was administered the medication due to failures by an RN and an LPN to verify allergies before medication administration. The RN did not check the resident's allergies before entering a new order, and the LPN administered the medication without reviewing the allergy information. This oversight was confirmed through staff interviews and an investigation by the DON.
An LPN failed to follow professional standards and facility policy for medication administration by not referencing the MAR before administering medications and not documenting immediately after. The LPN relied on familiarity with residents and shift reports, leading to a deficiency in nursing and pharmacy services.
The facility failed to honor a resident's right to self-determination and choice in significant aspects of their life. Despite the resident's documented preferences and cognitive ability, staff frequently left the resident in bed during meals and activities, contrary to their expressed wishes. Interviews and observations confirmed the resident's dissatisfaction and the staff's inappropriate actions.
The facility failed to maintain the privacy of confidential information during medication administration. An LPN left the medication cart unattended in the hallway with the computer screen unlocked and open, displaying resident information. This occurred while the LPN administered medication to multiple residents, leaving the computer screen accessible to anyone passing by.
A resident with multiple diagnoses, including multiple sclerosis and dementia, was neglected when a staff member transferred them using a mechanical lift without the required second staff member. This resulted in the resident being lowered to the floor after starting to slide off the bed.
The facility failed to maintain proper care of respiratory equipment for a resident who required oxygen therapy. Observations revealed that the filters on the resident's oxygen concentrator contained a gray dusty substance, indicating they had not been cleaned as required. A registered nurse confirmed the filters were dusty and should be cleaned weekly. The resident had diagnoses including Diabetes, High Blood Pressure, and Alzheimer's Disease.
The facility failed to ensure the accurate and safe disposition of controlled medications for a resident. The documentation lacked evidence that two licensed nurses were present and signed during the disposal of Morphine and Lorazepam, as required by facility policy. This deficiency was confirmed by the DON.
The facility failed to document attempts of non-pharmacological interventions before administering PRN psychotropic medications to two residents diagnosed with dementia, anxiety, and depression. The Director of Nursing confirmed the lack of documentation for both residents.
The facility failed to store food in accordance with safety standards, as two open containers of Imperial Butter Pecan 2.0 Cal Med Pass in the first-floor pantry refrigerator were found without open dates. A Registered Nurse confirmed that the containers should have been dated and discarded.
A resident with a history of unsteadiness on feet and other medical conditions required two-person assistance for transfers. However, a nursing assistant attempted to transfer the resident alone, resulting in a complete dislocation of the resident's left hip hemiarthroplasty. The facility's investigation confirmed the neglect, as the nursing assistant did not follow the care plan.
Expired Insulin Left on Medication Carts and Cart Left Unsecured
Penalty
Summary
Expired multi-dose insulin pens and vials were found on medication carts in two nursing units. Review of facility policy showed multi-use vials are to be dated when opened and discarded within 28 days or by the manufacturer’s expiration date. On observation of the A Wing medication cart, two opened Lantus multi-dose insulin pens were found with open dates of [DATE] and [DATE], along with one opened Humalog multi-dose insulin vial with an open date of [DATE]. On observation of the B Wing medication cart, one opened Lantus multi-dose insulin pen and one opened Humalog multi-dose insulin vial were also found with open dates of [DATE]. During interview, an LPN confirmed the insulin pens were expired and should be discarded, and the DON later confirmed the opened Humalog and Lantus insulin pens should have been discarded because they were expired. The facility also failed to keep one nursing unit medication cart secured. Review of the facility policy on medication cart security stated the nurse must secure the cart during medication pass and that medication carts must be securely locked at all times when out of the nurse’s view. During observation of the B Wing medication cart, it was found unsecured and parked next to the wall near room [ROOM NUMBER] while the RN was in the main dining room with a resident and not in view of the cart. The RN confirmed at the time that the cart should have been locked while out of view.
PHI Visible During Medication Administration
Penalty
Summary
The facility failed to maintain privacy of PHI during medication administration for one of six medication passes observed. A facility policy titled, The Privacy Plan dated 2/23/26, stated that the company must ensure the confidentiality, integrity, and availability of all PHI that it creates, receives, maintains, or transmits. During an observation on 3/03/26 at 12:30 p.m., RN Employee E1 was administering medications in the main dining room and left the computer screen containing resident PHI visible to anyone passing in the corridor. Housekeeping and dietary staff were observed passing by the visible computer screen, and RN Employee E1 confirmed during interview that the screen containing resident PHI was visible to anyone passing in the corridor.
Incomplete Transfer Documentation and Missing Clinical Information
Penalty
Summary
The facility failed to ensure that necessary resident information was communicated to the receiving health care provider when one resident was transferred to the hospital, and the resident’s transfer documentation was incomplete. Facility policy titled Transfer/Discharge Documentation, dated 2/18/25, required that when a resident is transferred to acute care, the facility provide the original transfer form and advance directives with the resident and retain copies in the medical record, along with contact information for the practitioner responsible for care, resident representative information, resident status, reason for transfer, recent vital signs, diagnoses, allergies, medications, relevant labs and diagnostics, special instructions and precautions, special risks, and comprehensive care plan goals. The clinical record for the resident showed an admission date of 12/20/25 and diagnoses including partial intestinal obstruction, difficulty swallowing, unsteady on feet, weakness, and need for assistance with personal care. A progress note dated 1/02/26 at 12:33 a.m. documented that the resident was transferred to the hospital, but the record lacked evidence that the resident’s necessary clinical information was communicated to the receiving health care provider. During an interview on 3/06/26 at 11:00 a.m., the DON confirmed that the facility lacked evidence that the resident’s necessary clinical information was provided upon transfer and that the clinical record lacked complete documentation.
Widespread Late Administration of Scheduled Medications
Penalty
Summary
The deficiency involves the facility’s failure to provide resident-directed care and treatment consistent with physician orders and professional standards of practice for medication administration. Facility policy titled "Administering Medications" requires that medications be administered in accordance with prescriber orders, including required timeframes, and within one hour of the prescribed time unless otherwise specified. Review of medication administration records for two evening shifts showed that numerous scheduled medications were administered more than one hour late for 37 of 62 residents. On one evening, multiple residents had medications scheduled for 8:00 p.m. that were not administered until between approximately 10:05 p.m. and 11:12 p.m., and one resident had a 6:30 p.m. medication administered at 8:31 p.m. Another resident’s medications scheduled for 8:00 p.m. were not given until after midnight. On the subsequent evening shift, additional residents had medications significantly delayed beyond the one-hour window. Medications scheduled for 4:30 p.m., 5:00 p.m., 6:30 p.m., 7:00 p.m., and 8:00 p.m. were administered between approximately 7:21 p.m. and 10:44 p.m., with some 4:30 p.m. and 5:00 p.m. medications not given until after 8:30 p.m. and as late as 10:43 p.m. These delays affected residents receiving single medications as well as those receiving multiple medications at a time, including instances where residents had up to 11 or 12 medications scheduled for a specific time that were administered several hours late. During a phone interview, the Nursing Home Administrator confirmed that the listed medications were administered late. The cited deficiency is related to Pennsylvania regulations governing responsibility of the licensee, management, and nursing services.
Failure to Follow Repositioning Care Plan for Resident
Penalty
Summary
The facility failed to adhere to the care plan for a resident identified as R224, who was at risk for skin integrity issues due to impaired mobility. The care plan specified that the resident should be turned and repositioned every two hours to prevent skin breakdown. However, observations on two consecutive days revealed that the resident remained in the same position, lying on their back, during multiple checks throughout the day. The Director of Nursing confirmed that the care plan required repositioning every two hours, yet the resident was not repositioned as required. The resident's medical history included conditions such as hypertension, hypothyroidism, and chronic systolic congestive heart failure, which could contribute to their vulnerability to skin integrity issues. The failure to follow the care plan was a direct violation of the facility's policy and the resident's care needs.
Failure to Provide Physician-Ordered Contracture Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with limited range of motion due to a contracture. The resident, identified as R19, had a physician's order dated 10/23/24 to use a rolled-up washcloth in the right hand to manage the contracture until a palm grip could be ordered. This order included instructions to change the washcloth daily and ensure it was washed and dried thoroughly between changes. However, during observations on 3/25/25, 3/27/25, and 3/28/25, it was noted that the resident did not have the washcloth or palm grip in place as ordered. The Director of Nursing confirmed during an observation on 3/28/25 that the resident did not have the required washcloth or palm grip on the right hand, acknowledging that it should have been in place according to the physician's orders. This deficiency was identified as a failure to follow the facility's policy on the use of assistive devices and to provide the necessary treatment to prevent further decline in the resident's range of motion.
Failure to Adhere to Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to provide oxygen to a resident according to the physician's orders. The resident, identified as R224, had a physician's order dated 3/20/25 for oxygen to be administered at 1.5 liters per minute via nasal cannula only during hours of sleep. However, observations on multiple occasions revealed that the resident was receiving supplemental oxygen throughout the day, contrary to the specified order. This discrepancy was confirmed by the Director of Nursing during an interview. Resident R224 was admitted with diagnoses including hypertension, hypothyroidism, and chronic systolic congestive heart failure. Despite the clear physician's order and care plan intervention for oxygen administration only at night, the resident was observed receiving oxygen during the day while in bed and sitting in a wheelchair. This failure to adhere to the physician's order constitutes a deficiency in providing appropriate respiratory care as per the facility's policy and the resident's care plan.
Medication Labeling and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and timely disposal of medications, as evidenced by observations and staff interviews. In the C/B medication room, an opened vial of Tubersol PPD was found without an open date, making it impossible for staff to determine the discard date. Additionally, another vial of Tubersol PPD was observed with an open date of 2/8/25, indicating that it was expired and should have been discarded. These findings were confirmed by an LPN, who acknowledged the lack of an open date on one vial and the expiration of the other. Similarly, in the B-Wing medication cart, an open injector pen of Humalog insulin was found with an open date of 2/17/25, indicating that it was expired. This was also confirmed by another LPN, who acknowledged that the Humalog insulin pen was expired and should have been discarded. The facility's policies on medication storage and labeling, as well as the manufacturer's guidelines for Tubersol PPD and Humalog insulin, were not adhered to, leading to these deficiencies.
Failure to Verify Allergies Leads to Medication Error
Penalty
Summary
The facility failed to adhere to nursing standards of practice for safe medication administration, specifically regarding the verification of medication allergies. A resident with a documented allergy to Keflex, an antibiotic, was administered the medication due to a series of oversights by the nursing staff. The resident, who had been admitted with conditions including chronic obstructive pulmonary disease, edema, and chronic atrial fibrillation, had Keflex listed as an allergy in their clinical record. Despite this, RN Employee E1 received a verbal order for Keflex from the physician and failed to verify the resident's allergies before entering the order into the facility's computer system and notifying LPN Employee E2. LPN Employee E2 subsequently administered the Keflex without reviewing the resident's allergy information. It was only after the medication was given that both RN Employee E1 and LPN Employee E2 realized the error. The Director of Nursing's investigation confirmed these lapses, and interviews with the involved staff corroborated the failure to check the resident's allergies prior to medication administration. This incident highlights a critical breakdown in the medication administration process, as outlined in the facility's policy and Pennsylvania Code Title 49.
Failure to Adhere to Medication Administration Protocols
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of practice for medication administration on Unit C. During an observation of medication administration, an LPN did not reference the Medication Administration Record (MAR) for three residents before administering their medications. The LPN administered medications to residents without verifying the right resident, right medication, right dosage, right time, and right method of administration as required by the facility's policy. Additionally, the LPN did not document the administration of medications immediately after giving them to each resident, as stipulated by the facility's policy and professional standards of practice. During an interview, the LPN admitted to not referencing the MAR before administering medications and not documenting the administration immediately after each resident. The LPN stated that they relied on their familiarity with the residents and received updates during shift reports. The LPN also mentioned that they were taught at a previous job to save time by administering all medications first and then documenting afterward. This practice led to the failure to adhere to the facility's policy and professional standards, resulting in a deficiency in nursing services and pharmacy services as per the relevant state codes.
Failure to Honor Resident's Right to Self-Determination
Penalty
Summary
The facility failed to honor Resident R17's right to self-determination and choice in significant aspects of their life. Resident R17, who has intact cognitive status as indicated by a BIMS score of 15, expressed a desire to be out of bed for meals and activities, including attending bible study and resident council meetings. Despite these preferences being documented in the resident's care plan and MDS assessment, observations revealed that Resident R17 was frequently left in bed dressed in pajamas during times they wished to participate in activities or meals in the dining room. On multiple occasions, staff did not assist Resident R17 in getting out of bed in a timely manner, resulting in missed activities and meals in the dining room, contrary to the resident's expressed wishes and documented care plan interventions. Interviews with Resident R17 confirmed their dissatisfaction with not being assisted out of bed as per their preferences. The resident reported wanting to be up in their wheelchair for meals and activities but was often left in bed. This was corroborated by observations on several dates where the resident was found in bed during meal times and scheduled activities. The Nursing Home Administrator and the Director of Nursing acknowledged that residents have the right to be out of bed for meals and activities and confirmed that the staff's actions were inappropriate and did not align with the resident's wishes or the facility's policies on resident rights and self-determination.
Failure to Maintain Privacy of Confidential Information
Penalty
Summary
The facility failed to maintain the privacy of confidential information during medication administration on Unit C. The facility's policy on Confidentiality of Information and Personal Privacy, dated 1/2/24, mandates safeguarding the personal privacy and confidentiality of all resident personal and medical records. However, an observation on 4/9/24, between 3:50 p.m. and 4:20 p.m., revealed that an LPN left the medication cart unattended in the hallway with the computer screen unlocked and open, displaying resident information. This occurred while the LPN administered medication to multiple residents, leaving the computer screen accessible to anyone passing by. The LPN confirmed during an interview that the medication cart and computer screen were left unattended and out of view, with resident information accessible to passersby.
Failure to Ensure Safe Transfer of Resident
Penalty
Summary
The facility failed to ensure that a resident was free of neglect during care. Resident R8, who has multiple diagnoses including multiple sclerosis, dementia, and chronic obstructive pulmonary disease, is dependent on staff for transfers from chair to bed. The resident's care plan, Kardex, and physician orders all specified that transfers should be conducted using a mechanical lift (Sara lift) with the assistance of two staff members. However, on the date of the incident, NA Employee E3 transferred Resident R8 using the Sara lift without the required second staff member. This resulted in Resident R8 being lowered to the floor after starting to slide off the bed while still attached to the lift. The facility's investigation confirmed that NA Employee E3 did not follow the protocol requiring two staff members for the transfer. The Nursing Home Administrator and Director of Nursing acknowledged that the mechanical lift should always be operated by two staff members when used with a resident. The incident was classified as neglect, as the facility failed to provide the necessary services to avoid physical harm, pain, mental anguish, or emotional distress to Resident R8.
Failure to Maintain Proper Care of Respiratory Equipment
Penalty
Summary
The facility failed to maintain proper care of respiratory equipment for a resident (R22) who required oxygen therapy. According to the facility's policy, filters from oxygen concentrators should be washed every seven days. However, observations revealed that the filters on Resident R22's oxygen concentrator contained a gray dusty substance, indicating they had not been cleaned as required. Resident R22 had a physician's order for oxygen at two liters per minute via nasal cannula for shortness of breath. During an interview, a registered nurse confirmed that the filters were dusty and should be cleaned weekly. Resident R22 had diagnoses including Diabetes, High Blood Pressure, and Alzheimer's Disease.
Failure to Ensure Proper Disposition of Controlled Medications
Penalty
Summary
The facility failed to implement procedures to ensure the accurate and safe disposition of controlled medication records for Resident CR68. According to the facility's policy, Schedule II-V medications remaining after a resident's discharge or order discontinuation must be disposed of by two licensed nurses or a licensed nurse and a licensed pharmacist. Resident CR68, who was admitted to the facility and ceased to breathe on 2/18/24, had 12.5 milliliters of Morphine and 29.75 milliliters of Lorazepam transferred to a Federally approved waste container. However, the documentation lacked evidence that two licensed nurses were present and signed during the disposal process. This deficiency was confirmed by the Director of Nursing during an interview on 4/12/24.
Failure to Attempt Non-Pharmacological Interventions Before Administering PRN Psychotropic Medications
Penalty
Summary
The facility failed to provide evidence that non-pharmacological interventions were attempted prior to the administration of PRN psychotropic medications for two residents. Resident R39, diagnosed with dementia, anxiety, and depression, received Haldol and Lorazepam without documented attempts of non-pharmacological interventions. Specifically, Haldol was administered on one occasion, and Lorazepam was used twice in April 2024 without any evidence of alternative calming methods being tried first. Similarly, Resident R60, also diagnosed with dementia, anxiety, and depression, received Vistaril multiple times from October 2023 to March 2024 without documented attempts of non-pharmacological interventions. The MARs and clinical records for Resident R60 showed that Vistaril was administered numerous times across several months without any evidence of non-pharmacological approaches being attempted prior to medication administration. The Director of Nursing confirmed the lack of documentation for both residents.
Failure to Date and Discard Opened Food Containers
Penalty
Summary
The facility failed to ensure that food was stored in accordance with standards for food safety in one of two refrigerators reviewed. Specifically, during an observation of the first-floor pantry refrigerator, two open containers of Imperial Butter Pecan 2.0 Cal Med Pass were found without open dates. According to the facility's policy on Food Receiving and Storage, beverages must be dated when opened and discarded after twenty-four hours. This deficiency was confirmed during an interview with a Registered Nurse, who acknowledged that the containers should have been dated and discarded due to the lack of an open date.
Neglect During Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was free from neglect during care, resulting in actual harm. The resident, who had a history of hypomagnesemia, hyperlipidemia, hypertension, and unsteadiness on feet, required extensive assistance with two-person transfers. However, a nursing assistant attempted to transfer the resident alone, which led to the resident's left leg giving out and a complete dislocation of the left hip hemiarthroplasty. The nursing assistant's actions were contrary to the resident's care plan, which specified the need for two-person assistance during transfers. The incident occurred when the nursing assistant tried to lay the resident down by themselves, resulting in the resident falling and landing hard on the bed. The resident immediately reported pain in the left hip and was later found to have a completely dislocated left hip hemiarthroplasty. The facility's investigation confirmed that the nursing assistant did not follow the care plan and attempted the transfer without the required assistance, leading to the resident's injury. The facility's policies on identifying types of abuse and safe lifting and movement of residents were not adhered to in this case. The nursing assistant's failure to follow the care plan and the facility's procedures resulted in the resident experiencing significant pain and requiring hospital transfer for further treatment. The facility acknowledged the deficiency and took immediate action to address the issue, including suspending the nursing assistant and providing additional education to staff.
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What surveyors actually found near you
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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.
Illustrative
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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) |
|---|---|---|---|---|
| Shippenville Nursing And Rehab | 3.7 mi | ★★★★★ | 1 | 0 |
| Clarview Nursing And Rehab Cen | 7.8 mi | — | 0 | 0 |
| Penn Highlands Jefferson Manor | 12.7 mi | ★★★★★ | 17 | 0 |
| Dr Arthur Clifton Mckinley Ctr | 14.9 mi | ★★★★★ | 4 | 0 |
| Upmc Northwest Transitional Care Unit | 20.9 mi | ★★★★★ | 2 | 0 |
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