Clarion Wellness and Rehabilitation Center

Inspectors wroteBased on clinical record review, staff interviews, and policy review, the facility failed to administer medications as ordered by the physician for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 61 residents.

Inspectors wroteBased on clinical record review, observations, staff interviews, and policy review the facility failed to implement care plan interventions to reduce the risk for falls for 1 out of 20 residents reviewed (Resident #19). The facility reported a census of 62 residents.

Inspectors wroteBased on clinical record review, staff interview, hospital record review, and facility policy review, the facility failed to provide adequate nursing supervision to prevent an accident and injuries for 1 of 1 resident reviewed (Resident #23) related to a suicide attempt. Resident #23 voiced he wanted to kill himself and had a plan on 5/17/25 (he attempted to use his fingernails to try to dig out a vein) and 5/18/25 (he placed a pen over his wrist and inner arm bend), the facility sent him to the emergency room (ER) on both dates. Upon return on 5/17/25 the facility implemented temporary one-to-one (1:1) supervision. The facility discontinued the supervision the same day around 9:30 PM without putting any further safety interventions in place. Resident #23 returned to the ER on [DATE] related to suicide ideation and gestures. The facility reported a census of 62 residents.

Inspectors wroteBased on clinic record review, staff interviews, and policy review, the facility failed to administer medications per physician orders for 1 out of 1 resident reviewed (Resident #23) for significant medication errors. The facility reported a census of 62 residents.

Inspectors wroteBased on clinical record review and staff interviews, the facility failed to have a complete and accurately documented medical record for 1 of 20 residents reviewed (Resident #23). The facility reported a census of 62 residents.

Inspectors wroteBased on review of the facility's Quality Assurance Performance Improvement (QAPI) plan, the facilities past 2 surveys, and staff interview, the facility failed to correct their own deficiencies for 1 of 1 areas of concern. The facility reported a census of 62 residents.

Inspectors wroteBased on facility record review and staff interview, the facility failed to have the minimum required members present at their quarterly Quality Assessment and Performance Improvement (QAPI) meetings as directed by Centers for Medicare and Medicaid Services (CMS). The facility reported a census of 62 residents.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to provide wound care in a manner to prevent infection for 1 of 3 residents reviewed with wounds (Resident #3). The facility reported a census of 63 residents.

Inspectors wroteBased on clinical record review, hospital record review, policy review, resident and staff interviews, the facility failed to provide care and services to promote healing of pressure wounds for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 56 residents.

Inspectors wroteBased on observations, resident interview, facility records review, staff interview, and policy review, the facility failed to provide sufficient staff to meet the needs of residents who resided in the facility (Residents #6 and #7) for 2 of 5 resident reviewed for call lights. The facility reported a census of 56 residents.

Inspectors wroteBased on clinical record review, facility policy review, residents and staff interviews the facility failed to treat residents with respect and dignity in a manner that promotes maintenance or enhancement of their quality of life for 3 out of 6 residents reviewed. (Residents #1, #2 and #4). The facility identified a census of 66 residents.

Inspectors wroteBased on clinical records review, staff interview, facility investigation review, and policy review, the facility failed to notify the Department of Inspections, Appeals, and Licensing (DIAL) of 2 of 2 allegations of physical and verbal abuse within 24-hours of staff learning of the incidents. 1. On 3/20/24 around 11:30 PM, Resident #47 notified a Certified Nursing Aide (CNA) of alleged physical abuse. On 3/26/24 around 5:50 AM a Dietary Aide learned of Resident #47's allegation of physical abuse by a second CNA. No one reported the allegation of abuse until the Dietary Aide reported it to the Director of Nursing (DON) on 3/26/24 around 6:00 PM. The facility began their investigation of the alleged abuse on 3/26/24 and reported the incident to that evening at 10:08 PM. 2. On 6/16/24 around 11:30 PM a CNA documented they witnessed alleged verbal abuse towards Resident #316. [...]

Inspectors wroteBased on resident's record review, staff interviews, facility investigation review, time card detail, employee files, and policy review, the facility failed to separate staff members accused of alleged physical and verbal abuse from dependent residents in a timely manner for 2 of 2 residents reviewed (Residents #47 and #316). 1. Resident #47 reported an allegation of physical abuse on 3/20/24 to a Certified Nurse Aide (CNA). The CNA failed to report the allegation to Administration, which allowed the alleged abuser to work multiple days after the allegation. In addition, one dietary staff member learned of the allegation in the morning of 3/26/24, but failed to report the allegation until 5:00 PM that evening. This allowed the staff member to continue to work their entire shift on 3/26/24. 2. A CNA witnessed another CNA swear at a behavioral resident on 6/16/24. [...]

Inspectors wroteBased on observations, resident interviews, staff interviews, clinical record review, facility investigation, police report, and facility policy, the facility failed to provide a safe environment free from physical, verbal, and psychosocial abuse for 2 of 2 residents reviewed (Residents #47 and #316). 1. Despite Resident #47 reported alleged physical abuse on 3/20/24, the alleged abuser continued to work until the Director of Nursing (DON) learned of the allegations and started an investigation on 3/26/24. The facility allowed the alleged abuser to return to work on 4/3/24 and he continued to work at the facility. Resident #47 reported the alleged staff member on multiple occasions entered and stayed in her room alone. Resident #47's Care Plan updated on 3/28/24 instructed the alleged staff member to not enter her room alone. [...]

Inspectors wroteBased on clinic record review, staff interviews, resident interview, Nurse Practitioner interview, and policy review, the facility failed to administer medications per physician orders for 2 out of 2 residents reviewed (Resident #25 and #2) for significant medication errors. 1. The facility failed to provide Resident #25 their ordered Revlimid (anticancer medication that slows the progression of multiple myeloma and various types of cancer) from 4/25/24 to 6/5/24. 2. Resident #2 received medications not prescribed to her. Resident #2 received her roommates' medications (Resident #10) instead of her own. The facility reported a census of 61 residents. The State Agency informed the facility of the Immediate Jeopardy on 10/16/24 at 2:47 PM that began on 4/25/24. The facility staff removed the Immediate Jeopardy on 10/16/24 through the following actions: a. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure staff used proper food handling procedures to prevent possible contamination of food during lunch service with food uncovered. The facility reported a census of 61 residents.

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 resident reviewed for catheter care (Resident #363). The facility reported a census of 61 residents.

Inspectors wroteBased on review of employee file, facility policy, and staff interview, the facility failed to provide a valid Dependent Adult Abuse Mandatory Reporter Certificate, for the time of an alleged abuse (3/20/24) for Staff C, Certified Nursing Assistant (CNA). The facility reported a census of 61 residents.

Inspectors wroteBased on clinical record review, policy review and staff interview, the facility failed to ensure a consistent code status between the Iowa Physician's for Scope of Treatment (IPOST), Care Plan, and the Electronic Health Record (EHR) for 1 of 1 resident reviewed for advanced directives (Resident #16). The facility reported a census of 61 residents.

Inspectors wroteBased on observation and staff interviews, the facility's Dietary Staff failed to perform the proper functions of food and nutrition services for the pureed food process for 3 of 3 residents requiring a pureed diet. The facility reported a census of 61 residents.

Inspectors wroteBased on observations, facility record review, and staff interviews, the facility failed to provide a comfortable home-like environment that was free from foul odors for 1 of 1 residents reviewed (Resident #24). The facility reported a census of 59 residents.

Inspectors wroteBased on interviews, clinical record review, and facility document review the facility failed to update a Resident's Care Plan with Interventions implemented after a resident fell for three of nine residents reviewed for accidents and hazards (Residents #21, 38, and #47).

Inspectors wroteBased on observation and interviews, the facility failed to enhance or maintain a resident's dignity while eating for four of four random residents reviewed for assisted dining. While assisting the four residents who required help with eating, the facility staff stood over the residents to provide them with bites of their meal.

Inspectors wroteBased on observation and interviews, the facility failed to cue or assist a resident who required assistance with meals for one of four random residents reviewed.

Inspectors wroteBased on interviews, the facility failed to provide ready access to their money as requested. The facility did not allow residents access to their money stored in the resident's trust account for two of two residents reviewed (Residents #62 and #6) for personal funds.

Inspectors wroteBased on clinical record review, policy review, and staff interviews, the facility failed to notify the physician in a timely manner of the significant weight loss of 1 of 1 resident reviewed (Resident #38). The facility reported a census of 59 residents.

Inspectors wroteBased on clinical record review, policy review, and staff interview, that facility failed to develop and implement a comprehensive care plan that included all of the resident ' s medical needs for 1 of 21 residents reviewed (Resident #32). The facility reported a census of 59 residents.

Inspectors wroteBased on interviews and clinical record reviews, the facility failed to follow physician orders as written for three of four residents reviewed (Residents #17, #32, and #47).

Inspectors wroteBased on observations, interviews, and clinical reviews the facility failed to have a restorative program to prevent the development or worsening of movement disorders and maintain joint mobility for two of two residents reviewed for impaired mobility (Resident #21 and #47).

Inspectors wroteBased on interviews, clinical record reviews, and facility policy review, the facility failed to assess and intervene for a resident with constipation for one of one reviewed (Resident #5) for bowel and bladder.

Inspectors wroteBased on interviews, clinical record reviews, facility policy review, and interviews, the facility failed to ensure the safety of two of nine residents reviewed for accidents and hazards (Residents #21, and #47). After each resident fell, the facility failed to complete a thorough investigation and then implement new, and unique interventions for multiple of their falls to prevent future falls for Residents #21 and #47.

Inspectors wroteBased on observations, interviews, and clinical record reviews, the facility failed to ensure a resident received oxygen as ordered by the physician for one of three residents reviewed (Resident #26). In addition, the facility failed to change and/or date the oxygen tubing for residents who used oxygen for one of three residents reviewed (Resident #6).

Inspectors wroteBased on facility record review, resident, and staff interviews, the facility failed to provide nursing staff to assure resident safety by not responding to call lights in a timely manner to 4 of 21 residents reviewed (Resident #6, #26, #29, and #31).

Inspectors wroteBased on observations, interviews, and clinical record reviews, the facility failed to ensure a resident received psychotherapy or psychiatry services for two of two residents reviewed for mood and behavior (Residents #5 and #17).

Inspectors wroteBased on observations and interviews observed the medication cart unlocked and unattended with random staff and a resident walk by the cart. The facility reported a census of 59 residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure sanitary conditions while assisting a resident with eating for two of four random residents reviewed for assisted dining.

Inspectors wroteBased on observations, interviews, and clinical record reviews the facility failed to not touch additional items with soiled gloves after emptying a urinary catheter for one of one residents reviewed (Resident #55) for catheter care.