Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 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.
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.
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 | — | 0 | 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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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.