Clarion Wellness: Medication Error Deficiency - IA
The medication error at Clarion Wellness and Rehabilitation Center went undetected from October 23 through October 27, when a certified medication aide finally noticed the medication cart contained 5-milligram amlodipine tablets instead of the prescribed 2.5-milligram doses.
Federal inspectors found that Resident #1, diagnosed with hypertension, was supposed to receive a reduced dose starting October 23. The physician had ordered a change from 5 milligrams once daily to 2.5 milligrams twice daily. But the facility's pharmacy never received the order.
For four days, day shift staff administered medication they didn't have. Evening shift staff documented giving doses that weren't in the medication cart.
The error came to light on October 27 when Staff A, a certified medication aide, told Staff B, a licensed practical nurse, that the cart contained the wrong medication strength. By then, Resident #1's blood pressure had climbed to 157/96 — well above the normal range of 120/80.
Staff B contacted the physician and received orders to hold the evening dose and resume the correct 2.5-milligram doses twice daily starting October 28. The facility notified the resident's sister and the director of nursing.
Director of Nursing confirmed the breakdown during a November 25 interview with federal inspectors. The order to change the medication "did not get faxed to the pharmacy as their pharmacy is not integrated into their EHR," he explained. "The nurse should have faxed the medication change to the pharmacy but forgot."
The facility operated without the correct 2.5-milligram medication cards in the cart until October 27, after discovering the error.
When inspectors pressed the director about the scope of the mistake — asking if day shift gave the wrong dose four times while evening shift documented giving medication they didn't possess four times — he confirmed both scenarios had occurred.
The director said he addressed the error by speaking with all nurses and certified medication aides about the "5 rights of medication administration." He now prints daily order reports and faxes them to the pharmacy as a double-check system. The facility also plans to switch to a pharmacy that integrates with their electronic health record system.
However, the director acknowledged he had no documentation of the staff education because he conducted it verbally.
The facility's medication administration policy, dating from July 2017, requires all medications be given as prescribed by the resident's physician. The policy specifically directs nurses and medication technicians to compare the drug and dosage on the resident's medication administration record with the drug label before administering any medication.
The policy includes a clear warning: "If there is any reason to question the dosage or the schedule, the nurse or med tech should check the physician's orders."
Federal inspectors cited the 61-bed facility for failing to ensure residents remain free from significant medication errors. The violation received a "minimal harm or potential for actual harm" designation.
The case illustrates how communication breakdowns between nursing homes and pharmacies can directly impact resident safety. For four days, a resident with high blood pressure received inadequate medication while staff documented administering doses they never possessed.
The resident's blood pressure reading of 157/96 represented a significant elevation that could have led to more serious cardiovascular complications if the error had continued undetected.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clarion Wellness and Rehabilitation Center from 2025-11-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Clarion Wellness and Rehabilitation Center in Clarion, IA was cited for violations during a health inspection on November 25, 2025.
Federal inspectors found that Resident #1, diagnosed with hypertension, was supposed to receive a reduced dose starting October 23.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.