Clarion Wellness And Rehabilitation Center
Clarion Wellness and Rehabilitation Center in Clarion, IA — inspection on November 25, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Based 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.
Findings include:The Minimum Data Set (MDS) for Resident #1, dated 9/6/25, listed a diagnosis for hypertension (high blood pressure).
The Physician's Order dated 10/22/25 directed to change Resident #1's order for amlodipine from 5 milligrams (mg) daily to 2.5 mg two times daily to start on 10/23/25.
The Electronic Medication Administration Record (EMAR) indicated Resident #1 received 2.5 mg two times daily from 10/23/25 to 10/26/25 and on the morning of 10/27/25. In addition, the facility held evening dose for 10/27/25.
The Electronic Health Record (EHR) indicated on 10/27/25 Staff A, Certified Medication Aide (CMA), informed Staff B, Licensed Practical Nurse (LPN), the medication cart had amlodipine 5 mg daily, when it should have a dose of 2.5 mg two times a day.
Staff B contacted and received an order to hold the evening dose and resume 2.5 mg two times daily on 10/28/25. Resident #1 had a blood pressure of 157/96 (average 120/80) at that time.
The facility notified Resident #1's sister and the DON of the medication error. In interview on 11/25/25 at 8:24 AM the Director of Nursing (DON) stated the order to change from amlodipine 5 mg daily to 2.5 mg two times daily on 10/23/25 did not get faxed to the pharmacy as their pharmacy is not integrated into their EHR.
The nurse should have faxed the medication change to the pharmacy but forgot.
They did not have the 2.5mg medication cards in the medication cart until 10/27/25 after catching the medication error. As corrective action, he spoke with all the nurses and CMAs about the 5 rights of medication administration and now prints off the order listing report daily and faxes it to the pharmacy as a double check.
They also plan to change to a pharmacy that integrates with their EHR.
The DON reported he didn't have documentation of the education as he did it verbally.
When asked if the day shift gave the wrong dose of amlodipine 4 times and the evening shift charted, they gave a medication they did not have 4 times, he stated that they had.
The Administration of Medications policy dated July 2017 directed all medication shall be administered as prescribed by the resident's physician, nurse practitioner, or physician's assistant. It also indicated that prior to administering the resident's medication, the nurse or medication technician should compare the drug and dosage schedule on the resident's MAR with the drug label. NOTE: If there is any reason to question the dosage or the schedule, the nurse or med tech should check the physician's orders.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
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