Azria Health Clarinda

In the surveyor’s words

From the most serious findings on record at Azria Health Clarinda, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jan 9, 2024

  Based on clinical record review, facility records, hospital records, staff, family, and physician interviews, and facility policy review the facility failed to have a nurse assess 1 of 3 residents (Resident #1) after two Certified Nursing Assistants (CNA) reported the resident had experienced a change in condition. On [DATE] two CNAs reported to the nurse at about 6:30PM-7:00 PM they noted her oxygen saturation was 63% on room air, blood pressure (BP) was ,d+[DATE], they rechecked it and it was ,d+[DATE]. When the nurse on duty was notified she told the CNAs to put oxygen on her via oxygen concentrator at 2 liters (L). The CNAs rechecked Resident #1's oxygen saturation 20 minutes later and it was 92% but the resident seemed confused, not very aware and appeared to be in pain. […]

• Actual harm, isolatedF684Jan 20, 2022

  Based on clinical record review, staff interviews, clinic staff interview, and ARNP (Advanced Registered Nurse Practitioner) interview, the facility failed to assure staff completed a complete and thorough physical assessment with a timely identification of a change of condition which required transfer to the local emergency room (ER) for 1 of 2 residents reviewed (Resident #200). The facility failed to complete a thorough physical assessment with an identified change of condition or notify the physician until the resident transferred to the localER on [DATE] at 7:55 PM. Once in the ER, Resident #200 required intubation (tube placement to maintain open airway) and air lift transfer to a Level III hospital (intensive care or trauma hospital, requiring mechanical ventilation). […]

• Actual harm, isolatedF689May 27, 2021

  Based on observations, clinical record review, and staff and family interviews, the facility failed to provide adequate nursing supervision and assistance devices to prevent hazards for 2 of 4 residents reviewed (Resident #2 and 5). On 1/31/21, staff found Resident #2 on the floor in the bathroom. Staff A took the resident to the bathroom to use the toilet. Although the resident had a history of falls, experienced cognitive and memory problems, exhibited confusion, and required staff assistance for surface-to-surface transfers, Staff A left the resident in the bathroom and alone and unsupervised on the toilet. While sitting alone, the resident fell and complained of leg, hip, back and ankle pain. […]

• No harm, potential for more than minimal, patternF725May 7, 2026

  Based on observation, staff interviews, resident interviews, clinical review and policy review. The facility failed to respond to call lights in a timely manner for 4 of 4 residents reviewed (Resident #1, #15, #14, and #47). The facility reported a census of 60 residents. Findings Include:1. The Minimum Data Set (MDS) dated [DATE] documented Resident #1 had a Brief Interview for Mental Status (BIMS) of 00 that indicated severe cognitive impairment. The MDS further indicated that Resident #1 was dependent on staff for toileting hygiene, personal hygiene and transfers. On 5/4/26 at 12:35 PM a continuous observation revealed Resident #1's Wife turned the call light on. […]

• No harm, potential for more than minimal, patternF880May 7, 2026

  Based on observations, staff interviews, clinical record review, and policy review, the facility failed to ensure universal infection control measures and Enhanced Barrier Precautions (EBP) were maintained. The facility failed to ensure appropriate hand hygiene was completed during personal care for Resident #1, during wound care for 1 of 2 residents (Resident #41), during medication administration and during catheter care for 1 of 2 residents (Resident #5). The facility also failed to ensure appropriate Personal Protective Equipment (PPE) was worn for a resident that required EBP during catheter care (Resident #37). The facility reported a census of 60 residents.Findings Include:1. […]