Clarion Nursing and Rehab

In the surveyor’s words

From the most serious findings on record at Clarion Nursing and Rehab, in the surveyor’s own words.

• Actual harm, isolatedF600Mar 7, 2024

  Based on review of facility policy, facility documentation and clinical record, and resident and staff interviews, it was determined that the facility failed to ensure that one of three residents reviewed (Resident R1) was free of neglect during care which resulted in actual harm of a completely dislocated entire left hip hemiarthroplasty (a complete dislocation of a partial hip replacement that replaces half of the hip joint). This deficiency is cited as past non-compliance. Findings include: Review of facility policy entitled, Identifying Types of Abuse, dated 1/2/24, revealed that Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. […]

• No harm, potential for more than minimal, patternF761Mar 6, 2026

  Based on review of facility policy, observations, and staff interview, it was determined that the facility failed to discard expired multi-dose insulin pens (medication to treat elevated blood sugar levels) in two of four medication carts (A and B Wings) and also failed to safely secure medications on one of four nursing unit medication carts (B Wing). Findings include: Review of a facility policy entitled Labeling of Medications and Biologicals dated [DATE], indicated that multi-use vials will be dated when opened, and discarded within 28 days or according to the manufacturer's expiration date. […]

• No harm, potential for more than minimal, patternF684Jan 9, 2026

  Based on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to provide resident-directed care and treatment consistent with physician orders, and professional standards of practice related to medication administration for 37 of 62 residents on two evening shifts on 12/05/25 and 12/06/25. (Residents R1, R2, R3, R4, R6-R28, and R30-R39)Findings include: The most recent facility policy entitled Administering Medications revealed that medications are administered in accordance with prescriber orders, including required timeframe, and that medications are administered within one hour of their prescribed time, unless otherwise specified (before and after meals). […]

• No harm, potential for more than minimal, patternF658Apr 12, 2024

  Based on review of rights of medication administration, facility policy, observation, and staff interview, it was determined that the facility failed to provide nursing services consistent with professional standards of practice for medication administration during observation of one of three resident units (Unit C). Findings include: Review of Eight Rights of Medication Administration published by [NAME] (a prominent medical publisher that provides essential health information for practitioners, faculty, residents, students and healthcare institutions) on 5/28/2011, rights of medication administration include: Right Patient, Right Medication (includes checking label and checking physician order), Right Dose (includes checking order), Right Route, Right Time, Right Documentation (after… […]

• No harm, potential for more than minimal, patternF756Aug 13, 2021

  Based on review of clinical records and facility policy and staff interviews, it was determined that the facility failed to ensure that pharmacy recommendations were acted on in a timely manner for three of 22 residents reviewed (Residents R7, R11, and R20). Findings include: Review of a policy entitled Consultant Pharmacist Reports dated 9/22/20, indicated that a record of consultant pharmacist's recommendations will be made available in an easily retrievable form to nurses, prescribers, and care planning team, comments and recommendations concerning medication therapy are communicated in a timely fashion and enable a response prior to the next medication regimen review, and non-urgent cases are acted upon within 30 days. […]