Clarion Wellness and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Clarion Wellness and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF609Oct 17, 2024

  Based on clinical records review, staff interview, facility investigation review, and policy review, the facility failed to notify the Department of Inspections, Appeals, and Licensing (DIAL) of 2 of 2 allegations of physical and verbal abuse within 24-hours of staff learning of the incidents. 1. On 3/20/24 around 11:30 PM, Resident #47 notified a Certified Nursing Aide (CNA) of alleged physical abuse. On 3/26/24 around 5:50 AM a Dietary Aide learned of Resident #47's allegation of physical abuse by a second CNA. No one reported the allegation of abuse until the Dietary Aide reported it to the Director of Nursing (DON) on 3/26/24 around 6:00 PM. The facility began their investigation of the alleged abuse on 3/26/24 and reported the incident to that evening at 10:08 PM. 2. […]

• Immediate jeopardy, patternF610Oct 17, 2024

  Based on resident's record review, staff interviews, facility investigation review, time card detail, employee files, and policy review, the facility failed to separate staff members accused of alleged physical and verbal abuse from dependent residents in a timely manner for 2 of 2 residents reviewed (Residents #47 and #316). 1. Resident #47 reported an allegation of physical abuse on 3/20/24 to a Certified Nurse Aide (CNA). The CNA failed to report the allegation to Administration, which allowed the alleged abuser to work multiple days after the allegation. In addition, one dietary staff member learned of the allegation in the morning of 3/26/24, but failed to report the allegation until 5:00 PM that evening. […]

• Immediate jeopardy, isolatedF600Oct 17, 2024

  Based on observations, resident interviews, staff interviews, clinical record review, facility investigation, police report, and facility policy, the facility failed to provide a safe environment free from physical, verbal, and psychosocial abuse for 2 of 2 residents reviewed (Residents #47 and #316). 1. Despite Resident #47 reported alleged physical abuse on 3/20/24, the alleged abuser continued to work until the Director of Nursing (DON) learned of the allegations and started an investigation on 3/26/24. The facility allowed the alleged abuser to return to work on 4/3/24 and he continued to work at the facility. Resident #47 reported the alleged staff member on multiple occasions entered and stayed in her room alone. […]

• Immediate jeopardy, isolatedF760Oct 17, 2024

  Based on clinic record review, staff interviews, resident interview, Nurse Practitioner interview, and policy review, the facility failed to administer medications per physician orders for 2 out of 2 residents reviewed (Resident #25 and #2) for significant medication errors. 1. The facility failed to provide Resident #25 their ordered Revlimid (anticancer medication that slows the progression of multiple myeloma and various types of cancer) from 4/25/24 to 6/5/24. 2. Resident #2 received medications not prescribed to her. Resident #2 received her roommates' medications (Resident #10) instead of her own. The facility reported a census of 61 residents. The State Agency informed the facility of the Immediate Jeopardy on 10/16/24 at 2:47 PM that began on 4/25/24. […]

• Immediate jeopardy, isolatedF700Sep 4, 2022

  Based on interviews, record review, policy review, and review of manufacturer recommendations, the facility failed to assess the risk of resident entrapment and/or obtain informed consent for the use of bed rails/grab bars for one (Resident #148) of two residents reviewed for entrapment from bed rails. In addition, the facility failed to conduct ongoing evaluations of risks and ongoing assessments to ensure a grab bar was meeting Resident #148's needs. Staff placed a grab bar (also known as an assistance handle, bed bar, and transfer aide) on Resident #148's bed on [DATE] without assessing the risks/benefits of the grab bar for the resident and without obtaining the resident/resident responsible party's consent. […]