Clarion Wellness and Rehabilitation Center
110 13th Avenue SW, Clarion, IA 50525 · Wright County · 76 certified beds · avg 64 residents/day · certified since Sep 17, 1997
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Oct 17, 2024 · F-0609
The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation.
Why it matters: When incidents aren't reported promptly, abusers may continue harming residents and outside authorities can't step in.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Nov 4, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Oct 17, 2024 · F-0610
The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do.
Why it matters: When allegations aren't investigated, harm to residents can continue unchecked.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Nov 4, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Oct 17, 2024 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 4, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Oct 17, 2024 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 4, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (37)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Nov 25, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Aug 28, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Aug 28, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Aug 28, 2025 | D · Potential for harm, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Aug 28, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Aug 28, 2025 | D · Potential for harm, one-off | The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. |
| Aug 28, 2025 | D · Potential for harm, one-off | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. |
| Aug 28, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jul 9, 2025 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jul 9, 2025 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint |
| Feb 11, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Oct 17, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Oct 17, 2024 | ▲ K · Immediate jeopardy, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Oct 17, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Oct 17, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Oct 17, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 17, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Oct 17, 2024 | E · Potential for harm, repeated | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. |
| Oct 17, 2024 | D · Potential for harm, one-off | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Jul 20, 2023 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Jul 20, 2023 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to manage their own money and financial affairs. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jul 20, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (9 → 7).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 17 | 0 | E |
| 2024 | 9 | 4 | K ▲ |
| 2025 | 11 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $24,174.
| Date | Type | Amount / length |
|---|---|---|
| Oct 17, 2024 | Fine | $24,174 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Iowa avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.12 | 4.37 | 3.95 | bottom 1% in Iowa; bottom 18% in the U.S. |
| Registered Nurse hours | 0.39 | 0.85 | 0.69 | bottom 5% in Iowa; bottom 21% in the U.S. |
| Weekend total nurse staffing | 2.77 | 3.86 | 3.50 | bottom 2% in Iowa; bottom 19% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.18 | 0.51 | 0.48 | bottom 2% in Iowa; bottom 9% in the U.S. |
| Total nursing staff turnover (%) | 44.9 | 44.0 | 45.8 | bottom 42% in Iowa; top 50% in the U.S. |
| RN turnover (%) | 62.5 | 42.1 | 42.9 | bottom 22% in Iowa; bottom 19% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 2.83, RN 0.36, weekend 2.52. Staffing rating: 2/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Aerofund Holdings INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/18/2011 |
| Burnam, Soon | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/18/2011 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 07/18/2011 |
| Caretrust GP LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/18/2011 |
| Caretrust Reit INC | Organization | ADP of the SNF | NOT APPLICABLE | 07/18/2011 |
| Cozzens, Spencer | Individual | Managing Control - Governing Body | NOT APPLICABLE | 09/30/2015 |
| Cozzens, Spencer | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/30/2015 |
| Cozzens, Spencer | Individual | ADP of the SNF | NOT APPLICABLE | 07/11/2025 |
| Ctr Partnership LP | Organization | ADP of the SNF | NOT APPLICABLE | 07/18/2011 |
| Elohim Medical Staffing Agency INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/18/2011 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/2011 |
| Gazebo Park Health Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 07/18/2011 |
| Helping Hands Nursing Solution INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/18/2011 |
| Jorgensen, David | Individual | Corporate Director | NOT APPLICABLE | 09/09/2024 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Koenig, Debra | Individual | Corporate Officer | NOT APPLICABLE | 09/09/2024 |
| Onshift INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/18/2011 |
| Port, Barry | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 08/28/2025 |
| Sato, Ami | Individual | Corporate Officer | NOT APPLICABLE | 09/09/2024 |
| Smith, Dustin | Individual | Managing Control - Governing Body | NOT APPLICABLE | 01/08/2020 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you keep residents' medical records accurate, complete, and secure?"
- "How does your quality improvement program work, and can you share a recent example of a problem you found and fixed?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Rotary Senior Living | 9.2 mi | Eagle Grove, IA | ★★★☆☆ | 2/5 | |
| Rehabilitation Center of Belmond | 11.2 mi | Belmond, IA | ★★★★★ | 4/5 | |
| Kanawha Community Home, INC. | 15.4 mi | Kanawha, IA | ★★★★★ | 5/5 | |
| Crestview Nursing and Rehabilitation | 19.0 mi | Webster City, IA | ★★☆☆☆ | 2/5 | |
| Southfield Wellness Community | 19.1 mi | Webster City, IA | ★☆☆☆☆ | 1/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 165362.