Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Iron County Medical Care Facility during CMS and state inspections, most recent first.
Surveyors found that several doors equipped with 15-second delayed egress hardware lacked required signage and did not function as intended, with some doors failing to initiate the irreversible opening sequence and others bypassing it entirely. These deficiencies were confirmed during testing and observation with the Acting Maintenance Director.
Surveyors observed a large amount of cigarette butts scattered throughout the smoking area and in the grass, indicating that required smoking regulations and proper disposal methods, such as the use of approved ashtrays and metal containers, were not being followed. This was confirmed by the Acting Maintenance Director.
Surveyors observed that the facility did not label the generator's above ground diesel fuel tank with an NFPA 704 placard in a visible location, as required by NFPA 30. This deficiency was confirmed by the Acting Maintenance Director and represents noncompliance with multiple NFPA standards.
Empty and full oxygen cylinders were found mixed together on a cart in the Cedar Wing oxygen storage room, rather than being properly segregated as required by NFPA 99. This was confirmed by the Acting Maintenance Director during the survey.
The facility did not provide documentation that the kitchen hood fire suppression system in one wing had received the required hydrostatic testing, as confirmed by the Acting Maintenance Director during record review. This deficiency could impact up to 30 occupants in the event of a fire emergency.
An exercise bike in the inpatient gym area was found plugged into an extension cord, contrary to NFPA 99 and NFPA 70 standards for electrical safety. The improper use of the extension cord was confirmed by the Acting Maintenance Director during the survey.
The facility did not ensure that monthly Medication Regimen Reviews were reviewed, addressed by a physician, or maintained in residents' clinical records. For several residents with complex medical conditions, pharmacy reports were missing for multiple months, and facility leadership acknowledged that there was no process in place to ensure pharmacy consults were addressed or documented as required.
Surveyors identified a medication error rate of 13.33% after observing multiple instances where nurses crushed potassium chloride ER capsules against physician orders, allowed a resident to chew a capsule without water, failed to document or notify the physician about medication administration issues, and did not shake liquid medication before administration. These actions were not in accordance with facility policy or physician instructions.
Staff failed to perform hand hygiene between resident rooms during water pass and while providing catheter care, resulting in the use of contaminated gloves to touch environmental surfaces and resident items. Staff acknowledged not following hand hygiene protocols, and the DON was informed of the risk for cross-contamination.
A resident with COPD, anxiety, and dementia was given supplemental oxygen at a higher flow rate than ordered by the physician, with no documented assessment or physician notification to support the change. The oxygen tubing was not replaced according to facility protocol, and nebulizer equipment was not cleaned or stored in a sanitary manner as required. Staff interviews and record reviews confirmed these failures to follow physician orders and facility policies for respiratory care.
A resident with multiple diagnoses received both vitamin D2 and D3 concurrently after a physician accepted a pharmacy recommendation to switch formulations, but the original vitamin D2 order was not discontinued. This resulted in duplicate weekly administration and excessive dosing, which was not identified due to a missed step in the medication order review process.
The facility's QAPI committee failed to meet quarterly with all required members, with key personnel such as the Medical Director, DON, IP, and NHA frequently absent. This inconsistency placed all 115 residents at risk for quality care concerns.
A resident did not receive a dose of hydrocodone-acetaminophen that was signed out by an RN, leading to an investigation. The RN had a history of careless documentation and suspicious behavior, including increased PRN administration. The RN refused a drug test and was terminated as per facility policy.
The facility failed to report injuries of unknown source to the state agency for two residents with severe cognitive impairments. One resident was found with facial fractures, and another with multiple fractures, but neither incident was reported as required by facility policy.
The facility failed to complete an investigation for an incident where a resident with severe cognitive impairment and multiple medical conditions was found on the floor with fractures. Despite the severity, the investigation was not completed as required by the facility's procedures.
The facility failed to assess and monitor pressure injuries for a resident, leading to inadequate care. The resident had a pressure injury on the left gluteal area and a deep tissue injury on the left heel, but there was no proper documentation or treatment. A stage II pressure injury on the sacrum was also not documented or treated according to the facility's policies. The DON and staff were unaware of the current status of these injuries, and the required weekly skin assessments were not completed.
The facility failed to report PBJ information to CMS, resulting in inaccurate staffing level reports. A review of the CMS PBJ Staffing Data Report for FY Quarter 1 2024 revealed multiple instances of no RN hours and a lack of licensed nursing coverage for 24 hours a day. An RN responsible for PBJ data submission confirmed that the facility missed the submission deadline, potentially affecting all 115 residents.
Noncompliance with Delayed Egress Door Requirements
Penalty
Summary
Surveyors observed that several doors in required means of egress were equipped with 15-second delayed egress hardware but did not meet the requirements set forth by NFPA 101. Specifically, the door to the main nurses station from Willow Wing and Door 12 were missing the required signage stating, "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS." Additionally, the Birch Wing Alcove exit, Door 17, and other doors failed to initiate the irreversible opening sequence when tested multiple times, indicating that the delayed egress function was not operating as intended. In contrast, Door 9 and Door 8, while appropriately signed, immediately opened and bypassed the irreversible opening sequence upon testing, further demonstrating noncompliance with the required delayed egress operation. These deficiencies were confirmed through direct observation and testing by the surveyor, with the Acting Maintenance Director present at the time. The report does not mention any specific residents or their medical conditions in relation to these findings. The focus of the deficiency is on the improper installation, signage, and functioning of delayed egress hardware on multiple doors, which did not comply with the standards for special locking arrangements as required by NFPA 101.
Failure to Enforce Smoking Regulations and Proper Disposal of Cigarette Butts
Penalty
Summary
The facility failed to ensure that smoking regulations were fully implemented and adhered to as required by regulatory standards. During an exterior tour of the building, a large number of cigarette butts were observed scattered on the ground throughout the designated smoking area and in the surrounding grass. This observation was confirmed by the Acting Maintenance Director at the time of discovery. The presence of cigarette butts indicates that proper disposal methods, such as the use of metal containers with self-closing covers and noncombustible ashtrays, were not being utilized as required in areas where smoking is permitted.
Failure to Label Generator Fuel Tank with Required NFPA 704 Placard
Penalty
Summary
The facility failed to comply with requirements for labeling the generator's above ground diesel fuel tank with an NFPA 704 placard. During an observation on April 23, 2025, it was noted that the fuel tank was not marked with the required placard in a location visible upon approach, as mandated by NFPA 30, 21.7.2.1. This deficiency was identified during a survey and confirmed by the Acting Maintenance Director at the time of discovery. The report specifies that this failure to label the fuel tank properly is not in accordance with NFPA 110, NFPA 99, NFPA 111, and NFPA 70 standards. The deficiency could potentially affect all occupants in the event of a fire, as the lack of proper labeling may hinder emergency response or safety procedures. No specific residents or patient conditions are mentioned in the report.
Improper Storage of Oxygen Cylinders
Penalty
Summary
The facility failed to ensure proper storage of nonflammable gas cylinders in accordance with NFPA 99 requirements. During an observation in the Cedar Wing oxygen storage room, it was found that empty oxygen cylinders were not segregated from full oxygen cylinders. Specifically, 38 cylinders were observed mixed together on a cart, rather than being separated as required by regulations. This deficiency was confirmed at the time of discovery by the Acting Maintenance Director. The report does not mention any specific patients or their medical conditions in relation to this deficiency. The focus of the finding is on the improper storage practice of oxygen cylinders, which did not meet the established standards for gas equipment storage.
Failure to Complete Required Hydrostatic Testing of Kitchen Hood Fire Suppression System
Penalty
Summary
The facility failed to ensure that cooking facilities were protected in accordance with NFPA 96 standards. During a record review, it was found that the kitchen hood fire suppression system in the Cedar Wing had not undergone the required hydrostatic testing, as the two most recent inspection records did not show evidence of this testing being completed. No documentation was provided by the end of the survey to confirm that the hydrostatic test had been performed. This deficiency was confirmed by the Acting Maintenance Director at the time of the record review. This lapse could affect up to 30 occupants in the event of a fire emergency, as noted in the findings.
Noncompliant Use of Extension Cord for Exercise Equipment in Patient Care Area
Penalty
Summary
A deficiency was identified when, during an observation in the inpatient gym area, an exercise bike was found plugged into an extension cord. This setup did not comply with NFPA 99 and NFPA 70 requirements regarding the use of power strips and extension cords for electrical equipment in patient care areas. The observation was confirmed by the Acting Maintenance Director at the time. The report specifies that extension cords are not to be used as a substitute for fixed wiring and must be removed immediately after temporary use, which was not adhered to in this instance. No additional details about the specific occupant affected, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain and Address Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRR) were properly reviewed, addressed by the physician, and maintained in the clinical records for four out of five residents reviewed. For multiple residents with complex medical histories, including dementia, diabetes, anxiety, depression, and other conditions, pharmacy reports documenting the MRR were missing for several months. The Director of Nursing (DON) was unable to locate these reports in the electronic medical record and acknowledged that she did not keep them as required. The DON also confirmed that there was no way to determine what recommendations the pharmacist had made, whether the medical director or nurse practitioner had agreed or disagreed with those recommendations, or if any rationale for decisions was documented. Interviews with facility leadership, including the DON and Nursing Home Administrator (NHA), revealed that there was no designated staff member ensuring that pharmacy consults were being addressed. The NHA admitted that the system for handling pharmacy consults was broken and deficient. Review of the facility's own policy confirmed that written communications from the pharmacist should become a permanent part of the resident's medical record, but this was not being followed. As a result, the facility was unable to demonstrate compliance with federal requirements for drug regimen review and documentation.
Plan Of Correction
For Resident #67, the consultant pharmacist completed a drug regime review and submitted it to the DON and attending physician. The DON assured that the practitioner addressed any recommendations in the DRR. For Resident #36, the consultant pharmacist completed a drug regime review and submitted it to the DON and attending physician. The DON assured that the practitioner addressed any recommendations in the DRR. For Resident #65, the consultant pharmacist completed a drug regime review and submitted it to the DON and attending physician. The DON assured that the practitioner addressed any recommendations in the DRR. For Resident #90, the consultant pharmacist completed a drug regime review and submitted it to the DON and attending physician. The DON assured that the practitioner addressed any recommendations in the DRR. The DON/designee audited the EMR for all residents and identified those residents who did not have a DRR in April 2025. The DON notified the pharmacist that these reviews needed to be completed. DON and ADON had a phone conference with the pharmacy consultant about our process and how to correct it. To ensure the pharmacy recommendations are being answered according to policy, the process needs to come back to an in-house process instead of reports being sent electronically to an outside source, Theoria. DON and ADON met with the DNP about changing the processing of pharmacy consultation reports by bringing the process back internally instead of sending them to Theoria to process. The DNP was in agreement. On 4/21/2025, it was confirmed that the pharmacist would be at the facility in person on 4/24/2025 to meet and discuss survey findings and finalize the plan to bring the process back to an in-house process. On 4/24/2025, the DON and ADON met with the consulting pharmacist to review the Medication Regimen Review policy and discussed the new process as follows: 1) After receiving monthly pharmacy recommendations, the ADON will print and separate them for delivery as follows: a. Nursing will be handed the recommendations to be given to the Administrative Medical Assistant to initiate processing. b. The physician will be handed the recommendations to be reviewed and responded to by the DNP and/or medical director. c. GDRs — a meeting will be scheduled for the Behavior Team to review and give their recommendations to the DNP/medical director for review and response. 2) Once all recommendations have been reviewed and have a response, all reports will be given to the charge nurse for processing. 3) A copy of the summary of MRRs will be given to charge nurses to indicate orders they process. 4) Recommendations will then go to HIM to be scanned into the residents' medical records. 5) The DON/ADON will review the completion of recommendations weekly. On 4/25/2025, the current Pharmacy Consultation Reports from the pharmacist with new and outstanding recommendations were received. On 4/28/2025, the DON and ADON reviewed all GDRs with the IDT. The ADON distributed all pharmacy recommendations to either the Administrative Medical Assistant for processing or the DNP for review. One-on-one direction was given to the DNP about the internal process by the ADON. To prevent pharmacy recommendations responses from being delayed and to ensure they are part of the residents' medical records, the following has been completed and/or initiated: DON, ADON, and pharmacy consultant reviewed and updated the Medication Regimen Review Policy and changed the response timeframes for the attending physician/DNP to: 1) 45 days (from 60 days), after which the DON will bring them back to the attending physician/DNP. 2) 50 days (from 65 days), after which the DON will notify the Medical Director and/or the Administrator. The ADON completed one-on-one education with all charge nurses on the change of the internal process. On 5/5/2025, the DON verified that the processing of April's pharmacy recommendations had been completed and all had been sent to HIM to be scanned into the residents' medical records. To ensure the changes implemented are followed, the DON/ADON or designee will review: 1) The monthly Pharmacy Consultation Summary Reports weekly for progress. 2) If by Day 30, a pharmacy recommendation has still not been addressed, the DON will bring it back to the attending physician/DNP for review per the ICMCFS Medication Review Policy. The DON/ADON or designee will audit completed recommendations for: 1) Completion of pharmacy recommendations by the attending physician/DNP with signature and rationale. 2) That completed recommendations have been added to the residents' medical records. Audits will be conducted as follows: 10 audits for 1 month, 6 audits for 1 month, and 4 audits for 1 month. The DON will present a compliance report based on the audit findings at monthly QAPI meetings for review by the team for 3 months, with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. Ongoing monitoring thereafter will be continued by the DON/ADON to ensure compliance in accordance with the policy. The DON will be responsible for attaining and sustaining overall compliance with this plan of correction.
Medication Error Rate Exceeds 5% Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a calculated error rate of 13.33% based on four medication errors out of thirty opportunities. Surveyors observed multiple instances where nursing staff did not follow physician orders or facility policy during medication administration. For example, a registered nurse crushed potassium chloride extended-release capsules for two residents, despite clear physician instructions and labeling that the medication should not be crushed. In both cases, there were no physician orders or care plan indications permitting the medications to be crushed. Another resident was observed chewing a potassium chloride capsule, which was not administered with water as required by FDA guidelines and facility policy. The nurse did not document the resident's difficulty swallowing the medication, nor was the physician notified that the resident did not receive the full prescribed dose or that a change to a liquid form might be needed. Additionally, a nurse failed to shake a bottle of senna oral syrup before administration and combined the unshaken liquid with other crushed medications in coffee, again without a physician's order or care plan direction to do so. The Director of Nursing confirmed that medications labeled as "do not crush" should not be altered without a physician's order, and that proper procedures for medication administration, documentation, and disposal were not followed in these cases. Facility policy also requires hand hygiene between residents, destruction of unused medications, and notification of the physician if a resident does not take medications as prescribed, none of which were consistently observed during the survey.
Plan Of Correction
The facility will develop a plan to maintain a medication error rate of 5% or less. For Resident #95, a review of labs was completed by DON and ADON to assess for potassium toxicity, and the resident was monitored through daily nursing notes for any signs or symptoms. Follow-up labs were obtained and reviewed by DNP. For Resident #8, a review of labs was completed by DON and ADON to assess for potassium toxicity, and the resident was monitored through daily nursing notes for any signs or symptoms. Follow-up labs were obtained and reviewed by DNP. For Resident #70, a review of labs was completed by DON and ADON to assess for potassium toxicity, and the resident was monitored through daily nursing notes for any signs or symptoms. Follow-up labs were obtained and reviewed by DNP. For Resident #23, a review of bowel movements was completed by DON to assure that the resident did not have any unusual increased or decreased frequency of bowel movements. The resident was also monitored through daily nursing notes and CNA task documentation. ADON identified all residents who receive potassium and all who receive crushed, opened, or modified medications that had the potential to be affected. Immediate 1:1 education was given to nurses in the facility on Do Not Crush medications. DON and ADON reviewed the Medication Administration Policy and updated the Oral Crushed Medication section to reflect that a physician order is needed to crush any medication and to administer multiple crushed medications together. DON and ADON completed a Root Cause Analysis (RCA). They created a Relias module and posttest reinforcing the following: - If a pill is dropped onto the cart or floor, place it in the Drug Buster and retrieve a new pill to administer. - Shake well to mix suspensions. - Crushed medications require a Physician order to crush. - Potassium orders require a DO NOT CRUSH order but may be opened and sprinkled. - If a resident refuses medications, document in EHR and notify the Charge Nurse. - If medication has been prepared and then refused, destroy it in the Drug Buster. - Perform hand hygiene prior to administering medication. - Perform hand hygiene after medication administration. - If a resident is displaying difficulty with any medication (e.g., taste, form, size), notify the physician. - For employees who are casual/student status, on vacation, or on leave of absence (LOA), training will be completed before or during their next scheduled shift. DON provided a full list of residents who receive crushed medications to DNP for review and to write an order for long-acting medications indicating: 1) Do Not Crush OR 2) Do Not Crush, but may open and sprinkle and combine OR 3) May crush and Do NOT combine OR 4) May crush and combine Once orders are processed, MDS will update the Care Plan to reflect this. DON created a new form: Refusal of Medication/Medication Change Request Form, for charge nurses (notified by neighborhood nurses) to fill out for residents who may require a change in medication for any reason. Completed forms will be given to DNP for any necessary action. DON verified that audits are performed monthly by the pharmacy consultant for any residents who should have an order stating Do Not Crush. The Omniviews DO NOT CRUSH medication list was added to all units' medication information binders, placed at the north side nurses' station, and given to Administrative Medical Assistants. To ensure the policy review and changes are followed, DON/ADON or designee will randomly audit a medication pass with a focus on: - Medications are not being altered or combined without an order - No prepared medication stored in the medication cart - Performing hand hygiene - Medication disposed of appropriately if contaminated or refused - Shaking of liquid medications - Notification to the charge nurse for medication refusal Audits will occur on two nurses weekly on each shift for one month, then one nurse on each shift weekly for two months, and then one nurse monthly on an ongoing basis to ensure compliance with facility guidelines. The pharmacy consultant will audit residents' orders monthly and ensure Do Not Crush orders are present for medications that should not be crushed, sending recommendations if an order is missing. The MDS coordinator or designee will conduct quarterly audits to verify that any resident on crushed, opened, modified, or combined medications has a corresponding intervention in their care plan. DON will present a compliance report based on the audit findings at monthly QAPI meetings for review by the team for three months, with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. Ongoing monitoring thereafter will be continued by DON to ensure compliance in accordance with the plan of correction. DON will be responsible for attaining and sustaining overall compliance with this plan of correction.
Failure to Perform Hand Hygiene During Resident Care and Water Pass
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during routine care activities, specifically during the distribution and collection of water mugs and during catheter care. Certified Nurse Aide (CNA) "A" was observed delivering fresh water and removing used water mugs from multiple residents' rooms without performing hand hygiene between rooms. CNA "A" admitted to not using hand sanitizer between rooms and acknowledged the importance of hand hygiene in preventing cross-contamination. During catheter care for a resident, CNA "O" and CNA "C" donned gloves as part of Enhanced Barrier Precautions. CNA "O" performed perineal care and, without removing contaminated gloves, touched environmental surfaces such as closet handles and retrieved a clean incontinence brief. The same contaminated gloves were used to change the resident's brief and assist with clothing and protective boots. CNA "O" acknowledged that hand hygiene and glove changes should have occurred after cleaning the resident's genitals and catheter tubing. A registered nurse confirmed that gloves should be removed and hand hygiene performed before touching other surfaces. The facility's hand hygiene policy requires staff to perform hand hygiene before donning gloves and immediately after removing them, emphasizing that glove use does not replace hand hygiene. The Director of Nursing was made aware of the observations and expressed understanding of the deficiency related to the failure to perform hand hygiene and the potential for cross-contamination within the facility.
Plan Of Correction
The facility will develop a plan to ensure hand hygiene will be performed during a fresh water pass and post catheter care. For resident #11, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #32, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #33, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #38, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #50, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #52, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. For resident #55, DON and ADON monitored daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. None noted. Housekeeping disinfected the high-touch surfaces in room. The DON/ADON and designees identify residents on Enhanced Barrier Precautions who were potentially affected. For any identified, the DON/ADON will monitor daily nursing notes on the 24-hour report for any signs or symptoms of potential infection. Immediate 1:1 education was provided to Resident Assistants in the facility on proper hand hygiene protocol between residents when passing water jugs. All others were educated before or during their next working shift. DON and ADON completed policy reviews on the following: 1) Hand Hygiene Policy reviewed and updated to indicate when it's appropriate to perform hand hygiene: a. Perform Hand Hygiene before and after: i. Performing invasive procedures ii. Handling medications iii. Handling contaminated items iv. Contact with blood and body fluid, secretions, excretions, mucous membranes, etc v. Assisting with/providing personal care vi. Eating vii. Using the restroom viii. Sneezing, coughing, blowing or wiping nose. b. When in doubt, wash your hands. 2) Catheter Care Policy—updated to indicate it’s appropriate to remove gloves and perform hand hygiene after performing catheter care but before touching clean items. Then don new, clean gloves. 3) Drinking Water Distribution Policy—updated to indicate hand hygiene is to be performed before entering a resident’s room and after placing the empty jug on the cart. DON and ADON created an education module with posttest on Relias for: 1) All Resident Assistants on performing hand hygiene between resident rooms 2) All CNAs on when to perform hand hygiene after performing catheter care, but before touching clean items such as closet handle, clothing, or clean brief. Per facility policy, you are required to remove gloves, perform hand hygiene, and don new, clean gloves. For those employees who are casual/student status, on vacation, or on LOA, training will be completed before/during their next scheduled shift. To ensure compliance with hand hygiene after education, DON/ADON or designee will perform hand hygiene audits during a water pass 6x/week for 2 weeks, 4x/week x 2 weeks, then 2x weekly for two months. Audits for hand hygiene for residents on Enhanced Barrier Precautions will be completed by DON/ADON or designee with focus on reducing the risk for cross-contamination. Two audits weekly for 1 month, one audit weekly for 2 months. The DON will present a compliance report based on the audit findings to be reviewed during monthly QAPI meetings by the team for 3 months, with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. DON will be responsible for attaining and sustaining overall compliance with this plan of correction.
Failure to Administer and Maintain Oxygen and Nebulizer Equipment per Physician Orders and Facility Policy
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease (COPD), anxiety, and dementia was observed receiving supplemental oxygen at a flow rate of 3 liters per minute (L/min) via nasal cannula, despite the active physician order specifying oxygen at 2 L/min as needed. Multiple observations confirmed the oxygen was being administered at the higher rate without any documented assessment or physician notification to justify the change. The resident's medical record did not contain documentation supporting the increased oxygen flow, and the most recent vital signs indicated an oxygen saturation of 97% on room air, with no evidence of a clinical need for the higher oxygen rate. Additionally, the oxygen tubing in use was found to be dated over a month prior to the observation, exceeding the facility's protocol for changing tubing every two weeks. Staff interviews confirmed the tubing was out of date and that the protocol for timely replacement was not followed. The resident was unaware of the oxygen concentration being administered and reported feeling more short of breath recently. Further observations revealed that the resident's nebulizer equipment, including the medication chamber and mouthpiece, was left resting directly on the nightstand without a protective barrier and was not stored in a sanitary manner as required by facility policy. Staff confirmed that the nebulizer equipment should have been cleaned, dried, and stored in a plastic bag after each use, but this was not done. Facility policies for both oxygen and nebulizer care were not followed, resulting in deficiencies in both the administration and maintenance of respiratory equipment.
Plan Of Correction
The facility will ensure that residents who need respiratory care are provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident goals and preferences. For Resident #65, the DON and practitioner reviewed the resident's recent oximetry readings and assessed the resident's respiratory status, clarifying the oxygen liter flow ordered. The DON replaced, labeled, and dated the resident's oxygen tubing. The DON placed a barrier under the equipment and ensured a baggie was available to store tubing when not in use, per facility policy. The DNP reviewed the resident's record and completed an assessment with ongoing treatment for a diagnosis of COPD. No noted ill effects. On 4/17/2025, the DON identified those residents who are currently receiving oxygen and audited tubing for accuracy on labeling and to ensure correct storage units to coil and place tubing in a baggie when not in use. One of three was noted to have out-of-date oxygen tubing. The tubing was changed and labeled correctly. The DON also audited care plans for accuracy, and all three were up to date. The DON verified orders on all residents receiving oxygen to determine accuracy on the rate of flow the resident is receiving. The ADON obtained the current list of residents receiving nebulizer treatments. In each unit where these residents reside, the DON ensured nurses had proper cleaning supplies, an area to allow equipment to dry, and proper storage containers for nebulizer equipment. To prevent oxygen tubing from becoming outdated, ensure it is stored in a sanitary manner, and ensure oxygen is administered per physician order, the following has been completed and/or initiated: On 4/18/2025, the DON and ADON reviewed the following policies and deemed them appropriate with evidence-based practices: 1) Cleaning and Disinfecting Nebulizers Policy, 2) Oxygen Use and Set-up Policy, 3) Medication Administration Policy. On 5/1/2025, all nurses currently working in the facility received 1:1 education on the following: 1) Cleaning and Storage of oxygen tubing & nebulizer equipment, 2) 5 Rights of Medication Administration with a focus on checking the order to assure that oxygen is being administered at the ordered liter flow, 3) Hand Hygiene with a focus on during medication administration. For those employees who are casual/student status, on vacation, or on LOA, training will be completed before/during their next scheduled shift. The DON and ADON created a Relias education module and post-test for all licensed nursing staff, including a review of the Cleaning and Disinfecting Nebulizer Policy and Oxygen Use and Set-up Policy. The focus was on storing oxygen tubing, cleaning equipment after each use, changing oxygen tubing, and how/what to use to clean equipment. They also created a Relias education module and post-test for all CNAs, emphasizing storing tubing when not in use. 1:1 education was provided to AMA and NAA staff on the delivery of oxygen tubing and humidifier bottles, with an emphasis on: - Placing new tubing themselves and not delegating it out to another staff member. - Reapproaching the resident if unable to apply when they first attempt. - Reviewing the Oxygen Use and Set-Up Policy. To ensure the education and changes implemented are followed, monitoring has been implemented to ensure sustainability of compliance: - DON/ADON or designee will complete audits of oxygen administered per physician order and labeling of oxygen tubing for accuracy, weekly for 2 months, and with random audits for 1 month. - Storing of equipment in a sanitary manner will be audited 2 times per week for one month, weekly for one month, and randomly for one month. The facility will schedule follow-up evaluations to ensure that these practices are maintained over the long term and that any trends are addressed promptly. The DON will present a compliance report based on the audit findings to be reviewed during monthly QAPI meetings by the team for 3 months, with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. The DON/ADON will be responsible for attaining and sustaining overall compliance with this plan of correction.
Duplicate Vitamin D Therapy Administered Due to Failure to Discontinue Prior Order
Penalty
Summary
A deficiency occurred when a resident with diagnoses including a left femur fracture, mild cognitive impairment, urinary tract infection, and vitamin D deficiency received duplicate therapy of vitamin D. The resident was initially prescribed ergocalciferol (vitamin D2) 50,000 units weekly. Following a pharmacy recommendation, the physician accepted a change to cholecalciferol (vitamin D3) 50,000 units weekly, but the original vitamin D2 order was not discontinued. As a result, both vitamin D2 and D3 were administered concurrently throughout June, leading to an excessive total weekly dose of 100,000 units. The duplicate administration was confirmed through review of the medication administration record and pharmacy consultation reports. The DON and ADON acknowledged the error after reviewing the records and confirmed that the duplication was not detected due to a missed step in the double-checking process for physician orders. The facility's policy required thorough medication regimen reviews to prevent such issues, but the process failed to identify and resolve the duplicate therapy in this instance.
Plan Of Correction
The facility will develop a plan to ensure residents receive medications that are appropriate, necessary, and free from duplication. Review of the medical record indicates that Resident #90 has received the ordered dose of Vitamin D3 since July 1, 2024. The DON/designee reviewed the Drug Regime reviews for the month of April 2025. There was no duplicative therapy identified that the physician had not addressed. Physician Orders Policy given to the Nursing Administration Team and charge nurses in house for review, to verify and evaluate our current process. RCA completed by DON and ADON to identify how error occurred. Upon process review, we identified our transcription of orders would improve with redundancy built into the system. The Nursing Administrative Team revised the process to include a double note signature. 1:1 Education on the importance of double noting orders occurred for all charge nurses, neighborhood licensed staff, and nursing administrative team currently in the facility. All other nursing staff not in the building will be educated before or during their next shift. DON and ADON created a Physician Order Policy review with post-test for all licensed staff on Relias with focus on: double noting by licensed staff ensuring no duplicate orders and to identify the same medication under a different name. For those employees who are casual/student status, on vacation, or on LOA, Relias education will be completed before/during their next scheduled shift. To ensure the education and changes implemented are followed, monitoring has been implemented to ensure sustainability of compliance. ADON updated Provider Visitation Log Sheets for DNP and Medical Director to include space to verify the order has been double noted by a licensed staff member. DON/ADON or designee will audit 2 Provider Visitation Log Sheets (that contain up to 22 orders) and 6 Omnicare pharmacy recommendation sheets weekly for one month to ensure order was processed per facility policy to ensure double noting was completed by second licensed staff. Then 1 provider visitation log sheet and 4 Omnicare pharmacy recommendation sheets weekly for one month, then 1 provider visitation log sheet and 2 Omnicare pharmacy recommendations weekly for one month. DON will present a compliance report based on the audit findings to be reviewed during monthly QAPI meetings by the team for 3 months; with recommendations by QAPI for further monitoring if consistent compliance has not been achieved. DON will be responsible for attaining and sustaining overall compliance with this plan of correction.
QAPI Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members. During an interview and record review, it was found that the QAPI meeting sign-in sheets revealed inconsistent attendance by key members. On multiple occasions, essential members such as the Medical Director, Director of Nursing (DON), Infection Preventionist (IP), and Nursing Home Administrator (NHA) were absent. Specifically, the Medical Director was absent in three out of six meetings, the DON was absent in two meetings, and the IP and NHA were each absent in one meeting. This deficiency placed all 115 residents at risk for quality care concerns as the QAPI committee did not consistently meet with the required members to ensure proper oversight and quality improvement initiatives.
Failure to Prevent Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medication for a resident (R266). R266, who was cognitively intact and admitted with diagnoses including a spinal fracture and ankylosing spondylitis, did not receive a dose of hydrocodone-acetaminophen that was signed out by RN H. The discrepancy was discovered when R266 requested the medication for back pain, and it was noted that RN H had signed out the medication but not documented its administration in the electronic Medication Administration Record (MAR). R266 confirmed he had not received the medication at the time it was signed out, leading to an investigation by the facility's Director of Nursing (DON) and other staff members. The investigation revealed that RN H had a history of careless documentation, including a previous incident where she signed out a controlled substance in the MAR but not in the narcotic sign-out log. During the investigation, RN H admitted to administering the medication but could not provide a consistent account of the event. RN H's behavior, including leaving the facility without permission and a history of increased PRN administration, raised further suspicion. When asked to submit to a drug test, RN H refused, leading to her immediate termination as per facility policy. The facility's policies on medication administration and drug testing were reviewed, confirming that refusal to submit to a drug test is treated as a positive result. The DON and Nursing Home Administrator (NHA) confirmed the termination of RN H due to her refusal to submit to the drug test. The facility had previously re-educated RN H after the first documentation incident but had not changed its policy at that time. The report highlights the failure to prevent the misappropriation of narcotic medication and the subsequent actions taken by the facility to address the issue.
Failure to Report Injuries of Unknown Source
Penalty
Summary
The facility failed to report injuries of unknown source to the state agency for two residents with severe cognitive impairments. Resident #87, who was admitted with Alzheimer's Disease and was dependent on staff for all activities of daily living, was found on the floor with facial injuries and bleeding. Despite the severity of the injuries, which included facial fractures confirmed by a CT scan, the event was not reported to the state agency. The Director of Nursing admitted that the new cameras were not yet installed, making it impossible to validate the employees' statements, and the Nursing Home Administrator confirmed that the event was not reported because the investigation results ruled out abuse, although the facility was not able to immediately rule out abuse at the time of the incident. Resident #34, also admitted with Alzheimer's Disease and severe cognitive impairment, was found on the floor of her room and was sent to the hospital for x-rays and a CT scan, which revealed multiple fractures. Despite the resident's severe cognitive impairment and the unwitnessed nature of the injury, the event was not reported to the state agency. The Director of Nursing did not provide an explanation for the failure to report. The facility's policy on incident reporting clearly states that any incident requiring hospitalization should be reported to the Administrator and the State Health Department.
Incomplete Investigation of Resident Incident
Penalty
Summary
The facility failed to conduct a thorough and complete investigation for an incident involving a resident with severe cognitive impairment and multiple medical conditions, including Alzheimer's disease, anxiety disorder, major depressive disorder, type 2 diabetes, chronic pain, congestive heart failure, and primary hypertension. The resident, who requires substantial to maximum assistance to transfer, was found on the floor next to her wheelchair, complaining of left pelvic pain. The incident report revealed that the resident sustained a left inferior pelvic fracture, an anterior pelvic fracture, and a patella fracture. Despite the severity of the incident, the Director of Nursing acknowledged that the investigation into the incident was not completed, which is a violation of the facility's Incident Report Procedure that mandates investigations to be started within two working days and completed within fourteen days.
Failure to Assess and Monitor Pressure Injuries
Penalty
Summary
The facility failed to assess and monitor pressure injuries to promote the healing of a facility-acquired pressure injury for one resident. Resident #109 was admitted to the facility and initially had no pressure injuries. However, a pressure injury on the left gluteal area was identified on 3/7/24, but subsequent assessments and documentation were lacking. Additionally, a deep tissue injury on the left heel was identified on 3/12/24, but there was no further documentation or assessment of this injury in the resident's medical record. The Director of Nursing (DON) and other staff were unaware of the current status of these injuries, and there was no physician documentation on the pressure injuries. A skin assessment on 4/24/24 revealed a stage II pressure injury on the resident's sacrum, which had not been properly documented or treated according to the facility's policies. During interviews, the resident stated that nurses had not been assessing or treating the pressure injury on his bottom, and the DON confirmed that there was no additional documentation of the wounds in the resident's medical record. The facility's policies required weekly skin assessments and documentation for residents at risk for pressure injuries, but these were not completed for Resident #109. The lack of proper assessment, monitoring, and documentation of the pressure injuries led to a deficiency in the care provided to the resident. The facility's failure to follow its own policies and procedures for pressure injury assessment and treatment resulted in inadequate care for Resident #109. The DON and other staff members were not aware of the resident's pressure injuries, and there was no evidence of physician involvement in the assessment and treatment of these injuries. The facility's documentation practices were insufficient, and the required weekly skin assessments were not conducted, leading to a deficiency in the quality of care provided to the resident.
Failure to Report PBJ Information to CMS
Penalty
Summary
The facility failed to report Payroll Based Journal (PBJ) information to CMS, resulting in inaccurate reporting of staffing levels. This deficiency was identified through a review of the CMS PBJ Staffing Data Report for FY Quarter 1 2024, which revealed multiple instances of no RN hours and a lack of licensed nursing coverage for 24 hours a day on specific dates. An interview with an RN responsible for PBJ data submission confirmed that the facility missed the deadline for submitting the PBJ information to CMS. This failure had the potential to affect all 115 residents in the facility.
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What surveyors actually found near you
We read the 79 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Crystal Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Iron River Care Center | 11.9 mi | ★★★★★ | 42 | 0 |
| Florence Health Services | 12.9 mi | ★★★★★ | 28 | 0 |
| Freeman Nursing & Rehabilitation Community | 24.1 mi | ★★★★★ | 5 | 0 |
| Optalis Health And Rehabilitation Of Kingsford | 24.2 mi | ★★★★★ | 4 | 0 |
| Maryhill Manor | 28 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.