Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 River Care Center during CMS and state inspections, most recent first.
A resident with chronic pain syndrome, cancer, and intact cognition sustained a fall, striking the lower back on the bed frame and developing a large, very tender hematoma. Despite physician orders allowing ice then heat and later ordering warm compresses and scheduled oxycodone, staff delayed initiating non-pharmacological interventions, missed multiple ordered warm compress treatments, and failed to administer several scheduled oxycodone doses without documenting reasons. Pain assessments documented frequent, severe pain that interfered with sleep, rehab, and daily activities, and the resident reported staying in bed and becoming incontinent due to pain and fear of getting up. The DON and RN staff acknowledged delays in treatment and that increased pain was not communicated to the physician, while an x-ray later showed an L1 compression fracture associated with post-fall pain.
A resident with cancer, COPD, and anxiety, and intact cognition experienced a fall resulting in a large back hematoma/abrasion and later-confirmed L1 compression fracture with significant pain. Despite this change in condition and documented pain, the care plan was not revised to address post-fall pain, assessment of fracture-related pain, or non-pharmacological interventions such as warm compresses, contrary to facility policies requiring ongoing review and revision of the comprehensive care plan and incorporation of pain management interventions.
QAA committee meetings were held quarterly, but review of the signature sheets showed that required leadership attendance was not documented at two meetings. The SSC, who coordinated the QAPI program, confirmed the Administrator's signature was missing and could not recall whether the NHA attended. The records also did not show a governing board member or other leader with authority to change facility systems, despite the policy requiring the QAA committee to include leadership representation.
Infection Prevention and Control Program Failure: An RN removed medications from blister packs directly into an ungloved hand, handled drinking cups by the rim, and later dispensed a controlled substance into an unwashed, ungloved hand instead of using a medication cup. A housekeeper placed full waste bags from medication carts on the floor, and an RN performing wound care on a resident failed to perform hand hygiene or change gloves after touching soiled dressings during dressing changes.
The facility failed to provide the LTC Ombudsman with copies of written transfer notices for five residents who were hospitalized or sent to the ED. Record review found no documentation that the notices were sent, and the SSW Director reported that discharge lists for two months were not sent. The LTC Ombudsman stated she had not received a discharge list from the facility for several months, despite the facility policy requiring notice and evidence that it was sent.
Care plans were not revised to match current resident assessments and clinical changes. A resident with dementia was still care planned as an elopement risk even though staff said the resident no longer wandered or propelled a wheelchair, and the wander alert was not in place. Two other residents had severe cognitive impairment with documented aggressive behaviors, resisting care, and recurrent UTI/antibiotic treatment, yet their care plans remained outdated and did not reflect those current needs or interventions.
Failure to Obtain PASARR Level II Evaluation: A resident with dementia, psychotic disturbance, PTSD, and behavioral symptoms that interfered with care had a PASARR Level I screening with yes responses, but the record did not contain the required PASARR Level II evaluation. Social Services confirmed the Level II forms were not submitted, and the ADON could not find any Level II screening in the chart.
Incomplete care planning affected two residents. One resident had CKD stage 3, severe cognitive impairment, urinary incontinence, recurrent UTIs, and intermittent antibiotic treatment, but the care plan did not include resident-focused UTI or antibiotic-use interventions and toileting documentation was inconsistent. Another resident with dementia and severe cognitive impairment had reported behaviors toward female residents, yet no behavior care plan was in place for staff awareness and interdisciplinary communication.
Failure to follow wound care orders was identified for a resident with diabetes, wound infection, and PVD/PAD who had chronic left leg and foot ulcers. Hospital discharge instructions called for daily cleansing, debridement of loose slough, xeroform, ABDs, and kerlix, but the TAR showed no wound treatments completed and the EMR had no physician-ordered wound treatments. The DON and ADON acknowledged the missing orders.
Failure to update fall care plans after repeated falls and fractures. Two residents at high fall risk were involved: one resident with moderately impaired cognition fell twice, including a fall that resulted in a cervical fracture, and another resident slipped from bed and sustained an acute hip fracture. The DON confirmed that no new fall-prevention interventions were added to either resident’s care plan after the incidents, despite existing fall-risk plans and facility policy calling for relevant interventions to minimize serious consequences of falling.
Missing oxygen orders and tubing changes for a resident receiving nasal cannula oxygen. A resident with DM, wound infection, PVD/PAD, respiratory failure, and COPD was observed receiving oxygen via nasal cannula with undated tubing. The EMR contained no physician orders for oxygen, no flow-rate order, and no order for routine tubing changes, and the TAR showed the tubing had not been changed in July or August. The resident said he had needed oxygen during a prior hospitalization, and the DON acknowledged the missing orders.
Water damage and poor bathroom maintenance were observed in shared resident bathrooms serving rooms 203/205 and 207/209. In the bathroom for rooms 203/205, the wall behind the toilet had bubbled paint, felt wet and damp near the baseboards, and showed softened drywall with the corner separating when lightly pushed; missing baseboard tiles and a bathtub used for storage were also noted.
The facility failed to maintain comfortable temperatures, resulting in a non-homelike environment for four residents. Residents reported feeling cold, with temperatures recorded as low as 65 degrees. Maintenance staff acknowledged non-functioning heaters and drafts from door cracks. The Nursing Home Administrator was unaware of these issues, and staff wore jackets to stay warm. The facility's policy on maintaining a safe and homelike environment was not adhered to.
The facility inaccurately reported PBJ information to CMS, resulting in a deficiency for excessively low weekend staffing. The CMS PBJ Staffing Data Report for FY Quarter 2 of 2024 showed multiple instances of low staffing. Interviews revealed that the Business Office Manager/Human Resources submitted data without review, and the NHA was unaware of the staffing issue. The facility's policy requires verification of staffing data by the NHA, HR Director, and DON, which was not adhered to.
The facility's QAPI committee failed to meet the required membership and frequency of meetings, as the Medical Director or their designee was absent from two meetings. This non-compliance with the facility's policy could potentially decrease the quality of care for all 54 residents.
The facility failed to implement adequate infection control measures during a COVID-19 outbreak. Staff did not use PPE correctly, and there were no visual alerts or hand hygiene facilities at the alternative entrance used during construction. Five residents tested positive for COVID-19, and staff were observed not adhering to PPE protocols, such as wearing the same mask from a COVID-19 positive resident's room into the hallway. The facility's policy required visual alerts and instructions for PPE use and hand hygiene, which were not implemented, contributing to the deficiency.
The facility failed to properly manage medications brought in from home for nine residents, leading to the storage of opened, undated, and unlabeled medications in the medication room. Staff interviews confirmed that these medications should have been sent home or discarded, as per the facility's policies.
The facility failed to complete monthly medication regimen reviews for four residents, resulting in missing consultation reports and unaccounted pharmacist recommendations. The DON confirmed the absence of these reports and could not verify follow-up actions. Additionally, one resident's medication reviews were missing for several months, despite being on antipsychotic and antidepressant medications.
The facility did not adequately address or respond to concerns raised by residents during Resident Council meetings. Residents reported that their complaints were repeatedly discussed but not resolved, and the Activity Director admitted to not effectively reviewing or documenting these concerns. Meeting minutes showed inconsistencies and a lack of follow-up on issues like cold food, indicating a failure to act upon and communicate resolutions as required by policy.
A facility failed to report an allegation of potential sexual abuse between two residents, one with moderate and the other with severe cognitive impairment. Despite a grievance being filed by a resident, the incident was not reported to the State Survey Agency as required. Interviews revealed that the Social Services Designee informed the DON and NHA, but no investigation or report was made. The facility's policies mandate reporting such allegations, which was not adhered to.
The facility failed to investigate an allegation of potential sexual abuse between two residents. A resident with moderate cognitive impairment reported that another resident with severe cognitive impairment attempted to get into their bed repeatedly. Despite the facility's policies requiring immediate investigation of such allegations, no investigation or documentation was found.
The facility did not provide written transfer notifications to two residents and their representatives when they were transferred to the hospital. The Nursing Home Administrator admitted the oversight, and the Corporate Director of Clinical Services confirmed that such notifications are required by the facility's policy.
The facility did not provide written notification of the bed hold policy to two residents upon their transfer to a hospital. The Nursing Home Administrator confirmed that the required notice, which should specify the duration of the bed hold and information about the resident's return, was not given as per the facility's policy.
A facility failed to develop a trauma-informed care plan for a resident with dementia and behavioral disturbances, despite being informed of the resident's history of severe physical abuse. The resident's care plan lacked focus areas, goals, or interventions related to trauma, and no trauma assessment was conducted, contrary to the facility's policy.
A resident with dementia and muscle weakness suffered a skin tear during a transfer due to improper use of a sit-to-stand lift instead of the care-planned total mechanical lift. The CNA involved was in a hurry and did not follow the care plan, leading to the resident's arm hitting a door jamb. The facility's policy on safe transfers was not adhered to, and staff were unaware of the correct transfer method as per the resident's care plan.
A facility failed to conduct a trauma assessment for a resident with dementia and a history of physical abuse, resulting in inaccurate information for mental health professionals. Despite the resident's spouse informing the facility of the abuse history, no trauma assessment was completed, and the Social Services Director did not convey this critical information to the mental health provider. This led to potential uninformed care, contrary to the facility's trauma-informed care policy.
The facility failed to serve meals at satisfactory temperatures, affecting several residents. Observations revealed that food temperatures were not recorded, and items were served below the required holding temperature. A resident reported consistently receiving cold meals, and past complaints were noted. The facility's food safety policy was not followed, leading to this deficiency.
A facility failed to maintain current legal guardianship for a resident deemed incompetent, allowing a family member to make unauthorized decisions. The guardianship had expired, and the facility lacked updated documentation, with the family member refusing to provide it. The facility's policy did not ensure guardianship validity, leading to this deficiency.
A resident was readmitted with an indwelling urinary catheter but lacked necessary physician orders and a care plan. The facility did not have orders for catheter maintenance or a care plan to guide staff, as confirmed by the DON. This oversight was against the facility's policy on catheter use and removal.
Failure to Provide Ordered Pain Management After Fall With Back Hematoma and Compression Fracture
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered pain treatment and pain medication for a resident following a fall, resulting in prolonged, inadequately relieved pain and a decline in urinary continence. The resident, who had chronic pain syndrome, cancer, COPD, and anxiety disorder, was cognitively intact and had a history of frequent pain that interfered with sleep, rehabilitation, and daily activities. On the date of the fall, the resident reported that her legs gave out and her back struck the bed frame, causing unbearable pain and a large, tender hematoma on the lower back. The incident report documented a large hematoma/abrasion with missing skin and bleeding, and the resident rated her pain as 6/10 at that time. A physician progress note from that day documented a very tender large hematoma and contusion to the lower back, with instructions that ice could be used for two days followed by heat, and that oxycodone might need to be increased if pain was uncontrolled. In the days following the fall, the resident reported excruciating pain to a family member and stated that her pain medication did not relieve the pain. She reported staying in bed for days, being afraid to get up due to pain, and becoming incontinent in bed because she did not get up to use the bathroom. A CNA confirmed that after the fall the resident complained of pain, was concerned about the appearance of the hematoma, did not get out of bed due to pain, and was incontinent for a couple of days. Nursing pain assessments documented that the resident had frequent pain over multiple five-day periods, with pain frequently making it hard to sleep, limiting participation in rehabilitation, and limiting day-to-day activities. Pain intensity was documented as very severe/horrible shortly after the fall and later as 5, with notes linking the pain to the hematoma from the fall. Despite these findings, there were multiple failures to implement and consistently provide ordered pain-related interventions. The DON and RN staff acknowledged that non-pharmacological interventions such as cold or hot/warm compresses, which the physician and DON described as standard of care for a hematoma, were not initiated until about a week after the fall, and skin evaluations on 1/7 and 1/14 documented the back bruise/hematoma with "no interventions." When warm compresses were finally ordered on 1/14 to be applied three times daily, the MAR showed multiple missed administrations with no documented rationale. The resident’s scheduled oxycodone regimen for chronic pain and later for trochanter pain was also not administered at several scheduled times on multiple days, again without documentation of why doses were omitted. The DON acknowledged a delay in treatment, uncertainty about whether the physician was notified of increased pain, and that the resident’s increased pain was not communicated to the physician, while the physician stated that staff did not inform him of increased pain and that he was unaware of it until a follow-up visit. An x-ray ordered on 1/14 and completed on 1/16 revealed a compression fracture of the L1 vertebra associated with post-fall pain. The facility’s pain management policy required recognition, evaluation, and management of pain, use of non-pharmacological interventions such as cold compresses, and practitioner notification when pain was not controlled, but the documented actions and omissions showed that these standards were not followed for this resident. The cumulative effect of these failures—delayed initiation of non-pharmacological interventions, inconsistent provision of ordered warm compresses, missed doses of scheduled oxycodone without explanation, and lack of timely communication to the physician about increased pain—resulted in the resident experiencing prolonged pain that was not adequately relieved by medications and a decline in urinary continence, as the resident remained in bed and was incontinent due to fear of worsening pain when getting up.
Failure to Revise Care Plan After Fall-Related Compression Fracture and Pain
Penalty
Summary
The deficiency involves the facility’s failure to review and revise a resident’s comprehensive care plan following a significant change in condition related to pain. The resident was admitted with active diagnoses including cancer, COPD, and an anxiety disorder, and had intact cognition as evidenced by a BIMS score of 14/15. An incident report documented that at 3:00 a.m. the resident called out to staff after a fall, and staff found the resident on her bed with a large hematoma and abrasion on the middle/lower back, measuring approximately one inch in height and three inches in length, with areas of missing skin and slight bleeding. The resident reported pain at a level of 6 on a 0–10 scale. An x‑ray report later documented a compression fracture of the upper end plate of the L1 vertebra associated with trauma and severe localized pain. Despite this new injury and ongoing pain, review of the resident’s care plan showed it was not updated to address pain post‑incident or to include interventions such as warm compresses. The facility’s Comprehensive Care Plans policy required that the comprehensive care plan be reviewed and revised by the interdisciplinary team as needed with any changes in the resident’s plan of care, and the Pain Management policy required that pain management interventions, including non‑pharmacological measures such as cold compresses, be incorporated into the comprehensive care plan and revised if pain was not adequately controlled. The DON confirmed that no interventions were added to the care plan regarding non‑pharmacological pain interventions, assessment of pain from the fracture, or warm compresses, and acknowledged that the care plan should have been updated.
QAA Committee Meetings Lacked Required Leadership Attendance
Penalty
Summary
The facility failed to ensure that quarterly meetings of the Quality Assessment and Assurance (QAA) Committee were attended by the required members. During interview and record review on 8/14/25, the Social Services Coordinator, who was identified as the coordinator of the facility's QAPI program, confirmed that QAA committee meetings were held quarterly. Review of the QAA meeting signature sheets showed meetings on 10/16/24, 1/16/25, 4/30/25, and 7/30/25. The signature sheets for 4/30/25 and 7/30/25 did not include the Administrator's signature, and the Social Services Coordinator could not recall whether the Administrator attended those meetings. She also confirmed that the signature sheets did not show signatures from a governing board member or another leader with authority to change facility systems. The facility policy stated that the QAA Committee must be interdisciplinary and include, at a minimum, the DON, the Medical Director or designee, and at least three other staff members, including at least one Administrator, owner, board member, or other individual in a leadership role.
Infection Prevention and Control Program Failure
Penalty
Summary
The facility failed to implement its infection prevention and control program in accordance with facility policies during medication administration, waste handling, and wound care. During medication pass on 8/13/25, RN E removed medications from blister packs by pushing them directly into her ungloved hand before placing them into a medication cup or pill-crushing sleeve, and also separated plastic drinking cups by placing ungloved fingers along the rim where residents drink. On 8/14/25, RN E again dispensed a controlled substance from a blister pack directly into her unwashed, ungloved hand and stated, "I don't know why I do that," while confirming a medication cup should be used instead. Housekeeper F was observed removing soiled waste from two medication carts and placing the full bags of dirty waste on the floor while changing the liners in the refuse receptacles. On 8/14/25, RN G performed dressing changes on a resident's left distal medial foot and right gluteal cleft. RN G donned gloves before starting, but after removing the soiled dressing from the foot wound, cleansing the wound, and applying treatment and dressing, RN G did not perform hand hygiene or change gloves during the procedure after touching the soiled dressing. RN G then changed gloves and performed hand hygiene before moving to the second wound, but again did not perform hand hygiene or change gloves after touching the soiled dressing. The DON confirmed that medications should be dispensed into a medication cup and that refuse bags should not be placed on the floor.
Failure to Notify LTC Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to send copies of residents’ written Notices of Transfer to the representative of the Office of the State Long-Term Care Ombudsman for five residents who were hospitalized or transferred to the emergency department. The affected residents were Resident #9, Resident #3, Resident #56, Resident #44, and Resident #59. For each of these residents, the record review found no documentation in the EMR or on the written Notice of Transfer form showing that the Ombudsman was provided a copy of the notice. Resident #3 was transferred to the hospital ED on 6/4/25, Resident #56 was transferred to the ED on 6/1/25, Resident #44 was transferred to the hospital ED on 7/26/25, and Resident #59 was transferred to the hospital ED on 7/31/25. Resident #9 was hospitalized on an unspecified date. During interview, the Social Services Director reported that Notices of Transfer are sent by email to the LTC Ombudsman and stated she did not send the list of discharges for June 2025 or July 2025. The LTC Ombudsman reported she had not received a list of discharges from the facility since March 2025. The facility policy stated that the transfer or discharge notice will be provided to the LTC Ombudsman and that the facility will maintain evidence that the notice was sent.
Care plans not updated to reflect current resident assessments and needs
Penalty
Summary
The facility failed to implement its policy and procedure to develop and revise resident-specific comprehensive care plans for three residents reviewed for care planning. The report states that the comprehensive care plan was to be developed within 7 days of the comprehensive MDS assessment, prepared by an interdisciplinary team, and reviewed and revised after each comprehensive and quarterly MDS assessment and whenever resident needs changed. For Residents #32, #5, and #1, the care plans were not updated to reflect current assessments, behaviors, or treatment needs documented in the clinical record. For Resident #1, the EMR showed admission on 1/10/25 with diagnoses including Alzheimer's disease, anxiety disorder, and dementia. The 7/15/25 MDS showed a BIMS score of 11 and indicated substantial/maximal assistance was needed for wheeling 150 feet once seated in a wheelchair. The care plan still identified the resident as an elopement risk/wanderer and included a wander alert intervention for the right ankle. During interviews on 8/14/25, nursing staff stated the resident no longer wandered, did not propel her wheelchair, and had experienced a significant change in condition. At the time of observation, the resident was not wearing a wander alert guard, and staff agreed the care plan needed to be updated. For Resident #32, the record showed severe cognitive impairment with a BIMS score of 3 on the 8/4/25 MDS and coded verbal behavioral symptoms directed toward others. Progress notes documented agitation during morning care, hitting staff, yelling, spitting out medication, refusing ROM, disagreeable behavior with other residents, verbal aggression in the dining room, trying to strike staff, using foul language, resisting care, and increasingly aggressive behavior over several weeks. The current care plans remained focused on altered thought process and dementia-related wandering and urinating on the floor, with interventions that had not been updated since 2023. For Resident #5, the record showed severe cognitive impairment with a BIMS score of 4 on the 7/28/25 MDS, along with progress notes documenting treatment with Augmentin for a buttock abscess and Levaquin for a UTI. The current care plans did not reflect the resident's long history of UTIs or antibiotic use, and many focus areas and interventions had not been revised since 2022. Staff interviews confirmed that the care plans for Residents #32 and #5 should have included current behaviors, UTIs, antibiotic use, and updated interventions, and the DON stated that some residents' care plans had not been revised as they should have been per policy.
Failure to Obtain PASARR Level II Evaluation
Penalty
Summary
The facility failed to ensure that one resident with diagnoses including unspecified dementia with agitation and psychotic disturbance, and post-traumatic stress disorder, received a PASARR Level II evaluation after the resident’s PASARR Level I screening indicated yes responses in Section II. The resident’s record showed a significant change MDS assessment in which the BIMS was not completed because the resident was rarely or never understood, and Section E documented both physical and verbal behavioral symptoms directed toward others that significantly interfered with care. The resident’s active orders included Seroquel and Remeron, and the care plan addressed resistive care, impaired cognitive function/dementia, potential verbal and physical behaviors, and a history of trauma. Although the PASARR Level I form was completed and submitted, the medical record did not contain a PASARR Level II evaluation. Social Services staff confirmed the Level II forms were not submitted, and the ADON searched the record and could not find a Level II screening for 2025 or any previous year, indicating it had never been obtained.
Incomplete Care Planning for UTI Management and Behavioral Concerns
Penalty
Summary
The facility failed to develop a comprehensive, person-centered care plan for two residents reviewed for comprehensive care planning. For one resident, the record showed chronic kidney disease stage 3, severe cognitive impairment with a BIMS score of 4, and dependence for toileting hygiene. The resident also had documented urinary incontinence, with MDS assessments showing frequent incontinence and later always incontinent status. Progress notes showed treatment for a buttock abscess with Augmentin and later treatment for a UTI with Levaquin, and a dehydration risk evaluation identified renal disease and incontinence as risk factors. The current care plans did not include resident-focused care plans reflecting the resident’s current and historical UTIs or antibiotic use. The resident’s current care guide documented toileting and toileting hygiene interventions, but the record showed inconsistent toileting frequency across the reviewed dates, with the resident toileted three times per day on most days and only twice in a 24-hour period on one day. During interview, a CNA stated the resident often gets UTIs, that staff are not always informed when the resident has a UTI, and that the resident takes antibiotics off and on. The CNA also stated that care plans drive the CNA care guides so staff know individual care needs, and that residents are to be toileted, checked, and changed every 2 hours on every shift. For the second resident, the record showed dementia with a BIMS score of 3, indicating severe cognitive impairment. The DON stated that the resident had a behavior toward other female residents and that a care plan should have been developed for those behaviors as soon as they occurred so all staff would be aware of the potential for abuse. RN O stated that care plan changes were the responsibility of the interdisciplinary team and that care plans were supposed to be updated during IDT meetings. The facility policy required comprehensive care plans to be developed within 7 days after completion of the comprehensive MDS assessment, to include measurable objectives and timeframes, and to be reviewed and revised after each comprehensive and quarterly MDS assessment, but the report identified that the resident did not have a care plan developed for the reported behaviors.
Failure to Follow Wound Care Orders
Penalty
Summary
Failure to follow physician orders for wound care was identified for Resident #44, who was admitted to the facility with diagnoses including diabetes mellitus, wound infection, and peripheral vascular disease/peripheral arterial disease. The resident’s MDS documented three venous and arterial ulcers, and the hospital discharge document from 7/16/25 included wound follow-up instructions for chronic wounds on the left leg and foot. Those instructions directed staff to remove the dressing, cleanse with saline, scrub wounds with gauze to remove loose slough, apply a single layer of xeroform to all open wounds, cover with ABDs, wrap with kerlix, and change the dressing daily and as needed. Review of the July and August TARs showed no treatments completed for the left lower extremity wounds, and review of the EMR showed there were no physician-ordered treatments for those wounds. During interview, the resident reported having a couple of open sores on the left foot or leg. The DON and ADON acknowledged that there were no physician-ordered treatments for the left lower extremity wounds.
Failure to Update Fall Care Plans After Repeated Falls and Fractures
Penalty
Summary
The facility failed to ensure resident safety by implementing care planned interventions for two residents identified as high risk for falls. Resident R9 was admitted with diagnoses including congestive heart failure, chronic respiratory failure, anxiety disorder, dependence on supplemental oxygen, and difficulty walking. Her MDS assessment dated 7/8/25 showed a BIMS score of 10, indicating moderately impaired cognition. Accident and incident reports showed R9 fell on 6/28/25 in the bathroom and again on 7/2/25 in her room, when she was found on the floor with a large bruise on her forehead and was sent to the hospital, where she was diagnosed with a cervical fracture. Review of the record and interview with the DON showed the care plan was not updated after the 6/28/25 fall to add preventative interventions, despite the existing fall-risk care plan. Resident R59 was admitted with diagnoses including peripheral vascular disease or peripheral arterial disease, diabetes mellitus, and malnutrition. An incident report dated 7/30/25 documented that R59 was found on the floor next to the bed after stating he slipped out of bed while trying to reposition himself, and hospital radiology identified an acute sub-capital left hip fracture with impaction. Review of the EMR showed R59 was readmitted to the facility after the hospitalization, and the care plan contained no interventions added after the fall with fracture to prevent further falls. During interview, the DON acknowledged that no interventions had been added to R59's care plan following the fracture. The facility policy stated staff would identify and implement relevant interventions to minimize serious consequences of falling.
Missing oxygen orders and tubing changes for a resident receiving nasal cannula oxygen
Penalty
Summary
Failure to provide safe and appropriate respiratory care occurred for one resident who received oxygen via nasal cannula without documented physician orders for oxygen, the oxygen flow rate, or routine oxygen tubing changes. The resident had diagnoses including diabetes mellitus, wound infection, peripheral vascular disease or peripheral arterial disease, respiratory failure, and COPD, and was admitted to the facility on 7/22/25 after hospitalization in July when he required oxygen. During observations on 8/13/25 and 8/14/25, the resident was seen receiving oxygen through nasal cannula with undated oxygen tubing. Review of the EMR showed no physician orders for oxygen, no orders for the oxygen flow rate, and no orders for changing oxygen tubing. The TAR also showed the oxygen tubing had not been changed in July or August. During interview, the resident stated he was unsure when he started receiving oxygen but reported he required oxygen when hospitalized prior to admission. The DON acknowledged she was unaware of when the resident started oxygen and confirmed there were no physician orders for oxygen, flow rate, or tubing changes, while also stating residents who receive oxygen have tubing changed weekly and marked.
Water Damage and Poor Bathroom Maintenance
Penalty
Summary
The facility failed to effectively maintain the physical plant, including resident bathrooms. During an observation on 8/12/2025 at 2:50 PM, the shared bathroom for rooms 203/205 was found with bubbled paint on the wall behind the toilet. The surveyor noted the wall felt wet toward the baseboards and damp upward behind the toilet, and the drywall on the entire backside wall of the toilet showed water damage. The softened area extended upward approximately 3 1/2 feet, and when lightly pushed, the right-side corner attached to the right wall pushed inward, separating the corner of the wall to the right of the toilet from the wall behind the toilet. The report also identified missing bathroom baseboard tiles and a bathtub used for storage in resident bathrooms 203/205 and 207/209.
Failure to Maintain Comfortable Temperatures
Penalty
Summary
The facility failed to maintain comfortable temperatures, resulting in a non-homelike environment for four residents. Resident #1, with intact cognition, reported feeling cold for several days, noting that staff were also wearing extra clothing to stay warm. Resident #2, with moderate cognitive impairment, mentioned a persistent cold draft from the window, which was temporarily blocked with a towel, but maintenance had not resolved the issue. Resident #3, also with intact cognition, kept a log of room temperatures, which were recorded as low as 65 degrees, and reported wearing a winter coat indoors due to the cold. Resident #4, with intact cognition, described the coldest periods as occurring during the night and early morning, requiring extra blankets and a hat to stay warm. Observations and interviews with staff corroborated the residents' complaints. Maintenance staff acknowledged the low temperatures and non-functioning heaters at the end of hallways. Temperature readings taken by staff showed temperatures ranging from 65 to 68 degrees in various parts of the facility, below the facility's policy of maintaining temperatures between 71 and 81 degrees. Additionally, cracks at the bottom of doors leading to the outside were observed, contributing to drafts and cold air entering the facility. The Nursing Home Administrator was unaware of the door cracks, and staff reported wearing jackets during shifts due to the cold. The facility's policy on maintaining a safe and homelike environment was not adhered to, as evidenced by the low temperatures and drafts affecting resident comfort. The deficiency was identified through a combination of resident interviews, staff statements, and direct observations by the surveyor.
Inaccurate PBJ Reporting Leads to Low Weekend Staffing Deficiency
Penalty
Summary
The facility failed to accurately report Payroll Based Journal (PBJ) information to the Centers for Medicare and Medicaid Services (CMS), resulting in a deficiency related to excessively low weekend staffing. The CMS PBJ Staffing Data Report for the fiscal year Quarter 2 of 2024 indicated that the facility triggered for excessively low weekend staffing on multiple dates throughout January, February, and March 2024. During interviews, the Business Office Manager/Human Resources stated that they submit the PBJ information but do not review the data, while the Nursing Home Administrator expressed confusion about the low weekend staffing trigger. The facility's policy requires the Nursing Home Administrator, Human Resource Director, and Director of Nursing to verify the accuracy of staffing data submitted to CMS, but this verification process was not followed, leading to the deficiency.
QAPI Committee Membership and Meeting Frequency Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met the required membership and frequency of meetings, which could potentially decrease the quality of care for all 54 residents. The QAPI committee meetings were held on three occasions: August 14, 2023, January 30, 2024, and May 1, 2024. However, the Medical Director or their designee was not present at the meetings on August 14, 2023, and January 30, 2024. According to the facility's policy, the QAPI committee must include the Director of Nursing Services, the Medical Director or their designee, at least three other staff members, including the Administrator, Owner, a Board Member, or another individual in a leadership role, and the Infection Preventionist. The absence of the Medical Director or their designee at these meetings indicates non-compliance with the facility's policy requirements for the QAPI committee's composition and meeting frequency.
Inadequate Infection Control Measures During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure the correct use of personal protective equipment (PPE) and did not post visual alerts at the entry for staff and visitors regarding hand hygiene and source control during a COVID-19 outbreak. Observations revealed that the main entrance was closed for construction, and an alternative entrance was being used without proper signage or hand hygiene facilities. Staff were observed entering and exiting the facility without wearing masks or performing hand hygiene, and there was no process in place to inform individuals entering the facility of the recommended actions to prevent COVID-19 transmission. The Infection Preventionist (IP) confirmed that five residents tested positive for COVID-19, all residing on the 200 unit. Despite this, staff were observed not adhering to proper PPE protocols, such as wearing the same mask from a COVID-19 positive resident's room into the hallway and other rooms. Additionally, residents who tested positive were seen in common areas without proper isolation, and staff were observed wearing gloves from one resident's care to another without changing them or performing hand hygiene. The facility's policy required visual alerts and instructions for PPE use and hand hygiene, which were not implemented at the alternative entrance. The IP admitted that signage was not posted as required, and staff were not following CDC guidelines for infection prevention and control. The lack of proper signage, PPE use, and hand hygiene practices contributed to the deficiency in preventing the transmission of COVID-19 within the facility.
Improper Medication Storage and Handling
Penalty
Summary
The facility failed to ensure the proper return or destruction of medications brought in from home for nine residents out of a total population of 54. During an observation, four pink bins containing various medications were found in the medication storage room's upper wall cabinets. These bins included opened, undated, and unlabeled medications such as topical creams, stoma powder, antifungal medication, and prescription bottles for specific residents. Additionally, a seven-day pill container with unidentified pills and several unlabeled medication bottles were found without any resident identification. Interviews with staff revealed that these medications should not have been stored in the facility. Registered Nurse K acknowledged that the medications should have been sent home with the residents or discarded. The Nursing Home Administrator and Corporate Director of Clinical Services also recognized that the open, unlabeled, and un-inventoried medications should not have been retained in the facility. The facility's Medication Storage policy and Destruction of Unused Drugs policy require routine inspection and destruction of unused medications, which was not adhered to in this instance.
Failure to Complete Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure the completion of monthly medication regimen reviews for four residents, leading to the potential for administration of unnecessary or inappropriate medications. For three residents, the electronic medical records indicated that medication regimen reviews were completed, and recommendations were made by the pharmacist. However, there were no consultation reports available in the records to show what the recommendations were, when they were received, or how and when the facility followed up on them. The Director of Nursing (DON) confirmed the absence of these reports and could not account for the receipt and follow-up of the recommendations. For another resident, the facility did not have records of monthly medication regimen reviews for several months, despite the resident being prescribed antipsychotic and antidepressant medications. The DON acknowledged the absence of these reviews in the electronic medical record for the specified months. The facility's policy requires that the drug regimen of each resident be reviewed at least once a month by a licensed pharmacist, and that written communications from the pharmacist become a permanent part of the resident's medical record.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to adequately address and respond to concerns and grievances raised by residents during Resident Council meetings. During a confidential group meeting, several residents expressed that their complaints were repeatedly discussed in council meetings but were not addressed or resolved. The Activity Director acknowledged not effectively reviewing or documenting these concerns, which is contrary to the facility's policy that requires the liaison to respond to written requests from group meetings and communicate decisions back to the council. Additionally, a review of the Resident Council meeting minutes revealed inconsistencies and a lack of follow-up on previously discussed issues. For instance, concerns about cold food raised in the June meeting were not addressed in subsequent meetings, and there was no meeting held in July. This lack of documentation and follow-up indicates a failure to act upon and communicate resolutions to the residents' concerns, as required by the facility's policy.
Failure to Report Alleged Abuse Between Residents
Penalty
Summary
The facility failed to report an allegation of potential sexual abuse between two residents, resulting in a deficiency. Resident #3, who has moderate cognitive impairment, reported that Resident #205, who has severe cognitive impairment, attempted to get into their bed multiple times, including an incident at 1 a.m. Despite Resident #3's grievance, which was documented on a resident grievance form, the event was not reported to the State Survey Agency as required by the facility's policy. Interviews with facility staff revealed that the Social Services Designee reported the incident to the Director of Nursing (DON) and the Nursing Home Administrator (NHA). However, the DON did not personally report the event and was unsure if the NHA had done so. The NHA confirmed that there was no investigation into the grievance and that it was not reported. Additionally, there was no documentation of the event in the electronic medical records of either resident. The facility's policies on grievances and abuse reporting clearly state the requirement to report such allegations to the state agency, which was not followed in this case.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to investigate an allegation of potential sexual abuse between two residents, identified as Resident #3 and Resident #205. Resident #3, who has moderate cognitive impairment, reported through a grievance form that Resident #205, who has severe cognitive impairment, attempted to get into their bed repeatedly, including an incident at 1 o'clock in the morning. Despite these allegations, the Nursing Home Administrator confirmed that no investigation into the grievance was conducted, and there was no documentation of the event in the residents' Electronic Medical Records. The facility's policies on Resident and Family Grievances and Abuse, Neglect, and Exploitation require immediate investigation of any allegations involving abuse. The policies designate the Nursing Home Administrator and/or Social Service Designee as responsible for leading investigations and reporting allegations of abuse. However, in this case, the facility did not adhere to its policies, as there was no investigation or documentation of the alleged incidents involving Residents #3 and #205.
Failure to Provide Written Transfer Notifications
Penalty
Summary
The facility failed to provide written transfer notifications to two residents and their representatives when the residents were transferred to the hospital. Resident #7 was transferred on July 19, 2024, and Resident #15 on June 27, 2024, without any written notification documented in their medical records. On August 28, 2024, the Nursing Home Administrator acknowledged that the facility did not issue the required written notifications for these transfers. The Corporate Director of Clinical Services confirmed that written notifications were necessary according to the facility's policy, which mandates that transfer or discharge notices be provided to the resident, their representative, and the LTC ombudsman as soon as practicable when an immediate transfer is required due to urgent medical needs.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to two residents, identified as R7 and R15, upon their transfer to a hospital. Resident #7 was transferred on July 19, 2024, and Resident #15 on June 27, 2024. In both cases, the medical records lacked documentation indicating that the bed hold policy was communicated to the residents or their representatives. This was confirmed by the Nursing Home Administrator on August 28, 2024, who acknowledged that the facility did not provide the necessary written notice at the time of transfer. The facility's policy, dated May 28, 2024, requires that such notification be given to residents or their representatives, specifying the duration of the bed hold and information about the resident's return to the next available bed.
Failure to Implement Trauma-Informed Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered, and trauma-informed care plan for a resident with a primary diagnosis of dementia with behavioral disturbance. The resident, who was admitted to the facility with severe cognitive impairment, exhibited behavioral symptoms such as physical and verbal aggression towards others, as well as self-directed behaviors. Despite the resident's spouse informing the facility of a history of severe physical abuse, which was believed to contribute to the resident's behavioral symptoms, no trauma assessment was conducted upon admission or thereafter. The resident's comprehensive care plan lacked focus areas, goals, or interventions related to the history of trauma and potential triggers. The Social Services Director acknowledged awareness of the resident's history of abuse and confirmed that no trauma assessment or appropriate care plan was developed. The facility's policy on Trauma Informed Care outlines the need for a trauma-informed approach, including the use of screening and assessment tools and collaboration with the resident's support network to develop individualized care plan interventions. However, these procedures were not followed, resulting in a deficiency in providing trauma-informed care for the resident.
Failure to Ensure Safe Resident Transfers
Penalty
Summary
The facility failed to ensure safe resident handling during transfers, resulting in a skin tear for a resident with dementia, difficulty walking, and muscle weakness. The resident required substantial/maximal assistance for transfers, as indicated in her Minimum Data Set (MDS) assessment. Despite this, the resident was transferred using a sit-to-stand lift instead of the care-planned total mechanical lift, leading to a skin tear when her arm hit the door jamb during a hurried transfer to the bathroom by a CNA. The incident report revealed that the CNA was in a hurry and did not follow the care plan, which required a total mechanical lift due to the resident's previous fall from a sit-to-stand lift. The CNA admitted to transferring the resident alone and acknowledged that the resident became limp during the transfer, necessitating assistance from two additional CNAs to complete the transfer. The resident's care plan had conflicting interventions, with the use of a total mechanical lift not canceled until after the incidents. Interviews with facility staff, including the DON and the CNA involved, highlighted a lack of awareness and adherence to the resident's care plan. The DON was unaware of the care plan's requirement for a total mechanical lift, and the CNA involved in the previous fall incident also did not ensure the sling was properly secured. The facility's policy on safe resident handling and transfers was not followed, as the resident's individual plan of care was not adhered to, leading to the deficiency.
Failure to Conduct Trauma Assessment for Resident with Abuse History
Penalty
Summary
The facility failed to complete trauma assessments and identify behavioral triggers for a resident with a history of physical abuse, leading to inaccurate information being available to mental health professionals. The resident, who was admitted with a primary diagnosis of dementia with behavioral disturbance, exhibited severe cognitive impairment and behavioral symptoms such as physical and verbal aggression. Despite the resident's spouse informing the facility of a history of severe physical abuse, no trauma assessment was conducted upon admission or thereafter. The Social Services Director, who was aware of the resident's history, did not conduct a trauma assessment due to being new to the role. Consequently, the resident's electronic medical record lacked documentation of the abuse history, which was not communicated to the mental health provider during a recent assessment. This omission resulted in the mental health provider's history of present illness note inaccurately reflecting the resident's abuse history, potentially leading to uninformed and misguided care. The facility's policy on trauma-informed care emphasizes the importance of identifying trauma history and collaborating with relevant parties to develop individualized care plans, which was not adhered to in this case.
Failure to Serve Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at satisfactory temperatures, affecting four residents, including one identified as R42 and three others from a confidential group interview. During an observation on 8/26/24, it was noted that the cook, Staff L, did not record food temperatures for the lunch meal being served. Upon checking, the temperatures of the food items were found to be below the required holding temperature of 135 degrees Fahrenheit, with items such as potatoes and carrots measuring 129 and 118 degrees, respectively. Staff M, the Dietary Manager, confirmed that there were no recorded food temperatures for several previous dinners, and acknowledged past complaints about cold food. Resident 42 expressed dissatisfaction with the temperature of the meals, stating that the food was usually cold by the time it reached him. The resident's medical records indicated intact cognition with a Brief Interview for Mental Status evaluation score of 15 out of 15. Additionally, the Resident Council meeting minutes from 6/12/24 included a resident's comment that, although the food tasted good and had improved, it was still cold. During a confidential group interview, multiple residents reiterated complaints about receiving cold food. The facility's policy on food safety, which requires monitoring and maintaining proper food temperatures, was not adhered to, contributing to the deficiency.
Expired Guardianship for Incompetent Resident
Penalty
Summary
The facility failed to ensure that the legal guardianship for a resident, who was declared incompetent by a court of law, was renewed and active. The resident, identified as Resident #41, was deemed unable to make informed decisions regarding living arrangements, supportive services, financial affairs, and medical treatment. A family member, FM J, was appointed as the temporary guardian with authority over these decisions. However, the guardianship was temporary and had expired, yet FM J continued to make decisions on behalf of the resident without current legal authority. During the survey, the Nursing Home Administrator directed inquiries about guardianship to the Registered Nurse and the Director of Nursing. Upon review, it was found that the facility did not have updated guardianship paperwork for the resident. The Director of Nursing confirmed the expiration of the guardianship and reported that FM J refused to provide updated documentation, suggesting the facility contact the courthouse instead. The facility's policy on resident rights and advance directives did not include a process for ensuring that legal guardianship was current and valid, contributing to the deficiency.
Lack of Physician Orders and Care Plan for Urinary Catheter
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter had the necessary physician orders and a care plan in place. The resident was readmitted to the facility with a catheter but lacked physician orders for the catheter itself, the frequency of catheter changes, and the changing of the urinary drainage bag. Additionally, there was no care plan developed to guide staff on the maintenance and care of the catheter. The Director of Nursing confirmed that physician orders and a care plan are required for residents with catheters. Upon review, it was found that these were not entered into the resident's medical record upon readmission. The facility's policy on indwelling catheter use and removal emphasizes the need for justification or removal of catheters according to regulations and standards, which was not adhered to in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 28 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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Iron River
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Iron County Medical Care Facility | 11.9 mi | ★★★★★ | 0 | 0 |
| Florence Health Services | 21.2 mi | ★★★★★ | 28 | 0 |
| Freeman Nursing & Rehabilitation Community | 32.2 mi | ★★★★★ | 5 | 0 |
| Optalis Health And Rehabilitation Of Kingsford | 32.5 mi | ★★★★★ | 4 | 0 |
| Maryhill Manor | 36.6 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.