Iron County Medical Care Facility

Inspectors wroteBased on interview and record review, the facility failed to incorporate the key components of staffing needs for each resident unit and staffing needs for each shift, into their facility assessment potentially affecting all 109 residents residing in the facility.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on record review and interview, low staffing was confirmed to have the potential to affect the entire facility population through review of reports by six Residents (#47, #50, #69, #80, #93, and one Confidential Resident [CR]) of six residents reviewed for staffing concerns.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly label and store medications in 2 medication carts (200 Hall and 700 Hall) out of 3 medications carts observed. This deficient practice resulted in the potential for errors in medication administration and the potential for drug diversion.

Inspectors wroteAll times are noted in Eastern Daylight Time unless otherwise noted. Based on observation and interview, the facility failed to maintain two exterior doors and one interior door, resulting in an increased potential for pest infestation and a possible decrease in satisfaction of living for residents. Findings Include:On 6/23/2026 at 1:25 PM daylight was observed coming in under the exit door #20 in the Skyway Basement, and the door sweep was missing from this door. During this observation, Maintenance Director (MD) D agreed that daylight was visible under this door and stated the door sweep needed to be replaced and that these entry doors received a lot of use, resulting in wear and tear. [...]

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on observation, interview, and record review, the facility failed to implement fall prevention interventions for one Resident (#29) after an identified root cause to prevent subsequent falls and failed to adhere to care planned interventions to prevent hot liquid spills for one Resident (#89) of four residents reviewed for accidents and supervision.

Inspectors wroteAll times are noted in Eastern Daylight Time unless otherwise noted. Based on observation, interview, and record review, the facility failed to ensure respiratory equipment was stored in a clean and sanitary manner between resident use for three Residents (#20, #48, & #71) of three residents reviewed for respiratory care.

Inspectors wroteAll times are noted in Eastern Daylight Time unless otherwise noted. Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than 5% involving one Resident (#48) of three residents reviewed for medication administration, resulting in a medication error rate of 6%, with 2 errors out of 31 opportunities.

Inspectors wroteAll times are noted in Eastern Daylight Time unless otherwise noted Based on interview and record review, the facility failed to ensure that Medication Regimen Reviews (MRR) were reviewed, addressed by the Physician, and maintained in the clinical record for four Residents (#67, #36, #65, and #90) of five residents reviewed for MRR, resulting in the potential for the administration of unnecessary medications and adverse medication side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a medication error rate less than 5% in four Residents (#95, #8, #70, & #23) of 12 residents reviewed for medication administration. This deficient practice resulted in a medication administration error rate of 13.33%, based on 4 medication errors in 30 opportunities for error.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure hand hygiene was performed during fresh water pass and catheter care, for 7 Residents (R11, R32, R33, R38, R50, R52 and R55), out of 22 sample residents reviewed for hand hygiene. This deficient practice resulted in the potential for cross-contamination of infectious organisms between residents in the facility. All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted.

Inspectors wroteAll times recorded in Eastern Daylight Time (EDT), unless otherwise noted. Based on observation, interview and record review, the facility failed to 1. Ensure oxygen was administered per physician order and; 2. Ensure maintenance of oxygen and nebulizer equipment in a sanitary manner, for one Resident (#65) of one resident reviewed for oxygen administration.

Inspectors wroteBased on interview and record review, the facility failed to prevent duplicate drug therapy of Vitamin D for one Resident (#90) of five residents reviewed for unnecessary medications. This deficient practiced resulted in an excessive dose of D3 and the potential for Vitamin D toxicity. All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members. This deficient practice placed all 115 residents in the facility at risk for quality care concerns.

Inspectors wroteThis citation pertains to intakes MI00140019 and MI00140881. Based on interview and record review, the facility failed to prevent misappropriation of narcotic medication for one Resident (R266) of two residents reviewed for misappropriation.

Inspectors wroteBased on interview and record review, the facility failed to report injuries of unknown source to the state agency for two Residents (R87 and R34) of two residents reviewed for abuse.

Inspectors wroteBased on Interview and record review the facility failed to conduct a thorough and complete investigation for an incident for one Resident (#34) of four residents reviewed for incidents. This deficient practice could result in adverse outcomes and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and monitor pressure injuries to promote the healing of a facility-acquired pressure injury for One Resident (R109) of six residents reviewed for pressure injuries.

Inspectors wroteBased on interview and record review the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid). This deficient practice resulted in inaccurate reporting of staffing levels with the potential to affect all 115 residents.