Iron River Care Center

Inspectors wroteThis deficiency pertains to Complaint 2724132All times are in Eastern Daylight Time (EDT) unless otherwise notedBased on observation, interview, and record review, the facility failed to provide physician ordered treatment and physician ordered pain medication for one Resident #1 (R1) of three residents reviewed for pain, resulting in prolonged pain not adequately relieved by medications and a decline in urinary continence.

Inspectors wroteThis deficiency pertains to Complaint 2724132All times are in Eastern Daylight Time (EDT) unless otherwise notedBased on interview and record review, the facility failed to ensure care plans were reviewed and revised for one Resident #1 (R1) of three residents reviewed for care plan timing and revision, resulting in the potential for unmet resident care needs.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to ensure quarterly meetings of the Quality Assessment and Assurance (QAA) Committee were attended by the required members.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on observation, interview, and record review, the facility failed to implement an infection prevention and control program in accordance with facility policies to prevent the potential transmission of communicable diseases and infections resulting in the potential for the transmission of pathogens and the spread of infectious organisms to all 55 residents in the facility.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to send a copies of residents' written Notice of Transfer to representative of the Office of the State Long-Term Care Ombudsman for five Residents (#3, #56, #9, #59, & #44) of five residents reviewed for hospitalization.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interviews, and record review, the facility failed to implement its policy and procedure to develop and revise individual resident specific comprehensive care plans revisions for three residents (Residents #32, #5 and #1) of 14 residents reviewed for care planning, resulting in the potential for unmet resident care needs and a failure to maintain their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure one resident (R2) of one Resident reviewed for PASARR (Preadmission screening/Annual Resident Review) obtained a PASARR level 2 (DCH-3878) evaluation to determine the appropriate setting for the individual and if specialized services were needed. This deficient practice resulted in the potential for unmet mental health needs.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to develop a comprehensive, person-centered care plan for 2 Residents (#5 & #32) of 14 residents reviewed for comprehensive care planning, resulting in recurring urinary tract infections (UTI's) for R5, and the potential for further unrecognized sexual and aggressive behaviors towards female residents as well as decline in uncommunicated care needs between disciplines and unmet care needs. This deficient practice resulted in the potential for unidentified and unmet individualized care needs.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to follow physician orders for wound care for one Resident #44 (R44) of one resident reviewed for physician orders for the care of wounds. This deficient practice resulted in the potential for infection and a delay in healing.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident safety by implementing care planned interventions for two residents at high risk for falls (Resident R9 and R59) out of four residents reviewed for falls. This deficient practice resulted in subsequent falls with injury including a broken neck.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on observation, interview, and record review, the facility failed to provide oxygen services including obtaining physician orders for oxygen, physician orders for the oxygen flow rate (amount of oxygen delivered to the patient), and routine changing of oxygen tubing for one Resident #44 (R44) of three residents reviewed for oxygen services.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on observation and interview, the facility failed to effectively maintain the physical plant including resident bathrooms. This resulted in water damage to the walls in resident rooms (shared bathrooms) 203/205 and 207/209, missing bathroom baseboard tiles, bathtub used for storage and the increased likelihood for further water damage, cross-contamination and bacterial harborage, with a possible decrease in the satisfaction of living, for residents who use these areas. Findings Include In an observation on 8/12/2025 at 2:50 PM., it was noted in the shared bathroom of rooms 203/205 the wall behind the toilet paint was bubbled out. This surveyor felt the wall and noted it to be wet towards the baseboards, and damp upwards behind the toilet. [...]

Inspectors wroteThis citation is related to Intake MI00148048 an MI00148473 Based on observation, interview, and record review the facility failed to ensure comfortable temperatures for a homelike environment for four Residents (#1, #2, #3, & #4) of four residents reviewed for comfortable temperature and homelike environment., resulting in expressions of physical discomfort.

Inspectors wroteBased on interview and record review, the facility failed to accurately report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid Services). This deficient practice resulted in the facility triggering for excessively low weekend staffing with the potential to affect all 54 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure required members of the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly, resulting in the potential for decreased quality of care for all 54 residents living in the facility.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on observation, interview, and record review, the facility failed to: 1. Ensure the correct use of personal protective equipment (PPE), 2. Post visual alerts at the entry for staff and visitors regarding information for hand hygiene and source control, and; 3. Post the process for everyone entering the facility of the recommended actions to prevent transmission of COVID-19 in accordance with standards of practice and Centers for Disease Control (CDC) recommendations for COVID-19, during an outbreak.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the return or destruction of Resident medications brought in from home and previously opened for nine Residents out of the total facility population of 54 Residents. This deficient practice resulted in the potential for medication diversion, and administration of undated, opened medications with the potential for reduced efficacy and cross-contamination of infectious organisms.

Inspectors wroteBased on interview and record review the facility failed to ensure completion of monthly medication regimen reviews for four Residents (#41, #43, #46 and #9) of five residents reviewed for unnecessary medications, resulting in the potential for administration of unnecessary or inappropriate medications and adverse effects of administered medications.

Inspectors wroteBased on interview and record review, the facility failed to provide responses to concerns/grievances for 4 Confidential Residents (CR301, CR302, CR303, CR305) reported during the Resident Council survey task. This deficient practice has the potential to result in unresolved resident concerns and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to report and allegation of potential sexual abuse between two Residents (Residents #3 and #205) of four residents reviewed for abuse. This deficient practice resulted in the potential for undetected abuse.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of potential sexual abuse between two Residents (Residents #3 and #205) of four residents reviewed for abuse.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to provide written transfer notification to the Resident and/or Resident's Representative for two Residents (R7 and R15) of three residents reviewed for facility initiated transfers.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted Based on interview and record review, the facility failed to ensure two Residents (R7 and R15) of three residents reviewed for hospital discharges, were provided with written notification of the bed hold policy.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered and trauma-informed care plan for one Resident (#41) of one resident reviewed for mood and behaviors, resulting in the potential for psychosocial distress and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe resident handling during transfers for one Resident (#18) of one resident reviewed for accidents, resulting in a skin tear and the potential for serious injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure completion of trauma assessments and failed to identify behavioral triggers for one Resident (#41) out of one resident reviewed for mood and behaviors with a history of physical abuse, resulting in inaccurate information available to Mental Health professionals and the potential for uninformed and misguided care.

Inspectors wroteThis citation pertains to intake MI00144174. Based on observation, interview, and record review, the facility failed to ensure palatable meals at satisfactory temperatures were served to four Residents (R42, and three residents in a confidential group interview) of 14 residents sampled for issues related to the dining experience. This deficient practice had the potential to negatively impact Residents' oral intake, weight, and worsen their medical condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure legal guardianship was renewed and active for one Resident (#41) declared incompetent by a court of law, of two residents reviewed for advance directives, resulting in the potential for unauthorized decisions made on the Resident's behalf.

Inspectors wroteAll times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to ensure one Resident (R15) of three residents reviewed for urinary catheters had physician orders for the catheter and a care plan for the catheter.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent resident to resident abuse for 2 residents (Resident #46, & Resident #37) of 6 residents residents reviewed for abuse. This deficient practice resulted in Resident #30 twisting Resident #46's right wrist causing pain, fear and increased anxiety, and Resident #42 perpetrating physical abuse to Resident #37 and another resident unknown with the potential for further continued abuse of residents residing in the facility to go unrecognized and the potential for further harm. (All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted.)

Inspectors wroteThis deficiency is related to Complaint Intakes MI00131768 and MI00136585. Based on observation, interview, and record review, the facility failed to provide care to prevent skin breakdown, promote healing, and prevent infection related to pressure injuries for two Residents (R104 and R155) out of two residents reviewed for pressure injuries. This deficient practice resulted in harm to R104 when their pressure ulcer wound infection progressed to organ failure, and the development of facility acquired pressure injuries for both R104 and R155.

Inspectors wroteThis citation relates to Intake #MI00138093. Based on interview and record review, the facility failed to provide effective safety interventions to prevent two falls with major injury (a hip fracture with surgical fixation, and a non-operable femur fracture) for one Residents (#154) of six residents reviewed for falls. This deficient practice resulted in surgical intervention, hospitalization, functional and medical decline, and increased pain requiring additional opioid pain medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety as evidenced by: A. Failing to ensure that potentially hazardous foods were kept free from contamination, labeled, dated, and discarded on or before the expiration date. B. Failing to ensure food preparation surfaces in the dietary department were properly disinfected. C. Failing to properly clean and disinfect dishes and utensils. This deficient practice had the potential to result in food borne illness among any or all the 52 residents in the facility.

Inspectors wroteThis citation pertains to Inake: MI00138093 Based on interview and record review, the facility failed to report to the State Agency resident to resident abuse for 2 residents (Resident #46, & Resident #37) of 6 residents residents reviewed for abuse, resulting in Resident #30 grabbing on to and twisting Resident #46's right wrist causing pain, fear and increased anxiety, Resident #42 being involved in 2 separate incidents of resident to resident abuse and the potential for continued abuse and falls with major injury of residents residing in the facility to go unrecognized and the potential for further harm. (All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted.)

Inspectors wroteThis citation pertains to Intake: #MI00138093. Based on interview and record review, the facility failed to report to the State Agency resident to resident abuse for 2 residents (Resident #46, & Resident #37) of 6 residents residents reviewed for abuse, resulting in Resident #30 grabbing on to and twisting Resident #46's right wrist causing pain, fear and increased anxiety, Resident #42 being involved in 2 separate incidents of resident to resident abuse and the potential for continued abuse and falls with major injury of residents residing in the facility to go unrecognized and the potential for further harm. (All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted.)

Inspectors wroteBased on observation, and interview, the facility failed to maintain a sanitary, home-like environment, resulting in the potential for pest harborage conditions and a non-home-like environment. (All times noted are Eastern Daylight Savings Time (EDST) unless otherwise noted.)

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain resident privacy in 2 residents(Resident #15 and #46) reviewed for privacy, resulting in increased anxiety and the likelihood of prolonged feelings of embarrassment, fear and increased anxiety.

Inspectors wroteBased on interview, and record review, the facility failed to appropriately revise and update care plans to reflect resident status for three Residents (#18, #20 and #40) of 14 Residents reviewed for care plans. This deficient practice resulted in the potential for implementation of interventions which were no longer appropriate and the potential for related complications from choking and/or aspiration.

Inspectors wroteThis citation pertains to Intake #MI00132047. Based on observation, interview, and record review, the facility failed to provide services to meet professional standards of care for two Resident (#18, #10) of three residents reviewed for standards of practice. This deficient practice resulted in delayed removal of staples on Resident #18's head for over seven weeks, with the potential for infection, pain, and adverse medical outcomes, and lack of assessment for appropriate wheelchair seating and positioning for Resident #10, resulting in discomfort, decreased mobility, risk of pressure ulcers, and other adverse outcomes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure ongoing assessment and monitoring for weight fluctuations for two Residents (#40, and #50) of 7 residents reviewed for nutritional needs. This deficient practice resulted in the potential for further clinical compromise.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician visits were completed as required for two Residents (R45 and R104) out of four residents reviewed for timeliness of physician visits. This deficient practice resulted in the potential for unidentified and unaddressed medical care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide fluids in the prescribed texture/consistency for two Residents (Resident #18 and #20) and did not provide food in the proper form serving mechanical soft rather than pureed food for one Resident (Resident #18) of 2 residents reviewed for food/beverages served in proper form. This deficient practice resulted in the delivery of fluids and food of inappropriate consistency for the prescribed diet with the potential for choking and aspiration (accidental breathing of food or fluid into the lungs, which can cause pneumonia).

Inspectors wroteBased on interview and record review, the facility failed to ensure the electronic medical record contained accurate documentation for one Resident (R1-50) out of three residents reviewed for the comprehensive plan of care. This deficient practice resulted in the potential for unmet care needs related to the inaccuracy of the medical record.