Deficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% worse than Michigan average
Michigan average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Apr 17, 2025
Visit Reason
The inspection was conducted based on complaint investigations related to medication administration, oxygen therapy, infection control, and medication regimen reviews at Iron County Medical Care Facility.
Complaint Details
The visit was complaint-related focusing on medication administration errors, oxygen therapy discrepancies, medication regimen review deficiencies, and infection control lapses.
Findings
The facility failed to ensure oxygen was administered per physician orders, maintain nebulizer equipment sanitation, perform monthly medication regimen reviews, prevent duplicate drug therapy, maintain medication error rates below 5%, and ensure proper hand hygiene during care activities, resulting in potential harm to residents.
Deficiencies (5)
Failed to ensure oxygen was administered per physician order and maintenance of oxygen and nebulizer equipment in a sanitary manner for one resident.
Failed to ensure Medication Regimen Reviews were reviewed, addressed by the Physician, and maintained in the clinical record for four residents.
Failed to prevent duplicate drug therapy of Vitamin D for one resident, resulting in potential Vitamin D toxicity.
Failed to maintain medication error rates less than 5%, resulting in a 13.33% medication administration error rate in four residents.
Failed to ensure hand hygiene was performed during fresh water pass and catheter care for seven residents, risking cross-contamination.
Report Facts
Medication errors: 4
Vitamin D dosage: 100000
Oxygen flow rate observed: 3
Oxygen tubing date: Mar 13, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN G | Licensed Practical Nurse | Interviewed regarding oxygen administration and maintenance of equipment for Resident #65 |
| DON | Director of Nursing | Interviewed regarding oxygen administration policies, medication regimen review deficiencies, and medication errors |
| ADON N | Assistant Director of Nursing | Interviewed regarding medication regimen review deficiencies and duplicate vitamin D administration |
| RN K | Registered Nurse | Observed and interviewed regarding medication administration errors including crushing medications without orders |
| LPN L | Licensed Practical Nurse | Observed administering potassium chloride capsules improperly and not documenting difficulties |
| LPN M | Licensed Practical Nurse | Observed administering medications improperly including unshaken liquid medication and crushing without orders |
| CNA A | Certified Nurse Aide | Observed failing to perform hand hygiene between fresh water passes to multiple residents |
| CNA O | Certified Nurse Aide | Observed failing to perform hand hygiene and don clean gloves during catheter care |
| RN B | Registered Nurse | Interviewed regarding hand hygiene and glove use during catheter care |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 24, 2024
Visit Reason
The inspection was conducted due to complaints regarding misappropriation of narcotic medication for one resident (R266) at the facility.
Complaint Details
The complaint investigation revealed that RN H signed out a PRN Norco medication for resident R266 but did not administer it as documented. RN H was previously disciplined for similar documentation issues and was terminated after refusing drug testing following this incident.
Findings
The facility failed to prevent misappropriation of narcotic medication by a nurse (RN H) who signed out medication but did not administer it to the resident, leading to her termination after refusal to submit to drug testing. The facility implemented corrective actions including audits, policy revisions, staff education, and formation of a Drug Diversion Committee.
Deficiencies (1)
Failure to prevent misappropriation of narcotic medication for one resident due to nurse signing out medication but not administering it.
Report Facts
Medication amount received: 30
Date of medication administration discrepancy: Sep 28, 2023
Date of discipline: Feb 10, 2023
Date of drug diversion investigation: Oct 6, 2023
Date of staff education completion: Oct 11, 2024
Date of audit compliance: Apr 16, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN H | Registered Nurse | Named in medication misappropriation finding and terminated for refusal to submit to drug testing |
| Director of Nursing | DON | Signed drug diversion investigation and reported RN H termination |
| Assistant Director of Nursing | ADON | Signed drug diversion investigation and involved in RN H interview |
| Nursing Home Administrator | NHA | Signed drug diversion investigation and confirmed RN H termination |
| Licensed Practical Nurse J | LPN | Reported resident's medication request and discrepancy |
| Licensed Practical Nurse I | LPN | Noted medication sign out discrepancy |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Apr 24, 2024
Visit Reason
The inspection was conducted based on complaints and allegations related to narcotic medication misappropriation, failure to report injuries of unknown source, incomplete investigations of incidents, pressure injury care deficiencies, inaccurate staffing data reporting, and Quality Assurance and Performance Improvement (QAPI) committee meeting deficiencies.
Complaint Details
The complaint investigation included allegations of narcotic medication misappropriation involving one nurse and one resident, failure to report injuries of unknown source for two residents, incomplete incident investigations, inadequate pressure injury care, inaccurate staffing data reporting, and failure of the QAPI committee to meet quarterly with required members.
Findings
The facility failed to prevent narcotic medication misappropriation by a nurse, failed to report injuries of unknown source to the state agency for two residents, did not conduct a thorough investigation for a resident incident, failed to properly assess and monitor pressure injuries for one resident, failed to submit accurate Payroll Based Journal staffing data to CMS, and failed to ensure the QAPI committee met quarterly with required members.
Deficiencies (6)
Failed to prevent misappropriation of narcotic medication for one resident due to nurse signing out medication but not administering it and refusal to submit to drug testing.
Failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities for two residents with injuries of unknown source.
Failed to conduct a thorough and complete investigation for an incident involving one resident.
Failed to assess and monitor pressure injuries to promote healing for one resident, including lack of documentation and physician orders.
Failed to electronically submit complete and accurate Payroll Based Journal staffing information to CMS, resulting in inaccurate staffing level reporting.
Failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with required members.
Report Facts
Residents affected: 1
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 115
Dates with no RN hours: 24
Dates with failed licensed nursing coverage 24 hours/day: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN H | Registered Nurse | Named in narcotic medication misappropriation and drug diversion investigation |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding narcotic misappropriation, injury reporting, incident investigation, pressure injury care, and staffing data |
| Nursing Home Administrator (NHA) | Administrator | Interviewed regarding narcotic misappropriation and injury reporting |
| Licensed Practical Nurse (LPN) J | Licensed Practical Nurse | Reported resident requesting medication and discrepancy in narcotic sign out |
| Licensed Practical Nurse (LPN) I | Licensed Practical Nurse | Noted narcotic sign out discrepancy |
| Registered Nurse (RN) C | Registered Nurse | Found resident on floor with injury and responsible for PBJ data submission |
| Certified Nursing Assistant (CNA) F | Certified Nursing Assistant | Witnessed resident prior to fall and provided statements |
| Licensed Practical Nurse (LPN) D | Licensed Practical Nurse | Performed skin assessment for pressure injury |
| Certified Nursing Assistant (CNA) E | Certified Nursing Assistant | Assisted with skin assessment and provided information on pressure injury |
| Registered Nurse (RN) G | Risk Manager | Reviewed QAPI policy and attendance |
Inspection Report
Routine
Deficiencies: 5
Date: Apr 20, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication storage and labeling, dietary services, adaptive equipment provision, infection prevention and control, and water management.
Findings
The facility was found deficient in proper labeling and storage of multi-dose medications, failure to serve planned meal items and provide adaptive eating equipment, lack of a comprehensive water management plan to control Legionella, and inadequate infection control surveillance for urinary tract infections.
Deficiencies (5)
Failure to label multi-dose insulin and ophthalmic medications according to pharmacy recommendations and ensure proper storage, leading to potential administration of expired medications.
Failure to follow the menu and serve planned meal items according to resident tray cards, resulting in potential inadequate intake and unmet nutritional needs.
Failure to provide adaptive eating equipment and utensils for residents who need them, resulting in increased difficulty with nutritional consumption and potential dehydration.
Failure to develop and implement a comprehensive Water Management Plan to address control and spread of Legionella bacteria, risking proliferation and transmission among residents.
Failure to ensure an infection control program with surveillance to identify and investigate urinary tract infections, resulting in potential for unidentified infections and inaccurate infection control data.
Report Facts
Residents affected: 3
Residents affected: 13
Residents affected: 2
Residents affected: 114
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN C | Licensed Practical Nurse | Named in medication labeling and storage deficiencies |
| RN G | Registered Nurse | Named in medication labeling and storage deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding medication storage expectations and infection control |
| Certified Dietary Manager M | Certified Dietary Manager | Interviewed regarding dietary service deficiencies and adaptive equipment |
| Certified Nurse Aide N | Certified Nurse Aide | Observed serving incorrect jelly on diabetic tray |
| Certified Nurse Aide L | Certified Nurse Aide | Observed serving beverages without lids and straws for residents needing adaptive equipment |
| Environmental Director A | Environmental Director | Interviewed regarding water management plan deficiencies |
| Infection Preventionist P | Infection Preventionist/Registered Nurse | Interviewed regarding infection control surveillance deficiencies |
| Infection Preventionist X | Infection Preventionist | Reviewed infection control line listing and mapping |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 8, 2023
Visit Reason
The inspection was conducted following complaints regarding sexual abuse between residents and concerns about controlled substance management and potential drug diversion within the facility.
Complaint Details
The complaint investigation was substantiated with findings that sexual abuse occurred between two residents who were cognitively impaired. The investigation also revealed failures in controlled substance management, including missing narcotics and inadequate security protocols.
Findings
The facility failed to protect a resident from sexual abuse by another resident, resulting in potential physical and psychosocial harm. Additionally, the facility failed to ensure secure inventory and proper tracking of controlled substances, resulting in missing narcotics and potential drug diversion.
Deficiencies (2)
Failed to protect residents from sexual abuse by another resident, resulting in potential physical and psychosocial harm.
Failed to ensure secure inventory and tracking of controlled substances, resulting in missing narcotics and potential drug diversion.
Report Facts
Residents affected: 2
Missing controlled substance quantity: 30
Medication order frequency: 2
Narcotic cards delivered: 2
Duration of closed-door incident: 45
15-minute checks: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN L | Registered Nurse | Named in sexual abuse incident and witness statement |
| RN E | Registered Nurse | Involved in controlled substance investigation for suspected drug diversion |
| RN U | Registered Nurse | Received call about medication shortage and involved in drug diversion investigation |
| RN G | Registered Nurse | Witnessed RN E's suspicious behavior during drug diversion investigation |
| CNA I | Certified Nurse Aide | Witnessed sexual abuse incident and assisted in removing Resident #3 from Resident #2's room |
| CNA V | Certified Nurse Aide | Noticed nurse under investigation fall asleep at computer during drug diversion investigation |
| Director of Nursing | Director of Nursing | Interviewed regarding sexual abuse incident and controlled substance policy failures |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding sexual abuse incident and controlled substance policy failures |
Viewing
Loading inspection reports...
