Iron County Medical Care Facility

In the surveyor’s words

From the most serious findings on record at Iron County Medical Care Facility, in the surveyor’s own words.

• Actual harm, isolatedF600Jul 8, 2022

  This citation pertains to Intake # 3 and Intake # 0. Based on observation, interview and record review, the facility failed to prevent abuse of two Residents (#1 and #4), from five reviewed for abuse. This deficient practice resulted in psychosocial harm with fear and helplessness for Resident #4 and the potential for physical and psychosocial harm, based on the reasonable person standard, for Resident #1. Findings include: Resident #4 The facility Abuse Investigation, dated 3/22/22, confirmed a written allegation of abuse of Resident #4, by Certified Nurse Aide (CNA) H. The Summary concluded, .Upon completion of our investigation, the facility could find evidence to substantiate this alleged abuse. […]

• Actual harm, isolatedF609Jul 8, 2022

  This citation pertains to Intake # MI 343 Based on observation, interview and record review, the facility failed to immediately report an allegation of abuse to the State Agency (SA), for one Resident (#4), from five reviewed for abuse. This deficient practice resulted in continued abuse by staff of Resident #4, with accompanying fear. Findings include: The facility Abuse Investigation, dated 3/22/22, revealed the facility Director of Nursing (DON) was informed of a written abuse allegation of staff abuse to Resident #4, on 3/16/22 at 10:00 a.m. The summary confirmed the Administrator (NHA) was informed on 3/16/22 at 10:05 a.m. […]

• Actual harm, isolatedF710Sep 1, 2021

  Based on interview and record review, the facility failed to ensure the physician supervised the medical care for one Resident (#1) from three reviewed for physician services, when the physician did not document the medical services provided. This deficient practice resulted in the lack of coordination of care, untreated severe low sodium with corresponding falls, resulting in a [CONDITION(S)], mentation changes and hospitalization , with subsequent death. Findings include: ALL TIMES ARE RECORDED IN EASTERN DAYLIGHT TIME (EDT) According to the electronic medical record (EMR) Admission Record, printed [DATE], Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF838Jun 24, 2026

  Based 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. Findings include: All times are in Eastern Daylight Time (EDT) unless otherwise noted.The facility assessment, last updated 2/12/2026, was reviewed. This document indicated the assessment was completed at the facility level to serve as a record for staff and management to understand the reasoning for decisions made regarding staffing and other resources.The section titled INFORMATION ABOUT NURSE STAFFING PLANS included a table with the heading of Overall Staffing Needs. […]

• No harm, potential for more than minimal, widespreadF868Apr 24, 2024

  Based 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. Findings include: (All times are recorded in Eastern Daylight Time unless otherwise noted.) During an interview on 4/24/24 at 1:34 PM, the Risk Manager, Registered Nurse (RN) G reviewed the QAPI policy, the attendance documentation for the QAPI meetings and identified the people and positions who were in attendance. […]