Iron River Care Center

In the surveyor’s words

From the most serious findings on record at Iron River Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 19, 2022

  All times were recorded in Eastern Time. This citation pertains to intake # MI 332. Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent the elopement of one vulnerable Resident (#38) of four residents reviewed for elopement. This deficient practice placed Resident #38 and 16 other facility residents identified as at risk for elopement at risk for injury, accident, or serious harm up to and including death. Findings include: An Immediate Jeopardy resulted when Resident #38 eloped from the facility into the community on 6/22/22 at approximately 6:15 p.m. unbeknownst to staff. The facility became aware when Resident #38 was returned to the facility approximately five minutes later by a neighbor [Neighbor HH]. […]

• Actual harm, isolatedF697Feb 3, 2026

  This 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.Findings include:Resident #1 (R1)Review of the Incident report titled Fall with Injury dated 1/5/26 at 3:00 a.m., read in part .Resident.announced to staff at the nurse's station, Help I've fallen. This nurse and CNA immediately went to resident's room. Resident was now on her bed, resting on her bent legs, head down, back showing. […]

• Actual harm, isolatedF600Aug 24, 2023

  Based 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. […]

• Actual harm, isolatedF686Aug 24, 2023

  This 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. […]

• Actual harm, isolatedF689Aug 24, 2023

  This 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. Findings include: All times are noted in Eastern Daylight Time unless otherwise noted. Review of Resident #154's Emergency Department transfer report, dated 05/20/23 at 2309 [11:09 p.m. […]