Ironwood Rehabilitation and Care Center

In the surveyor’s words

From the most serious findings on record at Ironwood Rehabilitation and Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Sep 26, 2024

  Based on review of medical records, the State Survey Agency's Long-Term Care Reporting Portal, and staff interviews, it was determined the facility failed to ensure residents' rights were protected to be free from abuse and neglect. This was true for 2 of 9 residents (#69 and #72) reviewed for abuse and neglect. This failure placed all residents at risk of ongoing abuse and neglect, and potential physical and psychosocial harm. Findings include: 1. Resident #72 was admitted to the facility on [DATE], with multiple diagnoses including osteoporosis with fracture to right humerus, right pelvis, and vertebra(e), hypertension, and bilateral hearing loss. Resident #72 passed away on 5/1/24. […]

• Actual harm, isolatedF550Oct 22, 2021

  Based on observation, record review, policy review, and resident and staff interview, it was determined the facility failed to respect and maintain a resident's dignity by placing a sign related to care outside their room door. This was true for 1 of 13 residents (Resident #38) who were reviewed for dignity. This deficient practice created psychosocial harm for Resident #38 when he expressed he felt like a bad person and felt very bad about it all of the time with the placement of the sign. Findings include: The facility's policy Resident Rights, revised January 2017, stated, The center recognizes the resident's right to a quality of life that supports privacy, confidentiality, independent expression, choice, and decision making, consistent with State law and Federal regulation. […]

• No harm, potential for more than minimal, widespreadF801Sep 26, 2024

  Based on documentation and staff interview, it was determined that the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition services, including resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population. These deficiencies had the potential to affect all residents requiring medical nutrition therapy, nutritional assessments, and appropriate supplementation and dietary interventions. […]

• No harm, potential for more than minimal, patternF684May 1, 2026

  Based on record review, SOM Appendix PP, and staff interview it was determined the facility failed to provide quality care for residents. This was true for 4 of 20 (#2, #4, #8, and #51) whose records were reviewed. This deficient practice created the potential for harm when Resident #2's bowel protocol was not followed, when staff did not follow physician's orders for Resident #4 and #8, and when Resident #51 did not have a skin assessments completed. Findings include:SOM Appendix PP updated 4/25/25 documented quality of care is a fundamental principle applying to all treatment and care provided to facility residents where the facility must ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the… […]

• No harm, potential for more than minimal, patternF921May 1, 2026

  Based on observation, policy review, resident interview, and staff interview, it was determined the facility failed to ensure residents were provided a safe, comfortable, and homelike environment. This was true for 2 of 2 residents (#13 and #30) whose rooms were observed with wear or damage and for residents living in 2 of 3 Halls (South and East Halls) who experienced uneven flooring. These deficient practices created the potential for the residents to experience accidents and psychosocial harm due to the conditions of the rooms and uneven flooring. Findings include:1. a. […]