Inspection visit
Health inspection
11 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0580
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room,
etc.) that affect the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation, and interviews the facility failed to notify the physician and hospice services
after a resident was found with copious amounts of sanguineous fluid visible in a tracheostomy mask and
the tracheostomy tube. This affected one resident (Resident #2) out of three residents reviewed with
tracheostomy care. The facility census was 120.
Findings include:
Record Review of Resident #2 revealed this resident was admitted to the facility on [DATE] with the
following medical diagnoses: malignant neoplasm of the larynx, chronic obstructive pulmonary disease,
acute bronchitis, hypoxia, mood disorder, tracheostomy, obstructive sleep apnea, anemia, dyspnea, and
diabetes mellitus type II.
This resident is non-verbal, but is alert and oriented to person, place, and time with a current BIMS score of
10 on the most recent MDS quarterly assessment completed on 02/17/20, indicating minimal/moderate
cognitive impairments. This resident has no known drug allergies. Review of physician orders revealed this
resident was to receive tracheostomy care each shift and as needed.
On 02/25/20 at 10:52 A.M., observation of Resident #2's tracheostomy and trach oxygen mask observed
with copious amounts of blood, suction machine at bedside, not plugged in.
On 02/25/20 10:58 A.M. interview with Licensed Practical Nurse #201 verified the tracheostomy site for
Resident #2 was unclean and observed with a moderate/large amount of sanguineous fluid. Tracheostomy
mask had pooled red fluid collecting in the bottom of the reservoir and was noted to be bubbling on
occasion during respirations by the resident. The nurse verified that the resident required suctioning and
proceeded to suction the resident while providing trach care. No concerns on trach care as it was
completed per sterile technique. Resident noted without any difficulty breathing or other respiratory
problems.
On 02/26/20 5:45 P.M. observation of Resident #2 revealed this resident had a large amount of tan sputum
and mucous which has again collected in the tracheostomy mask. Director of Nursing(DON) notified and
verified that this resident needed to be suctioned immediately. DON suctioned the resident without difficulty
and provided trach care per sterile technique. DON verified during care that trach site is unkept and
required care immediately to maintain a patent airway for the resident. Suction machine and ambu-bag in
room.
Review of Nursing Notes revealed neither the Physician or Hospice were notified of the condition of
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 14
Event ID:
365564
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365564
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harbor Healthcare of Ironton
1050 Clinton Street
Ironton, OH 45638
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0580
Resident #2 until 02/27/20.
Level of Harm - Minimal harm
or potential for actual harm
On 02/27/20 12:40 P.M. interview with the DON verified the facility did not notify the Physician or Hospice
after the resident was found with bloody sputum which was collecting in his tracheostomy mask on
02/25/20. She verified these individuals should have been notified.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365564
If continuation sheet
Page 2 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365564
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harbor Healthcare of Ironton
1050 Clinton Street
Ironton, OH 45638
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0679
Provide activities to meet all resident's needs.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, and staff interview the facility failed to assess a resident's activity
interests and provide on-going activities. This affected one of one sampled resident reviewed for activities
(Resident #14).
Residents Affected - Few
Findings include:
Review of Resident #14's medical record revealed she was admitted on [DATE] with diagnoses that
included: chronic respiratory failure, fever, chronic obstructive pyelonephritis, major depressive disorder,
and anoxic brain.
Review of Resident #14's significant change Minimum Data Set (MDS) dated [DATE] revealed no speech,
rarely never understands, was rarely understood, and her cognition was severely impaired. Resident # 14
had no behavior and did not reject care. Staff assessment for activities revealed she did not read, liked
listening to music, liked being around animals, did not keep up on the news, did not like to do things with
groups of people, did not like participating in favorite activities, did not like spending time away from the
nursing home, did not like spending time outdoors, and did not like participating on religious activities.
Resident #14 was dependent on two staff for bed mobility and did not transfer in the previous seven days.
Review of Resident #14 activities participation review dated 12/14/19 revealed she was bedfast, and the
television was on in her room.
There was no activity assessment conducted to determine Resident #14's music preference or television
show preferences.
Observation of Resident #14, in her room, on 02/25/20 at 10:32 A.M. and 2:54 P.M. revealed no music or
television was on. On 02/26/20 at 8:55 A.M. revealed she was in her room, no music or television was on.
At 11:06 A.M. Resident #14's television was on a recreational vehicle (RV) program.
Interview of Activity Aide (AA) #16 on 02/27/20 at 9:50 A.M. revealed Resident #14 liked country music. AA
#16 revealed she turned Resident #14's television on whatever channel it was on nothing.
Interview of Activity Director (AD) #43 on 02/27/20 at 9:50 A.M. confirmed no activity assessment was
conducted. AD #43 stated Resident #14 was not interviewable and the family was not here when she was.
AD #43 confirmed Resident #14's television preferences or music preferences were not obtained.
Review of the facility's activities and social services policy (dated December 2006) revealed residents shall
have the right to choose the types of activities which they wish to participate in.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365564
If continuation sheet
Page 3 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365564
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harbor Healthcare of Ironton
1050 Clinton Street
Ironton, OH 45638
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on medical record review and interview, the facility failed to ensure a resident did not receive an
antibiotic that was listed as an allergy. This affected one (Resident #361) of one resident sampled for
antibiotic use. The facility census was 120.
Residents Affected - Few
Findings include:
Review of Resident #361's medical record revealed an initial admission date of 12/31/19 and a re-entry
date of 02/15/20. Diagnoses include, respiratory failure, acute bronchitis, and upper respiratory infection.
Resident #361 was noted to have allergies to Ciprofloxacin (an antibiotic), Diflucan ( an antifungal),
Cephalexin (an antibiotic), Omnicef (an antibiotic), Paxil ( an selective serotonin reuptake inhibitor for
depression and anxiety), and Zithromax ( an antibiotic). Reactions to all of these allergies were noted as
unknown.
Review of Resident #361's medicare 5 day Minimum Data Set (MDS) 3.0 dated for 02/20/20 revealed an
intact cognition with a Brief Interview for Mental Status (BIMS) of 15. Resident #361 required extensive
assistance from one staff member for bed mobility, transfers, and toilet use and was occasionally
incontinent of bowel and bladder.
Review of Resident #361's physician orders for February 2020, revealed an order dated for 02/15/20 for the
resident to receive Omnicef ( Cefdinir, an antibiotic) 300 milligrams (mg) by mouth, two times a day for a
upper respiratory infection for three days.
Review of Resident #361's medication administration record (MAR) for February 2020, revealed resident
received the ordered medication, Omnicef on 02/15/20 at 8:00 P.M. and on 02/16/20 at 8:00 A.M. before the
order was discontinued.
Review of a nursing progress note entered for Resident #361 on 02/15/20 at 6:15 P.M. revealed the
charting system had identified a possible drug allergy for the medication Cefdinir 300 mg. Another note
dated for 02/15/20 at 9:36 P.M. revealed the resident was started on antibiotic therapy with no signs or
symptoms of adverse reactions.
Interview on 02/25/20 at 4:30 P.M. with the Assistant Director of Nursing (ADON) #110 confirmed Resident
#361 had received two doses of an antibiotic medication that was listed on her allergy list. The ADON #110
also confirmed the floor nurse had received an alert from the charting system that there was an known
allergy to this medication and did not clarify this with the physician prior to administration of the medication.
Interview on 02/26/20 at 5:15 P.M. with Resident #361 revealed she knew she was allergic to some
medication and antibiotics but she was not sure which ones they were.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365564
If continuation sheet
Page 4 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365564
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harbor Healthcare of Ironton
1050 Clinton Street
Ironton, OH 45638
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, medical record review, and staff interview the facility failed to ensure devices were in place to
protect the resident's palm from breakdown. This affected one of four sampled residents reviewed for
impaired skin integrity (Resident #14).
Residents Affected - Few
Findings include:
Review of Resident #14's medical record revealed she was admitted on [DATE] with diagnoses that
included: chronic respiratory failure, fever, chronic obstructive pyelonephritis, major depressive disorder,
and anoxic brain.
Review of Resident #14 significant change Minimum Data Set (MDS) dated [DATE] revealed no speech,
rarely never understands, was rarely understood, and her cognition was severely impaired. Resident #14
had no behavior and did not reject care. Resident #14 was dependent on two staff for bed mobility and did
not transfer in the previous seven days. Resident #14 had limited range of motion of both side of upper and
lower extremities. The resident's hands were contracted.
Review of telephone orders revealed on 01/30/20 bilateral palm guards to decrease skin break down and
improve skin integrity were ordered.
Observation of Resident #14 on 02/24/20 at 10:30 A.M., at 11:30 A.M., at 2:30 P.M., and on 02/25/20 at
10:46 A.M., at 1:55 P.M., and 2:54 P.M. revealed no palm protectors were in place.
Interview of State Tested Nursing Assistant (STNA) #96 on 02/27/20 at 8:35 A.M. revealed she was unable
to locate Resident #14's palm protectors on 02/26/20 so a washcloth was placed in her hands until new
ones could be obtained.
Interview of Licensed Practical Nurse (LPN) #30 on 02/27/20 at 8:43 A.M. confirmed Resident #14 had no
palm guards on 02/24/20 and 02/25/20.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365564
If continuation sheet
Page 5 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365564
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harbor Healthcare of Ironton
1050 Clinton Street
Ironton, OH 45638
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
record review, observation, and interviews the facility failed to provide appropriate respiratory related
services to residents. This affected three residents (Residents #2, #14, and #316) of three residents
reviewed who were receiving respiratory services in the facility. The facility census was 120.
Residents Affected - Few
Findings include:
1. Record review of Resident #2 revealed this resident was admitted to the facility on [DATE] with the
following medical diagnoses: malignant neoplasm of the larynx, chronic obstructive pulmonary disease,
acute bronchitis, hypoxia, mood disorder, tracheostomy, obstructive sleep apnea, anemia, dyspnea, and
diabetes mellitus type II.
This resident is non-verbal, but is alert and oriented to person, place, and time with a current BIMS score of
10 on the most recent MDS quarterly assessment completed on 02/17/20, indicating minimal/moderate
cognitive impairments. This resident has no known drug allergies. Review of physician orders revealed this
resident was to receive tracheostomy care each shift and as needed.
On 02/25/20 at 10:52 A.M., observation of Resident #2's tracheostomy and trach oxygen mask observed
with copious amounts of blood, suction machine at bedside, not plugged in.
On 02/25/20 at 10:58 A.M., interview with Licensed Practical Nurse #201 verified the tracheostomy site for
Resident #2 was unclean and observed with a moderate/large amount of sanguineous fluid. Tracheostomy
mask had pooled red fluid collecting in the bottom of the reservoir and was noted to be bubbling on
occasion during respirations by the resident. The nurse verified the resident required suctioning and
proceeded to suction the resident while providing trach care. No concerns on trach care as it was
completed per sterile technique. Resident noted without any difficulty breathing or other respiratory
problems.
On 02/26/20 at 5:45 P.M., observation of Resident #2 revealed this resident had a large amount of tan
sputum and mucous which has again collected in the tracheostomy mask. The Director of Nursing(DON)
notified and verified that this resident needed to be suctioned immediately. The DON suctioned the resident
without difficulty and provided trach care per sterile technique. The DON verified during care that trach site
is unkept and required care immediately to maintain a patent airway for the resident. Suction machine and
ambu-bag in room.
2. Review of Resident #14's medical record revealed she was admitted on [DATE] with diagnoses that
included: chronic respiratory failure, fever, chronic obstructive pyelonephritis, major depressive disorder,
and anoxic brain.
Review of Resident #14's significant change Minimum Data Set (MDS) dated [DATE] revealed no speech,
rarely never understands, was rarely understood, and her cognition was severely impaired. Resident #14
had no behavior and did not reject care. Resident #14 was dependent on two staff for bed mobility and did
not transfer in the previous seven days. Resident #14 had a tracheotomy and received oxygen therapy.
Review of Resident #14's telephone orders dated 02/17/20 revealed the resident's oxygen was humidified
at night only.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365564
If continuation sheet
Page 6 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365564
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harbor Healthcare of Ironton
1050 Clinton Street
Ironton, OH 45638
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Observation of Resident #14 on 02/24/20 at 10:30 A.M., at 11:30 A.M., at 2:30 P.M., and on 02/25/20 at
10:46 A.M., at 1:55 P.M., and 2:54 P.M. revealed her oxygen was humidified and the resident's breathing
sounded congested.
Interview of Licensed Practical Nurse (LPN) #30 on 02/27/20 at 8:43 A.M. confirmed Resident #14's oxygen
was not supposed to be humidified during the day. LPN #30 revealed the order was changed to only
humidify Resident #14's oxygen at night as she was more congested. She stated at times the resident's
breathing was so loud you could hear her in the hallway. She confirmed Resident #14's oxygen was
humidified on 02/24/20 and 02/25/20.
3. Record review revealed Resident #316 was admitted to the facility on [DATE] with diagnoses including
congestive heart failure, history of cerebrovascular disease, chronic respiratory failure, Stage III kidney
disease and diabetes mellitus.
The physician orders for 02/2020 included oxygen at four liters per nasal cannula, notify physician when
oxygen saturation less than 90%, and change oxygen tubing weekly and as needed.
On 02/24/20 at 10:58 A.M. Resident #316 was observed resting in bed receiving oxygen at four liters per
nasal cannula. There was no date on the oxygen tubing.
On 02/25/20 at 2:15 P.M. Resident #316 was observed being transported by therapy staff to the therapy
department. No date was noted on the oxygen tubing.
On 02/25/20 at 2:53 P.M. during interview,Registered Nurse (RN) #109 confirmed no date was on the
oxygen tubing. Resident #316 reported the oxygen tubing was changed on 02/24/20, however, the medical
record indicated the oxygen tubing was changed on 02/21/20. RN #109 stated without a date on the tubing,
she was unable to determine when the tubing was changed and would replace tubing with new tubing and
ensure a date was on the oxygen tubing.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365564
If continuation sheet
Page 7 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365564
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harbor Healthcare of Ironton
1050 Clinton Street
Ironton, OH 45638
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure timely communication from the dialysis center to
ensure continuity of care. This affected one resident (Resident #108) of two residents reviewed for dialysis.
Residents Affected - Few
Findings Include:
Record review revealed Resident # 108 was admitted to the facility on [DATE] and readmitted after acute
care hospitalization on 02/04/20 with diagnoses including atherosclerosis and gangrene bilateral legs,
congestive heart failure, end stage renal disease, diabetes mellitus Type II, and peripheral vascular
disease.
Review of the quarterly Minimum Data Set completed on 02/11/20 indicated no cognitive delay.
The physician orders for 02/2020 included low concentrated sweet diet, dialysis every Tuesday, Thursday
and Saturday; evaluate shunt site in right upper arm for thrill or bruit each shift and as needed; no blood
pressure or needle sticks in right arm; ensure right upper arm shunt site is free from signs/symptoms of
infection and document any positive finding in progress notes; and notify physician; and Renvela (a
medication used to control phosphorus levels in residents receiving dialysis) 800 milligrams (mg) with
meals.
Resident #108's care plan identified hemodialysis with interventions including to maintain patency of
dialysis access site, coordination of care with dialysis center, diagnostics as ordered.
A dietary progress note on 12/27/2019 at 3:00 P.M. indicated Resident #108 was at risk, with current weight
233 pounds, a weight loss of 10 pounds from previous week. Oral intake was 76%. Dietary plan was to add
renal diet and 1500 milliliters (ml) fluid restriction. The progress note identified Resident #108 was receiving
dialysis three times a week.
Review of the medical record for Resident #108 revealed dialysis transfer sheets were pre and post
treatment vital signs, weights and an area for communications of any concerns or changes. No information
from the dialysis center regarding laboratory test results nor dietician recommendations were present in the
medical record.
During an interview with Registered Dietician (RD) #145 on 02/26/20 at 2:16 P.M. she reported she had not
received any communication from the dialysis center regarding Resident #108's laboratory results or
dietician recommendations. RD #145 stated Resident #108 had been on a 1500 ml fluid restriction and
renal diet prior to his hospitalization and the diet and fluid restriction must not have been initiated after his
return from the hospital. RD #145 was not aware of any reason for the fluid restriction nor diet change. RD
#145 confirmed no information from the dialysis center addressing any recommendations regarding
Resident #108's diet.
On 02/27/20 at 11:10 A.M. during interview, the Director of Nurses (DON) reported the physician did not
approve the fluid restriction for Resident #108 and RD #145 was also aware of the physician order for no
fluid restrictions.
On 02/27/20 11:20 A.M., during interview, RN #109 confirmed Resident #108 was now receiving a renal
diet.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365564
If continuation sheet
Page 8 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365564
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harbor Healthcare of Ironton
1050 Clinton Street
Ironton, OH 45638
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0698
Review of the dialysis agreement dated 09/18/18 between the facility and the dialysis center indicated there
would be documented evidence of collaboration of care and communication.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365564
If continuation sheet
Page 9 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365564
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harbor Healthcare of Ironton
1050 Clinton Street
Ironton, OH 45638
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm
or potential for actual harm
Based on resident interview, a test tray, and staff interview the facility failed to ensure residents food was
palatable. This affected one of one sampled resident reviewed for food (Resident #160) and one randomly
observed resident (Resident #108).
Residents Affected - Few
Findings include:
Interview of Resident #160 on 02/24/20 at 3:03 P.M. revealed the food just did not taste good and the meat
was tough.
Interview of Resident #108 on 02/26/20 at 5:25 P.M. revealed he was unable to cut up his piece of chicken
by himself. He stated that the chicken was too tough to cut up with a fork and butter knife.
A test tray was requested for the evening meal on 02/26/20. At 5:35 P.M. the test tray revealed the apple
juice was 58 degrees Fahrenheit and warm to taste. The fried chicken sandwich was overcooked, dry, and
not palatable. This was verified by two surveyors whom agreed with each other's taste and confirmed by
Registered Dietitian #117.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365564
If continuation sheet
Page 10 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365564
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harbor Healthcare of Ironton
1050 Clinton Street
Ironton, OH 45638
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0805
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual
needs.
Based on observation, policy review, and staff interview the facility failed to ensure pureed food was
properly prepared and did not have large pieces of meat in it. This had the potential to affect nine residents
who received a pureed diet (Resident #2, #3, #18, #31, #79, #93, #106, #309, and #400). The faciity
census was 120.
Findings include:
Observation of pureed diet preparation on 02/25/20 at 10:00 A.M. revealed 18 servings of creamed chipped
beef was placed into a blender. The cream chipped beef was processed, however there were large pieces
of the meat around the top of the blender. When [NAME] #42 put the cream chipped beef into the pan
pieces that were not pureed mixed into the pureed food. This was confirmed by Registered Dietitian #117.
The facility identified Resident #2, #3, #18, #31, #79, #93, #106, #309, and #400 as receiving pureed foods.
Review of the Resident nutrition services policy (not dated) revealed each resident would be provided with
a diet that met the resident's special dietary needs.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365564
If continuation sheet
Page 11 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365564
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harbor Healthcare of Ironton
1050 Clinton Street
Ironton, OH 45638
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, staff interview, and policy review the facility failed to store and prepare food under
sanitary conditions. This had the potential to affect all but two residents' (Resident #14 and #66 did not
receive nutrition from the kitchen).
Findings include:
An initial tour of the kitchen on 02/24/20 from 8:50 A.M. to 9:05 A.M. revealed at least 15 pans were stored
wet/dirty and two dented cans were stored with the stock. This was confirmed with Dietary Manager (DM)
#83.
Observation on 02/25/20 at 10:00 AM revealed three fans in the kitchen had grease encrusted dust on
them and they were blowing over work areas and food preparation areas. This observation was confirmed
by DM #83.
Further observation in the kitchen on 02/27/20 at 2:12 P.M. revealed two food scoops had no end caps. This
observation was confirmed by Registered Dietitian #117.
The facility identified Resident #14 and #66 as receiving no food from the kitchen.
Review of the facility's sanitization policy (not dated) revealed the food service area would be maintained in
a clean and sanitary manner.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365564
If continuation sheet
Page 12 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365564
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harbor Healthcare of Ironton
1050 Clinton Street
Ironton, OH 45638
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, staff interview, medical record review, and policy review the facility failed to maintain an
infection prevention program that was followed by facility staff. This affected one of three residents reviewed
for respiratory care (Resident #14).
Residents Affected - Few
Findings include:
Review of Resident #14's medical record revealed she was admitted on [DATE] with diagnoses that
included: chronic respiratory failure, fever, chronic obstructive pyelonephritis, major depressive disorder,
and anoxic brain.
Review of Resident #14's significant change Minimum Data Set (MDS) dated [DATE] revealed no speech,
rarely never understands, was rarely understood, and her cognition was severely impaired. Resident # 14
had no behavior and did not reject care. Resident #14 was dependent on two staff for bed mobility and did
not transfer in the previous seven days. Resident #14 had a tracheotomy and received oxygen therapy.
Observation on 02/27/20 at 2:10 P.M. of tracheostomy (trach) care completed for Resident #14 by Licensed
Practical Nurse (LPN) #18 and assistance provided by LPN #30, revealed sterile control was not
maintained throughout the trach change process. LPN #18 washed her hands with soap and water and
dried them which then she applied regular gloves. LPN #18 removed the old trach oxygen mask and split
sponge. LPN #18 removed her gloves, then she opened the sterile trach supply kit and removed the sterile
items in the kit with her bare hands. LPN #18 removed the package of sterile gloves and put them on while
touching her arm with the sterile part of the gloves. After donning the sterile gloves LPN #18 grabbed the
outer part of the glove package that was touching the bedside table and placed it in the trash. LPN #18
gathered multiple four by four gauze from the bedside table and placed them in the sterile trach kit. LPN
#18 picked up the container of sterile normal saline from the bedside table and used her sterile gloves to
open the container. LPN #18 removed the inner cannula with her right hand while her left hand with the
sterile glove on was placed on the resident's bed and disposed of it. LPN #18 placed the four by four gauze
into the normal saline and used one gauze to clean around the trach. LPN #18 then used two cotton tip
applicators to wipe around the trach. LPN #18 picked up the sterile inner cannula by the portion that was
going to be inserted into the resident's tracheostomy with the same gloves she used to touch the resident's
bedside table, bed, and the old inner cannula.
Interview on 02/27/20 at 2:16 P.M. with LPN #18 and LPN #30 verified sterile technique was not maintained
during Resident #14's trach care.
Review of the facility's tracheostomy care policy (dated August 2013) revealed aseptic technique must be
maintained during all dressing changes and sterile gloves must be used. Soiled gloves were to be removed
and hands washed, and gloves were to be reapplied.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365564
If continuation sheet
Page 13 of 14
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
365564
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/27/2020
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Harbor Healthcare of Ironton
1050 Clinton Street
Ironton, OH 45638
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, observation and record review, the facility failed to ensure residents were provided with a secured
lock box. This affected one resident (Resident #105) of two residents reviewed for personal property.
Findings Include:
Record review revealed Resident #105 was admitted to the facility on [DATE] with diagnoses including
diabetes mellitus Type II, atherosclerotic heart disease, neuropathy, weakness, difficulty walking,
depression, hypertension, right foot drop and repeated falls.
Review of the quarterly minimum data set completed on 02/11/20 indicated Resident #105 had no cognitive
delay.
During an interview with Resident #105 on 02/24/20 at 11:18 A.M. he stated he had a locked drawer on his
night stand, however, the door did not lock. He stated he had two sets of keys, however, anyone could just
open the drawer. Resident #105 stated this had been reported to nursing staff, however, nothing had been
done to correct the problem.
On 02/26/20 at 11:08 A.M. observation of the locked drawer with the Administrator revealed the lock was
not catching on inner clasp of the drawer and the drawer was unable to lock. The Administrator confirmed
the lock would bend forward and no longer be able to secure the top drawer.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
365564
If continuation sheet
Page 14 of 14
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
11 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F679 - Activities
Provide activities to meet all resident's needs.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F698 - Dialysis
Provide safe, appropriate dialysis care/services for a resident who requires such services.
F804 - Food and drink
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
F805 - Food and drink
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the February 27, 2020 survey of HARBOR HEALTHCARE OF IRONTON?
This was a inspection survey of HARBOR HEALTHCARE OF IRONTON on February 27, 2020. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HARBOR HEALTHCARE OF IRONTON on February 27, 2020?
Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.