Health inspection·January 30, 2025

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident#25 revealed an admission date of 07/21/22 with diagnoses including diabetes mellitus type two, hypertension, congestive heart failure, and liver disease. Review of the nursing progress notes and resident census revealed Resident # 25 was transferred to the local hospital on [DATE]. Review of the medical record revealed no evidence the state Ombudsman was notified of Resident #25's transfer to the hospital on [DATE]. Interview on 01/28/25 at 1:23 P.M. with the Administrator revealed the Ombudsman was not notified in writing of the transfer to the hospital on [DATE] for Resident #25. 3. Review of the medical record for Resident #76 revealed an admission date of 02/03/23 with diagnoses including basal cell carcinoma, peripheral vascular disease, respiratory failure with hypoxia, hepatitis A, kidney failure, and neoplasm of bladder and kidney. Review of the nursing progress notes and resident census revealed Resident #76 was transferred to the local hospital on [DATE], 07/22/24 and 07/28/24. Review of the medical record revealed no evidence the state Ombudsman was notified of Resident #76's transfers to the hospital on [DATE], 07/22/24 and 07/28/24. Interview on 01/28/25 at 1:23 P.M. with the Administrator revealed the Ombudsman was not notified in writing of the transfers to the hospital on [DATE], 07/22/24 and 07/28/24 for Resident #76. Based on medical record review and staff interview, the facility failed to ensure the state Ombudsman's office was notified of resident discharge or transfer from the facility as required. This affected three (Resident #25, #76 and #99 ) of four residents reviewed. The facility census was 102. Findings include: 1. Review of the medical record for Resident #99, revealed an admission date of 09/12/24 and readmission date of 10/17/24. Diagnoses included but were not limited to infectious gastroenteritis and colitis, difficulty walking, abnormal posture, cerebral infarction and fracture of unspecified part of neck of left femur. Page 1 of 3 365564 365564 01/30/2025 Harbor Healthcare of Ironton 1050 Clinton Street Ironton, OH 45638

F 0623 Level of Harm - Minimal harm or potential for actual harm Review of the nursing progress notes and resident census record revealed Resident #99 was transferred to the local hospital on [DATE] and 11/28/24. Review of the medical record revealed no evidence the state Ombudsman was notified of Resident #99's transfers to the hospital. Residents Affected - Few Interview on 01/28/25 at 1:23 P.M. with the Administrator revealed the Ombudsman was not notified in writing of the transfers to the hospital for the dates of 10/05/24 and 11/28/24 for Resident #99. 365564 Page 2 of 3 365564 01/30/2025 Harbor Healthcare of Ironton 1050 Clinton Street Ironton, OH 45638

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a care plan that addressed dementia care and specific symptoms for depression care. This affected two (Resident #4 and #47) of five reviewed for dementia and depression. Facility census was 102. Findings include: 1. Review of the medical record for Resident #4, revealed an admission date of 10/22/21. Diagnoses included but were not limited to type 2 diabetes mellitus with diabetic polyneuropathy, bipolar disorder, major depressive disorder, dementia, and unspecified dementia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 out of 15. The resident was assessed to require substantial/maximal assistance with toilet hygiene, shower/bathe self, bed mobility, and transfers. This resident was also assessed to have non-Alzheimer's dementia, depression and bipolar disorder. Review of medical record revealed no plan of care for dementia care for Resident #4. Interview on 01/28/25 at 1:52 PM with Licensed Social Worker (LSW) #30 verified Resident #4 does not have a plan of care for dementia and the resident does have the diagnosis with moments of forgetfulness. 2. Review of the medical record for Resident #47, revealed an admission date of 07/23/20. Diagnoses included but were not limited to vascular dementia, adult failure to thrive, major depressive disorder, and unspecified psychosis not due to a substance or known physiological condition. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 12 out of 15. The resident was assessed to require total dependence on toilet hygiene, shower/bathe self, bed mobility and transfers. This resident was also assessed to have depression. Review of the plan of care revised on 02/28/23 revealed Resident #47 has an alteration in mood related to diagnosis of depression with no specific symptoms or behaviors noted. Review of the Patient Health Questionnaire (PHQ 9) dated 12/04/24, that is used to indicate a resident's severity of depression, revealed for Resident #47 to have answered yes to feeling tired or having little energy for a symptom presence. Interview on 01/28/25 at 2:46 P.M. with LSW #30 verified Resident #47 had indicated a symptom of depression of feeling tired or having little energy and it was not indicated on his care plan. 365564 Page 3 of 3