Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Harbor Healthcare Of Ironton during CMS and state inspections, most recent first.
A resident with dementia, Alzheimer’s disease, and high fall risk had repeated unwitnessed and witnessed falls, including episodes where staff documented he likely slid out of bed or wheelchair and transferred unassisted. Although a sign instructed him to call before he fell and staff confirmed he could use the call light to summon help, observations found the call light tied out of reach and later on the floor beside the bed, not accessible to him.
Ordered meds and respiratory treatments were not available for two residents. One resident with diabetes, a fractured femur, and respiratory failure missed scheduled insulin and a pain med dose because the meds were out of stock or not accessible through the pharmacy process. Another resident with respiratory failure did not receive ordered Acetylcysteine and sodium chloride nebulizer treatments because they had been reordered but not yet delivered; staff and the DON confirmed the medications were unavailable at the scheduled times.
Medication Administration Errors Exceeded Allowed Rate: The facility had a 9% med error rate, with three errors in 32 opportunities. An RN documented Fluticasone and Lamotrigine as given to one resident even though they were not observed being administered, and gave Vitamin B-6 to another resident instead of ordered Cyanocobalamin (B12). The DON confirmed Vitamin B-6 is not the same as B12, and the facility policy required meds to be given per prescriber orders.
The facility failed to notify the state Ombudsman of resident discharges or transfers, affecting three residents with various medical conditions. Despite multiple hospital transfers, the Ombudsman was not informed, as confirmed by the Administrator.
The facility failed to develop comprehensive care plans for two residents with dementia and depression, leading to deficiencies in addressing their specific needs. One resident lacked a care plan for dementia despite having multiple diagnoses, while another resident's care plan did not specify symptoms of depression, such as feeling tired or having little energy, as confirmed by an LSW.
Call Light Not Within Reach for High-Fall-Risk Resident
Penalty
Summary
The facility failed to ensure a resident at high risk for falls received assistance devices that were within reach to prevent accidents. Resident #31 had diagnoses including dementia, Alzheimer’s disease, and hypertension, and a fall risk assessment identified him as high risk for falls. His care plan included keeping frequently used items in reach and a “call before you fall” sign in the room, and the MDS documented moderately impaired cognition and dependence on staff for transfers. Nursing notes showed multiple unwitnessed and witnessed falls in the resident’s room and near his bed or wheelchair, with staff documenting that he likely slid out of bed or out of his wheelchair and that he was observed transferring unassisted on more than one occasion. During observations, the resident was seen in his room with a sign on the wall instructing him to call before he fell, but his call light was tied to the side rail on the opposite side of the bed and was not within reach. On another observation, the call light was found on the floor beside the bed and still not within reach. Staff interviews confirmed the resident was able to use the call light to summon assistance and that he needed the call light in reach to do so, consistent with the posted instruction to call before he fell.
Failure to Provide Ordered Medications and Treatments
Penalty
Summary
Pharmaceutical services were not provided to assure the accurate acquiring and administering of all drugs for two residents. One resident with diabetes, status post fractured left femur, morbid obesity, and acute and chronic respiratory failure had orders for Degludec insulin 60 units daily and Oxycodone-Acetaminophen 10-325 mg every six hours. Nursing documentation showed the resident was out of Degludec insulin, and the medication was not administered at the scheduled time even though pharmacy delivery records showed it had been delivered the day before. The DON stated the insulin should have been available, and an LPN confirmed it was not available and not given because it was reportedly on back order. The same resident also missed a scheduled dose of Oxycodone-Acetaminophen when nursing documented the medication was out of stock and emergency access could not be obtained because the pharmacy was believed to be closed. The MAR showed the dose was not given at the scheduled time, and staff interviews confirmed there was no medication available until later that morning. A second resident with acute and chronic respiratory failure had orders for Acetylcysteine inhalation solution and Sodium Chloride nebulization treatments, but an RN observed that both treatments were not available to administer because they had been reordered and not yet delivered. The MAR documented both treatments as not available, and the DON stated the pharmacy reported difficulty obtaining the medications.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with an observed error rate of 9% based on three errors in 32 opportunities for error. The errors were identified during medication administration observations involving two residents out of four observed, and the facility census was 115. During observation of RN #288 administering medications to Resident #3, Fluticasone nasal spray 50 micrograms was documented as given on the MAR even though it was not administered, and Lamotrigine 400 milligrams scheduled for 7:00 A.M. was also documented as given even though it was not observed among the medications administered. RN #288 stated she had six pills in the cup for the resident, including B-complex, vitamin D, Pregabalin, Phenobarbital, diazepam, and Fycompa. During observation of RN #288 administering medications to Resident #92, Vitamin B-6 50 milligrams was given, but Cyanocobalamin (B12) 500 micrograms, which was ordered for 7:00 A.M., was not observed to be administered. The DON confirmed that Vitamin B-6 is not the same as Cyanocobalamin (B-12) and should not have been given. The facility policy stated medications are to be administered in accordance with prescriber orders.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the state Ombudsman of resident discharges or transfers as required, affecting three residents. Resident #99, who had diagnoses including infectious gastroenteritis, cerebral infarction, and a femur fracture, was transferred to a local hospital on two occasions. However, there was no evidence that the Ombudsman was notified of these transfers. Similarly, Resident #25, with conditions such as diabetes mellitus, hypertension, and congestive heart failure, was transferred to the hospital, but the Ombudsman was not informed. Interviews with the Administrator confirmed the lack of notification for these transfers. Additionally, Resident #76, who had multiple diagnoses including basal cell carcinoma, respiratory failure, and kidney failure, was transferred to the hospital three times. The facility did not notify the Ombudsman of these transfers either. The Administrator acknowledged that the Ombudsman was not notified in writing for any of these instances, indicating a systemic issue in the facility's process for notifying the Ombudsman of resident transfers or discharges.
Deficiencies in Dementia and Depression Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents with dementia and depression, leading to deficiencies in addressing their specific needs. Resident #4, diagnosed with type 2 diabetes mellitus with diabetic polyneuropathy, bipolar disorder, major depressive disorder, and unspecified dementia, was admitted on an unspecified date. Despite being assessed to require substantial assistance with daily activities and having non-Alzheimer's dementia, depression, and bipolar disorder, there was no care plan in place for dementia care. This was confirmed by Licensed Social Worker (LSW) #30, who acknowledged the absence of a dementia care plan for Resident #4. Similarly, Resident #47, diagnosed with vascular dementia, adult failure to thrive, major depressive disorder, and unspecified psychosis, was admitted on an unspecified date. The resident required total dependence for daily activities and was assessed to have depression. However, the care plan revised on February 28, 2023, did not specify symptoms or behaviors related to the resident's depression. A Patient Health Questionnaire (PHQ 9) indicated that Resident #47 experienced symptoms of feeling tired or having little energy, which were not reflected in the care plan. This oversight was verified by LSW #30, confirming the deficiency in addressing the resident's specific symptoms of depression.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ironton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sanctuary At Ohio Valley | 0.4 mi | ★★★★★ | 0 | 0 |
| Crystal Care Of Coal Grove | 0.9 mi | ★★★★★ | 0 | 0 |
| Woodland Oaks | 3.1 mi | ★★★★★ | 0 | 0 |
| Kings Daughters Medical Center | 3.1 mi | — | 0 | 0 |
| Oakmont Manor | 3.3 mi | ★★★★★ | 2 | 0 |
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