Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ohio Eastern Star Hlth Care Ctr The during CMS and state inspections, most recent first.
Food was stored unsanitarily and kitchen sanitation was not maintained when a housekeeper entered a satellite kitchen without a hairnet and stood near prepared food. In the freezer, opened boxes of frozen egg patties, biscuits, and beef patties were left exposed in opened plastic bags, and a dietary cook confirmed the items should have been closed after opening. Facility policy required frozen food to be stored to protect food integrity and staff to wear hair restraints to prevent hair from contacting exposed food.
Improper Portion Control During Meal Service: During lunch service, a Dietary Server used incorrect utensils and estimated portions for multiple menu items, including fruit, soup, meat, and a tuna salad croissant. The weekly menu did not list portion sizes, and the DD stated serving utensils should match the required 4 oz portions for fruits, vegetables, regular meats, and desserts. The server confirmed the incorrect utensils were used and said he/she did not measure portions.
The facility failed to notify the MD when a resident missed scheduled Brilinta doses because the med was unavailable, and failed to notify the family/POA and MD when another resident was transferred to the hospital. One resident had severe cognitive impairment and missed doses were documented on the MAR, while the other resident had intact cognition, developed increased confusion, abnormal VS, and was sent out by EMS after respiratory decline. Documentation showed no evidence of the required notifications.
A resident with severe cognitive impairment, repeated falls, and multiple medical diagnoses had a video monitoring device ordered for fall prevention, but the monitor was kept on a ledge in the common area where it could be seen by anyone present. Surveyors observed the resident on the screen while he was in his room and later in bed, and a CNA confirmed the monitor was visible to residents in the common area.
Failure to Maintain Supervision During Toileting: A resident with dementia, severely impaired cognition, and need for assistance with toileting and toilet transfers fell after being left alone during toileting. Staff assisted the resident onto the commode with the walker and call light in reach, then left to help another resident, and the resident later fell in the bathroom after transferring off the commode without using the call light.
Improper Storage and Administration of Tramadol: A resident with dementia, chronic pain, osteoarthritis, and CKD had an order for Tramadol 50 mg QID. Surveyors observed a white pill in a med cup sitting on the med cart keyboard with no nurse on the unit, and an LPN confirmed it was the resident’s Tramadol that an RN was supposed to give before leaving. The narcotic sheet showed the dose was removed from the locked cabinet, and the MAR later reflected the dose was not administered at the scheduled time.
Infection control was not maintained during wound care when the DON used uncleaned scissors from her scrub pocket to cut Silvercel for a resident’s stage IV sacral ulcer before packing the wound. EBP was also not implemented for two residents: one with a PEG tube and enteral feeding orders had no EBP sign, PPE, order, or care plan in place, and another resident with MASD to the coccyx was not placed on EBP even though the facility’s posted sign listed wound care and feeding tube care as high-contact activities requiring gown and gloves.
Antibiotic stewardship was not followed for two residents with skin/soft tissue concerns. One resident with severe cognitive impairment received Cephalexin for a right inner thigh lump/cellulitis despite an incomplete infection tracker and no evidence the case met McGeer's criteria or that the MD was notified. Another resident with intact cognition received Clindamycin for MASD on the buttock and suspected cellulitis of a finger, but the documented signs and infection tracker entries did not meet McGeer's criteria, and there was no evidence the MD was notified.
A significant medication error occurred when an RN administered 100 mg of Morphine instead of the prescribed 15 mg to a resident, leading to adverse effects. The error was due to a failure to verify the medication order against the bottle's concentration and improper dosing methods. The facility did not conduct an immediate investigation into the incident.
A resident with dementia exhibited aggressive behaviors that were not adequately managed by the facility. Despite having orders for medications to address agitation, these were not consistently administered. The facility's staff were unfamiliar with emergency procedures, leading to delays in psychiatric evaluation. The resident's family was not consistently informed about the behaviors or medication refusals, contributing to the deficiency in care.
A resident with severe cognitive impairment and a history of wandering eloped from the facility unsupervised. The resident exited through a door that triggered an alarm, but the alarm was deactivated by a housekeeper who failed to notify nursing staff. The resident was found outside by a contractor and returned to the facility. The alarm was not loud enough to alert staff, contributing to the incident.
The facility failed to maintain kitchen cleanliness and ensure dishwashers reached the required sanitizing temperature, potentially affecting all residents. Observations revealed food debris, frozen corned beef juice, and improper dishwasher temperatures.
The facility failed to document nonpharmacological interventions or the reasons for administering as-needed psychotropic medications for a resident with dementia and other conditions. The resident received ABH gel and Ativan tablets multiple times without proper documentation, as confirmed by the DON.
Food Storage and Hair Restraint Lapses in Kitchen Areas
Penalty
Summary
The facility failed to store food in a sanitary manner and failed to maintain sanitary conditions while serving food. During an observation in the reach-in freezer, an opened cardboard box of exposed frozen egg patties in an opened plastic bag, an opened cardboard box of exposed frozen pre-made biscuits in an opened plastic bag, and an opened cardboard box of exposed beef patties in an opened plastic bag were found. A dietary cook confirmed the items were stored this way and stated the plastic bags should be closed and the boxes should be closed after opening so the food items would not be exposed. On the [NAME] unit, a housekeeper entered the satellite kitchen with a long ponytail and no hairnet and stood near prepared food. A sign near the kitchen door noted that a hairnet should be worn when entering the kitchen. The housekeeper confirmed she forgot to put on a hairnet before going into the kitchen. The facility policy stated frozen food must be packaged and stored to protect and preserve food integrity and quality, and all employees must wear hair restraints to prevent hair from contacting exposed food.
Improper Portion Control During Meal Service
Penalty
Summary
The facility failed to prepare and serve appropriate portions of food during lunch service for residents in the Lily neighborhood. Review of the portion size chart at the neighborhood serving station showed required portion sizes of 4 oz for fruits, vegetables, regular meats, desserts, and pureed meats with bread worked in; 3 oz for pureed sides, desserts, meats, ground meats, and pureed fruits and vegetables; and 5 1/3 oz for regular, mech soft, and pureed casseroles. However, the weekly menu did not list portion sizes for each food item. During observation of lunch meal service, Dietary Server #202 served mandarin oranges using a black plastic tablespoon and placed one to two scoops into each dessert bowl. The server also used a 2 oz ladle for cabbage soup, a 1 oz ladle for chipped beef, a 4 oz scoop for cooked carrots and green beans, and a black plastic tablespoon for the tuna salad croissant. The chipped beef was served as approximately three scoops onto four pieces of toast, the cabbage soup was served as approximately two scoops into a bowl, and the tuna salad croissant was prepared with approximately three spoonfuls of tuna salad. The Dietary Director stated the serving utensils for each food item should include 4 oz portions for fruit or vegetables, regular meats, and desserts, and the Dietary Server confirmed the incorrect serving utensils were used and stated, "I don't measure the portions; I just know what each person eats."
Failure to Notify Physician and Family of Missed Medication and Hospital Transfer
Penalty
Summary
The facility failed to notify the physician when Resident #15 missed scheduled doses of Brilinta 90 mg twice daily because the medication was unavailable. Resident #15 was admitted with diagnoses including acute respiratory failure with hypoxia, type 2 diabetes mellitus, major depressive disorder, unspecified dementia, insomnia, and cognitive communication deficit, and the MDS described severely impaired cognition. The MAR showed Brilinta was not given on 02/09/26 for either scheduled dose due to unavailability, and the 02/10/26 dose was administered late at 3:37 P.M. after the pharmacy sent the medication. The progress notes contained no evidence that the physician was notified of the missed doses, and RN #109 confirmed there was no documentation that the physician had been notified. The facility also failed to notify Resident #74's family/POA and physician when the resident was transferred to the hospital. Resident #74 had diagnoses including gastrointestinal hemorrhage, heart failure, and type 2 diabetes, was Full Code, and had intact cognition with a BIMS score of 14 out of 15. On 11/23/25, the resident was noted to have increased confusion and left-sided lung pain, and an X-ray showed hypoaeration of the lungs and right atelectasis; the CNP was notified and ordered an antibiotic, and the POA was notified and did not want the resident sent to the hospital. Later that night, the resident was found calling out for assistance, assessed with respirations of 38, heart rate of 138, blood pressure of 88/73, and temperature of 97.6 F, and EMS was called for transfer to the hospital. The progress notes showed no evidence that the family/POA or physician were notified of the hospitalization, and LPN UM #15 confirmed there were no documented notifications.
Resident Video Monitor Left Visible in Common Area
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when Resident #56's video monitoring device was kept in a common area where it could be seen by others. Resident #56 was admitted with diagnoses including fracture of the right pubis, unspecified dementia, severe protein-calorie malnutrition, depression, anxiety disorder, chronic kidney disease, and repeated falls. His MDS assessment showed severely impaired cognition, and a physician order dated 01/04/26 directed that a video monitoring device be in place for fall prevention. On 02/10/26, observation of the unit showed a monitor sitting on the ledge of a window in the common area, with Resident #56 visible on the screen while he sat in his room. The monitor remained in the same location during later observation, and residents were present in the common area. CNA #22 confirmed the monitor was a 'baby monitor' for Resident #56 due to falls and verified that anyone in the common area could see it. On 02/11/26, the monitor was still in the same location, and Resident #56 could again be observed on the monitor while he was in bed.
Failure to Maintain Supervision During Toileting
Penalty
Summary
The facility failed to ensure fall prevention strategies were in place for a resident prior to a fall. The resident had diagnoses including acute respiratory failure with hypoxia, type 2 diabetes mellitus, major depressive disorder, unspecified dementia, and cognitive communication deficit. The resident’s MDS showed severely impaired cognition and need for partial to moderate assistance with toileting hygiene and supervision or touching assistance with toilet transfers. The care plan identified the resident as at risk for falls, accidents, and injury and included interventions such as keeping the bed at a safe height, keeping the walker within reach, offering toileting in the early morning, assisting as needed, and keeping the bathroom door closed while the resident was in the room. The resident was later heard calling out for help and was found lying on the bathroom floor with blood to the posterior head after falling while transferring off the commode. The resident stated she fell backward, lost balance, and injured her head. The call light had not been used before the fall, and staff reported that the resident and her neighbor were both trying to use the restroom unassisted after visiting each other. Staff assisted the resident onto the commode with her walker and call light in reach, then left to assist the neighbor, and the resident fell while unsupervised. The fall report stated the resident had been at the sink unsupervised after transferring herself off the commode and not using the call light.
Improper Storage and Administration of Tramadol
Penalty
Summary
Medication storage and administration were not handled properly for a resident with dementia, chronic back pain, osteoarthritis, and diabetes with chronic kidney disease. The resident had an order for Tramadol 50 mg four times daily, and the care plan directed staff to administer medications per physician orders and monitor for pain and side effects. On observation, a white pill in a medication cup was found sitting on the medication cart laptop keyboard, and no nurse was present on the unit at that time. An LPN confirmed the pill was the resident’s Tramadol and stated the RN was supposed to administer it before leaving. The narcotic sheet showed Tramadol 50 mg was removed from the locked cabinet at 4:34 P.M., and the MAR documented that the afternoon dose was not administered at 4:35 P.M. with a note that it was administered at 6:30 P.M. by another nurse. The facility policy required staff to remain with the resident while medication is swallowed and to return to the medication cart and document administration immediately after giving the medication.
Infection Control and EBP Not Implemented During Wound and Device Care
Penalty
Summary
Infection control was not maintained during wound care for a resident with a stage IV sacral pressure ulcer and osteomyelitis. The resident was admitted with diagnoses including type 2 diabetes mellitus, high blood pressure, and chronic pain, and the quarterly MDS showed cognitive impairment with a BIMS score of 10 out of 15 and a need for staff assistance with self-care and mobility. The physician ordered daily dressing changes with Silvercel rope packed into the wound and covered with a sacral foam dressing. During an observation of the dressing change, the DON removed the Silvercel from its package and used scissors taken from her scrub pocket to cut the amount needed, without cleaning or sanitizing the scissors before cutting the clean dressing material. The DON then packed the wound and covered it with a sacral foam dressing, and later confirmed the scissors were not cleaned before use. Enhanced Barrier Precautions were not implemented for two residents who met criteria related to device care and wound care. One resident had a PEG tube, dysphagia, adult failure to thrive, and depression; the admission MDS showed that 51% or more of nourishment came from enteral feeding, and physician orders included PEG tube checks and daily cleansing of the site. There was no evidence of EBP orders, care plan interventions, or PPE requirements, and an observation showed no EBP notification sign or PPE outside the room. Another resident had severe cognitive impairment, MASD, and an order to apply zinc cream and an abdominal pad to open MASD on the coccyx every shift. Observations showed EBP was not in place, and an RN confirmed it was not implemented because the wound was not a pressure wound. The MDS nurse stated the facility did not have an EBP policy, while the facility’s posted EBP sign indicated gloves and gowns were required for high-contact care activities including feeding tube care and wound care.
Antibiotic Stewardship Not Followed for Two Residents
Penalty
Summary
The facility failed to follow its antibiotic stewardship process for two residents reviewed for infection control. Resident #15, who had diagnoses including acute respiratory failure with hypoxia, type 2 diabetes mellitus, major depressive disorder, unspecified dementia, and cognitive communication deficit, was assessed with severely impaired cognition. A progress note documented a hard, raised area on the right inner thigh with pain only when touched, and a CNP ordered Cephalexin for cellulitis. The infection tracker for this episode was largely incomplete, with most fields left unanswered, including the infection type, whether the surveillance definition was met, whether it was reportable, history, symptoms, onset date, and diagnostic testing. The evaluation notes stated the resident still had a lump after the antibiotic was completed and that Doppler and ultrasound testing were negative for DVT. The MDS nurse confirmed the resident did not meet McGeer's criteria for antibiotics and that there was no evidence the physician was notified. Resident #10, who had diagnoses including type 2 diabetes mellitus, major depressive disorder, hemiplegia and hemiparesis affecting the left non-dominant side, and osteoarthritis, had intact cognition on the quarterly MDS. A progress note documented an open area from MASD on the right buttock and redness with slight swelling around the right index finger cuticle; hospice was notified and gave orders for Clindamycin. The infection tracker identified a soft tissue infection of the right buttock and suspected cellulitis of the right index finger, but only redness, excoriation, and slight swelling were documented, with no other symptoms or diagnostics recorded. The physician order was for Clindamycin, and the MDS nurse confirmed the resident did not meet McGeer's criteria for antibiotics and that there was no evidence the physician was notified. The facility policy stated it was to implement an antibiotic stewardship program to promote appropriate antibiotic use and reduce adverse events associated with antibiotics.
Significant Medication Error with Morphine Administration
Penalty
Summary
The facility failed to prevent a significant medication error involving a resident who was administered an incorrect dose of Morphine. The error occurred when a registered nurse (RN) administered 100 mg of Morphine Concentrate Solution instead of the prescribed 15 mg. This mistake was due to the RN not verifying the medication order against the bottle's concentration and only reading part of the order. The resident, who had a history of a displaced fracture, COPD, and high blood pressure, experienced adverse effects such as tingling, spastic movements, chills, clammy skin, and diarrhea as a result of the overdose. The error was compounded by a series of miscommunications and procedural lapses. Initially, the facility had to obtain a temporary order for Morphine Solution due to the unavailability of the prescribed Morphine Immediate Release tablets. The pharmacy authorized the removal of Morphine Sulfate solution from the starter kit, but the narcotic count sheet did not reflect the correct order. The RN administered the Morphine using a cup instead of the calibrated syringe provided, which contributed to the dosing error. The error was only realized when the RN noticed discrepancies in the narcotic count sheet after administration. The facility did not conduct an immediate investigation into the medication error, and there was no written evidence of education provided to the staff involved. The Chief Executive Officer confirmed that an investigation was underway, but at the time of the report, no comprehensive investigation had been completed. The facility's policy on medication administration emphasized the importance of the six Rights of medication administration, which were not adhered to in this instance.
Failure to Manage Dementia-Related Behaviors
Penalty
Summary
The facility failed to appropriately revise and implement individualized treatment and services for a resident diagnosed with dementia, leading to a deficiency in care. Resident #73, who had vascular dementia, anxiety disorder, depression, and dysphagia, displayed verbal and physical behaviors that were not adequately managed. Despite having physician orders for medications like Ativan and ABH gel to manage agitation, these were not consistently administered as needed. The facility's records showed instances where Resident #73 was not given the prescribed medications during episodes of agitation, which contributed to increased distress among other residents. The facility's assessment indicated that they accepted residents with mental and behavioral health needs, including those with dementia. However, the care plan for Resident #73, which included interventions like redirection and calming activities, was not effectively implemented. The facility's staff, including the DON and LPNs, were unfamiliar with the procedures for emergency hospitalization (pink slip) and delayed necessary actions to address Resident #73's escalating behaviors. This lack of timely intervention and understanding of emergency procedures resulted in a delay in sending Resident #73 for a psychiatric evaluation. Interviews with staff and Resident #73's daughter revealed that the facility did not consistently communicate with the family about the resident's behaviors or medication refusals. The daughter expressed that she could have assisted in de-escalating situations if informed. The facility's failure to administer as-needed medications and the delay in seeking appropriate psychiatric evaluation contributed to the deficiency in providing adequate care for Resident #73, ultimately affecting the resident's well-being and safety.
Resident Elopement Due to Inadequate Alarm Response
Penalty
Summary
The facility failed to prevent a resident, identified as Resident #67, who was at risk for elopement, from leaving the facility unsupervised. Resident #67 had a history of severe cognitive impairment and wandering, as noted in her medical records and care plan. On the day of the incident, she was found outside the facility by a construction worker, having left through a door that led directly outside. The door alarm was activated, but the staff did not respond appropriately, as the alarm was not heard by the nursing staff. The incident occurred when Resident #67 was able to open a door that led outside, triggering an alarm. However, the alarm was deactivated by a housekeeper who did not notify the nursing staff, and the resident was not immediately missed. The resident was later found by a contractor and returned to the facility by the Maintenance Director and HR Assistant. The nursing staff was unaware of the resident's absence until she was brought back, indicating a lapse in supervision and monitoring. Interviews with staff revealed that the alarm system was not loud enough to be heard throughout the neighborhood, contributing to the failure to prevent the resident's elopement. The housekeeper who deactivated the alarm did not follow protocol by alerting the nursing staff, which delayed the response to the resident's absence. The facility's internal communication system was used to inform staff of the incident, but there was no immediate action taken to ensure all staff were aware of the situation and the necessary protocols to prevent future occurrences.
Failure to Maintain Kitchen Cleanliness and Dishwasher Temperature
Penalty
Summary
The facility failed to maintain the kitchen in a clean condition and to ensure kitchen equipment was in proper working order, which could potentially lead to contamination and foodborne illness. During an observation, it was noted that the bottom of two hot holding units were covered in food debris, and the walk-in freezer had a large, thick frozen puddle of a dark brown and red substance identified as corned beef juice. Additionally, plastic containers on the clean drying rack had sticky residue and sticker paper on them. The facility's policy required detailed cleaning of warming boxes, coolers, and freezers monthly, which was not adhered to in this instance. The facility also failed to maintain the proper rinse water temperature in their high-temperature sanitizing dishwashers. Multiple observations and tests conducted by the Dietary Manager (DM) revealed that the dishwashers in various neighborhoods did not reach the required 180 degrees Fahrenheit for sanitization. The highest temperature recorded was 170 degrees Fahrenheit, with several readings significantly lower, ranging from 147 to 170 degrees Fahrenheit. The facility's policy and the dishwasher's owner's manual both stipulated that the rinse temperature must be at least 180 degrees Fahrenheit. Interviews with the Dietary Manager confirmed that the normal practice was to test dishwasher temperatures with heat strips and thermometers, but these tests consistently showed that the dishwashers were not reaching the necessary temperature for proper sanitization. This failure to maintain the required temperature for dishwashing could potentially affect all residents in the facility, as it compromises the cleanliness and safety of the dishes used for food service.
Failure to Document Nonpharmacological Interventions Before Administering Psychotropic Medications
Penalty
Summary
The facility failed to ensure nonpharmacological interventions were attempted and/or behaviors were documented prior to the administration of as-needed psychotropic medications for Resident #37. The resident, who had diagnoses including unspecified dementia, muscle weakness, depression, unspecified mood disorder, anxiety disorder, and cognitive communication deficit, was administered ABH gel and Ativan tablets multiple times in March and April 2024 without documentation of nonpharmacological interventions or the reasons for the medication's necessity. The care plan for Resident #37 included interventions such as consulting with the physician about medication reductions, documenting mood and behavior, and monitoring for side effects, but these were not followed as required. The medical record review revealed that the MAR and progress notes for Resident #37 lacked documentation of behaviors or nonpharmacological interventions on several dates when ABH gel and Ativan tablets were administered. The Director of Nursing confirmed the absence of such documentation during an interview. This deficiency affected the quality of care provided to Resident #37, as the facility did not adhere to the required protocols for administering psychotropic medications on an as-needed basis.
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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 Mount Vernon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Country Club Retirement Center | 0.7 mi | ★★★★★ | 2 | 0 |
| Als Mount Vernon Inc | 1 mi | ★★★★★ | 15 | 0 |
| Country Court | 1 mi | ★★★★★ | 9 | 1 |
| Whispering Hills Rehabilitation And Nursing Center | 2 mi | ★★★★★ | 13 | 0 |
| Laurels Of Mt Vernon The | 2.1 mi | ★★★★★ | 1 | 0 |
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