Ohio Eastern Star Hlth Care Ctr the

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to store food in a sanitary manner and failed to maintain sanitary conditions while serving food. This deficient practice had the potential to affect all residents residing in the facility, who received meals from the kitchen. The facility census was 70. Findings Include:1. An observation on 02/10/26 at 7:57 A.M. revealed in the reach-in freezer there was 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. An interview on 02/10/26 at 7:45 A.M. [...]

Inspectors wroteBased on observation, interview, review of menus, and facility policy review, the facility failed to prepare and serve appropriate portions of food during meal service. This deficient practice had the potential to affect all 14 residents residing in the Lily neighborhood. The facility census was 70. Findings Include:Review of the portion size chart kept at each neighborhood serving station revealed the following requirements for portion sizes: 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 veggies; and 5 1/3 oz regular, mech soft, pureed casseroles. Review of the weekly menu revealed there were no portion sizes noted for each food item. An observation on 02/11/26 from 11:30 A.M. [...]

Inspectors wroteBased on interview, medical record review, and policy review, the facility failed to notify the physician when Resident #15 missed doses of medication and failed to notify the family/power of attorney (POA) and physician of Resident #74's transfer to the hospital. This affected two residents (#15 and #74) of 20 records reviewed. The facility census was 70.

Inspectors wroteBased on observation, interview, and medical record review, the facility failed to maintain Resident #56's privacy when a video monitor, monitoring his room, was kept in the common area. This affected one resident (#56) of one resident reviewed for privacy. The facility census was 70.

Inspectors wroteBased on interview and record review, the facility failed to ensure fall prevention strategies were in place for Resident #15 prior to a fall. This affected one resident (#15) of three residents reviewed for falls. The facility census was 70.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to properly store medications for Resident #9. This affected one resident (#9) out of two residents reviewed for pain management and had the potential to affect two of fifteen residents the facility noted as independently ambulatory. The facility census was 70.

Inspectors wroteBased on record review, observation, interview, and facility policy review, the facility failed to maintain infection control during wound care for Resident #50, failed to implement Enhanced Barrier Precautions (EBP) for two residents. These deficient practices affected one resident (Resident #50) out of four residents reviewed for pressure ulcers and affected two residents (Residents #56 and #78) out of five residents reviewed for transmission based precautions. The facility census was 70. Findings Include: 1. Review of Resident #50's medical record revealed an admission date of 07/15/25 with diagnoses including but not limited stage four (IV) sacral pressure ulcer with osteomyelitis, type two diabetes mellitus, high blood pressure, and chronic pain. [...]

Inspectors wroteBased on interview, record review, review of facility policy, and review of McGeer's criteria, revealed the facility failed to follow antibiotic stewardship for two residents (#10 and #15) of seven residents reviewed for infection control. The facility census was 70.

Inspectors wroteBased on closed medical record review, review of medication prescribing information, facility policy and procedure review and interview, the facility failed to prevent a significant medication error from occurring involving Resident #75 related to the administration of prescribed narcotic pain medication. Actual Harm occurred on 01/13/25 at 12:25 A.M. when Registered Nurse (RN) #201 administered Morphine Concentrate Solution, with a concentration strength of 100 milligrams (mg) per five milliliters (ml) (100 mg/5 ml), five milliliters (100 mg) to Resident #75, who had an order to receive 15 mg every eight hours. Following the identification of the significant medication error, the on-call physician was notified and Narcan (reversal agent) nasal spray was administered. [...]

Inspectors wroteBased on interviews, record review, and review of the facility assessment, the facility failed to appropriately revise and implement individualized treatment and services to ensure residents, who displayed behaviors and/or were diagnosed with dementia received the appropriate treatment and services to attain or maintain their highest practicable physical, mental and psychosocial well-being. The facility failed to appropriately address Resident #73's dementia-related behaviors. This affected one (Resident #73) of three residents reviewed for dementia. The facility census was 71.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #67 who was elopement risk did not leave the facility unsupervised. This affected one resident (#67) of three residents reviewed for elopement. The facility census was 71.

Inspectors wroteBased on observation, staff interview, review of an owner's manual, and review of the facility policy, the facility failed to maintain the kitchen in a clean condition and failed to maintain kitchen equipment in proper working condition to prevent contamination and/or food borne illness. The had the potential to affect all residents in the facility. The facility census was 68.

Inspectors wroteBased on record review and staff interview the facility failed to ensure nonpharmacological interventions were attempted and/or behaviors were documented prior to the administration of as needed psychotropic medications. This affected one (Resident #37) of five residents reviewed for unnecessary medications. The facility census was 68.

Inspectors wroteBased on interview, record review, and review of the facility abuse policy the facility failed to ensure all employees were checked against the Nurse Aide Registry (NAR) for findings concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of resident property. This affected four employees (Controller #217, Activities Assistant #234, Human Resources Director (HR) #235, and Dietary Aide (DA) #338) out of ten employees reviewed for proper screening procedures. This had the potential to affect all 59 residents residing at the facility.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect all 59 residents that received meals from the facility. No residents were identified as receiving nothing by mouth.

Inspectors wroteBased on review of the medical record, observation, and interview the facility failed to appropriately clean the wound according to standards of care, and failed to maintain appropriate hand hygiene during the dressing change for Resident #42. This affected one resident (#42) out of two residents observed for wound care. The facility census was 59.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This affected one resident (#59) out of one resident who was prescribed pureed diets of 59 residents who consumed meals from the facility's kitchen. No residents were identified to receive nothing by mouth.