Health inspection·March 7, 2023

F 0607 Level of Harm - Minimal harm or potential for actual harm guilty of abusing, neglecting, or mistreating other persons by a court of law; or have had a finding entered into the State NAR concerning abuse, neglect, mistreatment of residents, or misappropriation of their property. This facility will conduct employment background screening checks, reference checks and criminal conviction investigation checks on individuals making application for employment with this facility. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366076 If continuation sheet Page 2 of 6 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 366076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Eastern Star Hlth Care Ctr The 1451 Gambier Road Mount Vernon, OH 43050 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 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. Residents Affected - Few Findings include: Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including a non-ST elevation myocardial infarction, coronary angioplasty, hemiplegia, and hemiparesis following cerebral infarction (stroke) affecting the left non-dominant side, type two diabetes, major depressive disorder, and bradycardia with pauses. Review of the Minimum Data Set Assessment (MDS) 3.0 assessment dated [DATE] revealed Resident #42 was cognitively intact. Functionally, she required extensive assistance of two staff for bed mobility, dressing, toilet use, and personal hygiene. The resident had a stage II pressure ulcer (partial-thickness skin loss with exposed dermis) which was facility acquired. Review of the plan of care dated 11/29/22 revealed Resident #42 had a stage II pressure ulcer to the right lateral heel. Interventions included: Moon boots (pressure reducing boots) to be worn while in bed if the resident allows; air mattresses; treatment per physician orders; encourage adequate nutrition and hydration; monitor percent of meals eaten; supplements per the physician's orders; closely monitor labs and nutrition assessments risks and weights as ordered; turn and reposition every two hours from side to side or as appropriate for condition; and pressure ulcer risk assessment at least quarterly. Interview with Resident #42 on 02/27/23 at 8:45 A.M. revealed she did have a wound on her heel. The resident at the time denied feeling any pain in the wound and stated she does not have pain when the dressing is changed. She also stated the dressing was not changed daily but she thinks it is done on Fridays. Interview with Licensed Practical Nurse (LPN) #211 on 02/27/23 at 9:30 A.M. revealed the resident does have a wound on her right heel which is a pressure ulcer. Review of the physician's order dated 02/21/23 revealed an order for the right heel to be cleansed with wound cleanser, apply Silvercel (antimicrobial alginate dressing with silver) to the wound bed and cover with Mepilex (absorbent foam dressing), change every three days, and as needed. Monitor every shift and measure weekly. Observation on 02/27/23 at 10:30 A.M. of the dressing change for Resident #42 revealed LPN #311 donned personal protective equipment per the facility protocol for wounds that were draining. Upon observation of this dressing change, LPN #311 appropriately washed her hands prior to removing the old dressing and put on clean gloves. She then proceeded to remove the right heel Kerlix gauze that was dated 02/24/23. She then removed the Mepilex and discarded the old dressing. She then proceeded to clean the wound with two-by-two gauze sponges and wound cleanser as ordered. Upon the cleaning of the wound, LPN # was observed at first wiping the outside of the wound and then she switched the sponge to a clean side and proceeded to clean the center of the wound. LPN #311 then obtained a second (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366076 If continuation sheet Page 3 of 6 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 366076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Eastern Star Hlth Care Ctr The 1451 Gambier Road Mount Vernon, OH 43050 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few gauze sponge with wound cleanser on it and wiped the wound in a downward motion down the center of the wound and then wiped the outside of the wound with the other side of the sponge. After she wiped the outside edges of the wound the second time, she proceeded to wipe down the center of the wound with the used sponge. The wound bed was healthy pink color with epithelial tissue noted. It measured approximately 0.3 centimeters (cm) length by 0.5 cm width with a scant amount of serous drainage. LPN #311 then proceeded to discard the used gauze sponges and remove her gloves. She then donned a clean pair of gloves and proceeded to finish dressing the wound with the Silvercel to the wound bed and then covered it with the Mepilex and covered the whole area with a dry sterile pad and then wrapped the heel dressing with Kerlix gauze. Interview with LPN #311 on 02/27/23 at 10:00 A.M. verified she cleansed the wound from the outside to the inside (dirty to clean) and she removed her dirty gloves during the dressing change but failed to wash her hands or use hand sanitizer prior to donning clean gloves. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366076 If continuation sheet Page 4 of 6 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 366076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Eastern Star Hlth Care Ctr The 1451 Gambier Road Mount Vernon, OH 43050 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 - Few Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Review of the medical record for Resident #59 revealed an admission date of 12/15/22 with diagnoses including Alzheimer's disease, diabetes mellitus, depression, and anxiety disorder. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #59 had severely impaired cognition and required supervision with set-up only for eating. Review of the physician's orders for February 2023 revealed on 02/14/23 nectar consistency liquids were ordered and pureed diet with sugar substitute was ordered on 02/28/23. Interview on 03/01/23 at 11:20 A.M. Server #289 stated she already made Resident #59's tray because nursing wanted it and stated Resident #59 was on a mech soft diet. Observation on 03/01/23 at 11:24 A.M. of Resident #59's tray coming out of Resident #59's room by State Tested Nursing Assistant (STNA) #342. Observation and interview with Server #289 and STNA #342 verified there were pieces of clam that were not pureed stuck to the side of the soup bowl. Server #289 stated that she did not puree Resident #59's soup. Interview on 03/01/23 at 11:27 A.M. with Dietary Manager #265 verified the pieces of clam stuck to the side of the bowl and stated Resident #59's diet was changed last night because she pockets her food in her mouth. Interview on 03/02/23 at 7:45 A.M. with Chief Executive Officer (CEO) #252 stated Resident #59 was on a pureed diet due to pocketing her food, so Resident #59 's food doesn't have to be pureed according to policy. CEO #252 verified the order was written pureed diet with sugar substitute with no mentioned that she pockets her food. Review of the undated facility policy titled, Puree Diet Standard revealed for residents with a pureed diet as a result of a dysphagia diagnosis the diet will consist of pureed, homogenous, and cohesive foods. Food should be pudding-like; no coarse textures, raw fruits or vegetables, nuts, etc., are allowed. Any foods that require bolus fom1a1ion, controlled manipulation, or mastication are excluded. For residents with a pureed diet as a result of pocketing and who are not at risk for choking due to dysphasia can have texture to the pureed item with no larger particles of food than that as defined by the mince and moist diet. Mouth care should be performed after meal has been consumed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366076 If continuation sheet Page 5 of 6 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 366076 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/07/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ohio Eastern Star Hlth Care Ctr The 1451 Gambier Road Mount Vernon, OH 43050 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 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. Findings include: A tour of the main kitchen on 02/27/23 from 8:00 A.M. through 8:30 A.M. with Dietary Manager #265 revealed the following: • The small tabletop mixer had dried food splatter on the back of it. • The reach-in refrigerator contained sliced ham, chili, and lunch meat that was not labeled or dated. • The reach-in freezer contained pie crusts and angel food cake that was taken out of the original package without a label or date. • The walk-in refrigerator contained chopped garlic in a plastic container not labeled or dated. Dieatary Manager #265 verified the above findings at the time of the observation. Observation of the [NAME] Unit Pantry with Server #352 on 02/28/23 at 7:38 A.M. revealed the microwave was dirty, and in the reach-in freezer contained frozen omelets stored in a gallon-sized Ziploc bag with no label or date. Server #352 verified the findings at the time of the observation. Observation of the [NAME] Unit Pantry with Server #421 on 02/28/23 at 7:47 A.M. revealed that microwave was dirty. Server #421 verified the findings at the time of the observation. Review of the undated kitchen daily cleaning list revealed that equipment should be cleaned at least daily. Review of the undated facility policy titled, Food Safety and Sanitation revealed the facility takes all precautions necessary in order to ensure healthy and safe dining standards. The daily cleaning task list was created and maintained by the culinary director. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366076 If continuation sheet Page 6 of 6