Health inspection·January 3, 2025

F 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to care (including direct care and activities) directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities was ongoing and completed annually. Review of the MAR revealed Resident #73 was administered Ativan 0.5 mg as needed on [DATE] at 11:53 A.M. The Ativan was somewhat effective. A progress note dated [DATE] at 2:42 P.M. revealed Resident #73 went into another resident's room but came back out into the hallway. The MAR did not reveal as needed ABH gel was administered. Physician orders revealed Resident #73 was ordered ABH gel 0.5 ml topically every six hours as needed from [DATE] until [DATE]. A progress note dated [DATE] at 10:54 A.M. revealed Resident #73 followed an activities staff member into another resident's room. The nurse was able to redirect Resident #73 out of the room. The MAR revealed Resident #73 was administered as needed ABH gel on [DATE] at 11:34 A.M. The as needed ABH gel was effective. A plan of care dated [DATE] revealed Resident #73 demonstrated behaviors such as yelling at staff, attempting to hit staff, slamming her door, and attempting to go out the doors. Interventions included intervening or providing redirection, providing calming activities and one on one as needed. A progress note dated [DATE] at 6:39 P.M. Resident #73 followed the nurse into another resident's room. Resident #73 was able to be redirected. A progress note dated [DATE] at 3:42 P.M. revealed Resident #73 went into another resident's room and shut the door. The nurse went in and found Resident #73 attempting to open the closet door in the other resident's room. Resident # 73 eventually walked out of the other resident's room. Resident #73 went into other resident rooms at 3:56 P.M. and 4:00 P.M. Staff were able to get Resident #73 to return to her own room. A progress note dated [DATE] at 4:50 P.M. revealed the nurse called Viaquest (company that specializes in the mental and behavioral health treatment for residents at nursing facilities) and left a message. Resident #73's daughter was notified Resident #73 was attacking staff, kicking doors, attempting to leave the unit, and entering other residents' rooms. At 5:02 P.M. Resident #73's daughter arrived at the facility. A progress note dated [DATE] at 5:11 P.M. revealed a Certified Nurse Practitioner (CNP) from Viaquest called and left a message with new orders for Haloperidol Lactate (to treat acute agitation) two milligrams (mg) twice a day for 14 days and Haloperidol Decanoate (long-acting form of Haloperidol) 50 mg for four weeks with a dose to be administered immediately. At 5:16 P.M. another CNP from Viaquest called and suggested a pink slip (emergency hospitalization for a mentally ill individual who may be a harm to themselves or others) would be faxed to the facility. Review of the MAR revealed as needed ABH gel was not applied on [DATE] until 5:26 P.M. and was somewhat effective. A progress note dated [DATE] at 5:40 P.M. revealed Resident #73's daughter reported Resident #73 was in a calmer state and was sitting in recliner. Resident #73's daughter stated she was returning to work and could be called if anything else was needed. Resident #73 received the Haloperidol one ml injection prior at 5:45 P.M. prior to Resident #73's daughter leaving. Review of the Ohio Department of Mental Health and Addiction Services Application for Emergency admission form (DMHAS-0025) dated [DATE] at 5:28 P.M. revealed the name of the psychiatric hospital was left blank. The form was marked Resident #73 represented a substantial risk of physical harm to others as manifested by evidence of recent homicidal or other violent behavior, evidence of recent threats that place another in reasonable fear of violet behavior and serious physical harm, or other evidence of present dangerousness. The form was also marked that Resident #73 represented a substantial and immediate risk of serious physical impairment or injury to self as manifested by evidence that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366076 If continuation sheet Page 2 of 4 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 01/03/2025 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the person is unable to provide for and is not providing for the person's basic physical needs because of the person's mental illness and that appropriate provision for those needs cannot be made immediately available in the community. Resident #73 would benefit from treatment in a hospital for mental illness and is in need of such treatment as manifested by evidence of behavior that creates a grave and imminent risk to substantial rights of others or self. The Statement of Belief on the form instructed that the belief for why hospitalization was necessary had to be documented. The Statement of Belief was signed by Viaquest CNP and revealed Resident #73 had recurrent aggression amongst staff. Resident #73 was physically aggressive and attacking staff (kicking, scratching, punching, etc.). Resident #73 was unable to be consoled or redirected by staff. It is the provider's recommendation that Resident #73 be sent out for further evaluation and treatment. The next progress note dated [DATE] at 1:00 P.M. revealed Licensed Practical Nurse (LPN) #100 and the Director of Nursing (DON) pulled Resident #73's daughter aside and advised the daughter of the plan to send Resident #73 to the emergency department for a psychological evaluation and admission to psychiatric hospital to get treatment. Resident #73 would need urine analysis and blood work to rule out anything acute before the psychiatric hospital would admit Resident #73. It was explained that Resident #73 was a danger to staff and other residents. The paperwork including a pink slip, orders, code status, and face sheet was given to Resident #73's daughter. On [DATE] at 1:30 P.M. Resident #73 left the facility with the daughter to go to the emergency department for psychiatric evaluation. A progress note dated [DATE] at 9:50 P.M. revealed Resident #73 returned to the facility due to not meeting the criteria for admission to a psychiatric hospital. A progress note dated [DATE] at 12:00 P.M. revealed a meeting was held with Resident #73's daughter. Concerns with Resident #73 aggressive behavior towards staff and aggression starting to progress towards other residents were discussed. Resident #73's daughter made it clear she did not want Resident #73 sent to psychiatric hospital and wished to collaborate with Viaquest and Hospice for medication management. Resident #73 had been resting in bed with eyes closed since returning from the emergency department. Resident #73's daughter stated she would take off work to help with the transition to new medications. The resident's daughter also stated her biggest desire was communication from staff when Resident #73 was combative or staff were able to apply medication. The floor nurse was instructed to communicate with Resident #73's daughter any time Resident #73 became combative or aggressive. On [DATE] at 3:11 P.M. new orders were received from Viaquest CNP to discontinue all Haloperidol orders, increase sertraline (antidepressant) cream to 50 mg topically daily, to start Risperdal (to treat behavioral disorders) 0.5 mg topically twice a day, discontinue ABH gel for agitation once Risperdal was started, and start Ativan (to treat anxiety) one mg intramuscular (IM) twice a day for 14 days. On [DATE] at 12:13 P.M. new orders were received from hospice to discontinue sertraline, the scheduled Ativan, and Risperdal cream. A new order was received for Ativan, one mg every hour as needed. On [DATE] at 1:15 P.M. Resident #73 was absent of vital signs. Interview on [DATE] at 9:45 A.M. with daughter of Resident #73 revealed Resident #73 was not always administered the as needed medication for behaviors. The resident's daughter stated she had told the facility to notify her when Resident #73 had behaviors that could not be controlled or if Resident #73 refused medication. Resident #73's daughter felt that she could have assisted with deescalating the behaviors and get Resident #73 to agree to the as needed medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366076 If continuation sheet Page 3 of 4 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 01/03/2025 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 0744 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on [DATE] at 12:13 P.M. the DON revealed Resident #73 had become more aggressive with staff, and other residents could be in danger. The DON verified Resident #73 was not transported to the hospital for evaluation until [DATE] around 1:30 P.M. which was 20 hours after the pink slip was obtained. The DON stated the pink slip was obtained after the DON had left for the day and was not addressed until the next day. The DON also verified there was no documentation of behaviors after Resident #73 was given ABH gel on [DATE] at 5:26 P.M. and Haloperidol lactate on [DATE] around 5:30 P.M. The DON did not supply any documentation of additional interventions, including the intervention of one-on-one that was listed in the care plan, being put in place to keep Resident #73 and other residents safe on [DATE] and [DATE] when Resident #73 was transported to the hospital. The DON verified he was unfamiliar with how a pink slip worked. The DON verified the facility did not have a policy for pink slips or emergency discharges. Interview on [DATE] at 2:38 P.M. LPN #100 revealed Resident #73's behaviors were becoming worse on [DATE], and Resident #73 was biting staff. LPN #100 verified Resident #73 never harmed other residents but did go into other resident rooms. LPN #100 verified as needed medication was not always administered when Resident #73 had behaviors because the medication had to be gel or IM medication. LPN #100 also stated that none of the as needed medication worked anyway. LPN #100 stated the transfer to the hospital was delayed because she was unsure if the facility had to find a psychiatric hospital prior to Resident #73 being sent to the local hospital. LPN #100 verified she was unfamiliar with how a pink slip worked. Interview on [DATE] at 2:44 P.M. LPN #101 revealed she was working day shift on [DATE] and [DATE]. LPN #101 verified she had obtained a pink slip for Resident #73 on [DATE] because Resident #73 was combative and attacking the staff. Resident #73 went into other resident rooms and would kick at other residents if they walked past her. (Review of the medical record revealed no documentation of Resident #73 being aggressive towards other residents). LPN #101 stated Resident #73 would not take as needed medication, so it was not administered. LPN #101 verified as needed medication was administered on [DATE] when Resident #73's daughter came to the facility. LPN #101 stated her shift ended at 6:00 P.M. on [DATE] and she did not know if Resident #73 continued to have behaviors that evening. LPN #101 also stated she could not recall if Resident #73 had behaviors the morning of [DATE] prior to being sent to the hospital for evaluation. LPN #101 stated there was a delay in sending Resident #73 to the hospital because the facility needed to find a psychiatric hospital that would take Resident #73. LPN #101 verified they were unfamiliar with how a pink slip worked. This deficiency represents non-compliance investigated under Complaint Number OH00160152. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 366076 If continuation sheet Page 4 of 4