Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 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.
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.
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 | — | 8 | 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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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.