Stellar Care Center

Review of Resident #27 discharge summary revealed an incomplete discharge instructions with no evidence of education regarding diet or activities provided to Resident #27 or their representative.

Record review revealed no documentation of a discharge note being completed for Resident #27 for discharge on [DATE].Interview on 09/22/25 at 11:22 A.M. with Director of Nursing confirmed there is incomplete documentation of Resident #27 discharge from 07/24/25.This is an incidental finding discovered during the complaint investigation.

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Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

Review of an assessment titled Care Conference Summary dated 09/16/25 revealed attendees included Resident #8, dietary staff, social services, activities, and therapy.

The plan of care was reviewed with Resident #8.

Review of Resident #8 ' s care plan revealed the dietary care plan was initiated on 09/15/25, but the rest of the care plan was not completed until 09/23/25.

Interview on 09/23/25 at 3:05 P.M. with Administrator confirmed baseline care plans should be completed with 48 hours of admission to the facility.

Administrator confirmed Resident #8 admitted to the facility on [DATE] and her care plan was not completed until 09/23/25 and the care conference was completed on 09/16/25 with no evidence of a baseline care plan within 48 hours.

Record review revealed Resident #27 admitted to the facility on [DATE] with diagnoses including cerebral infarction, type two diabetes mellitus, cognitive communication deficit, chronic kidney disease, hypertension, hyperlipidemia, heart failure, gastro-esophageal reflux disease, hyperkalemia, and insomnia.

Review of Resident #27 care conference revealed the resident was admitted on [DATE] and care conference was completed on 09/16/25.

Review of care conference summary revealed no signatures of family, resident, or resident representative being involved in the conference.

Review of Resident #27 care plan revealed one care plan for a potential for nutrition/ hydration risk related to acute/ chronic disease, diuretic drug use, and therapeutic diet initiated on 09/15/25. No other care plans are observed or documented.

Interview on 09/16/25 at 1:40 P.M. with Director of Nursing (DON) confirmed Resident #27 care plan was not completed fully or timely.

Review of facility policy reviewed 04/28/25 titled Care Planning Revealed the care plan is based on the residents comprehensive assessment and is developed by a care planning/ interdisciplinary team.

This deficiency is an incidental finding discovered during the complaint investigation.

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Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

residents based on their preferences and shower schedules.

This affected two (#24 and #28) of five

Record review revealed Resident #24 admitted to the facility on [DATE] with diagnoses including Alzheimer ' s disease, chronic obstructive pulmonary disease, and hypertension.Review of a minimum data set (MDS) dated [DATE] revealed Resident #24 had no behaviors and was dependent on staff for bathing.Review of a care plan initiated on 09/05/25 revealed Resident #24 was at risk or had an ADL self-performance deficit related to cognition deficit, impaired vision, and weakness.

Interventions included but were not limited to use a mechanical lift and assist of two staff, dependent on staff for toileting, and dependent on staff for bathing.Review of a shower schedule revealed Resident #24 receives showers on Wednesdays and Saturdays.Review of shower sheets revealed Resident #24 did not receive a shower on 07/05/25, 07/09/25, 07/12/25, 08/06/25, and 09/10/25.2.

Record review revealed Resident #28 admitted to the facility on [DATE] with diagnoses including dementia, abnormalities of gait and mobility, and a new diagnosis on 05/05/25 of displaced avulsion fracture of left talus.Review of a care plan dated 12/31/23 revealed Resident #28 had an ADL self-care performance deficit related to disorder of bone density and structure, anxiety, history of left hip pain, dermatitis, history of falling, abnormalities of gait and mobility, mild protein calorie malnutrition, hyperosmolality and hyponatremia, hypokalemia, alcohol dependence, nicotine dependence and urinary tract infection.

Interventions included but were not limited to dependence to supervision/touching assist of one staff for bathing.Review of an MDS dated [DATE] revealed Resident #28 had no behaviors and was dependent on staff for bathing.Review of a shower schedule revealed Resident #28 received showers on Wednesdays and Saturdays.Review of shower sheets revealed Resident #28 did not receive a shower on 07/05/25, 07/09/25, 07/12/25, 08/23/25, 08/30/25, and 09/10/25.Interview on 09/16/25 at 10:08 A.M. with Anonymous Staff (AS) #178 revealed she was concerned about Resident #28 since she moved from the memory care unit to the first floor because she can have behaviors or be a little feisty so they won ' t change her or shower her some days.Interview on 09/22/25 at 10:18 A.M. with Director of Nursing (DON) confirmed Resident #24 and #28 each had missed multiple showers and there was no additional documentation to show they received showers.Review of a policy titled, Bathing Policy dated 04/28/25 revealed residents have the option to take a bath/shower/bed bath as often as they would like and choose what time of bath they want.This deficiency demonstrates non-compliance investigated under Complaint Number 1398689 and 1398688.

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Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

Review of a job description for Activity Director dated 05/24/22 revealed the AD supervises an activity program appropriate to meet the physical, social, cultural, spiritual, emotional, and recreational needs and interests of each residents; provides the opportunity for residents to engage in normal pursuits; as well as promoting a successful and well-balanced leisure lifestyle.

The AD plans quality of like of each resident as well as maintaining an open working relationship with the resident ' s family.

The AD should plan, develop, organize, implement, evaluate and direct the activity program; assess individual and group needs and develops related meaningful morning, afternoon, evening and special programs; prepares and posts a monthly schedule of activities, and coordinates, directs and conducts all planned activities.

This deficiency demonstrates non-compliance investigated under Complaint Number 1398688

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Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

receive it on nightshift.

notified of Prostat being unavailable or alternate options being available.

Interview on 09/15/25 at 1:27 P.M. with CNA #79 revealed she orders supplies for the facility. CNA #79 stated she places orders every Thursday and about three weeks prior, she had placed a large order which included Prostat which should have come in the following Wednesday or Thursday. CNA #79 stated part of the order came to the facility, but Prostat did not so she reached out to the person for procurement and notified them it did not come. CNA #79 stated she specifically ensured Prostat was on the order but did state sometimes orders will get declined. CNA #79 stated she waited for the order to come after contacting procurement, but it did not so she placed a new order and the Prostat arrived a day later. CNA #79 stated they did not receive the Prostat for over a week.

Interview on 09/16/25 at 11:05 A.M. confirmed Resident #24 did not have Prostat from 08/28/25 through 09/08/25 per nursing notes and there was not evidence of a physician being made aware or alternates being offered.

This deficiency demonstrates non-compliance investigated under Master Complaint Number 2624018, Complaint Number 2623116, 2618783, 1398689 and 1398688.

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Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

and in plastic packaging.

Interview on 09/17/25 at 2:49 P.M. with Licensed Practical Nurse (LPN) #8

confirmed she and the other staff on the unit were in a residents room at the time of the

contact with eyes, skin, and clothing should be avoided as this product may produce irritation. Do not allow this product to contact acidic materials as hazardous chlorine gas may be released.Review of the MSDS for nail polish remover revealed the vapors may be irritating to eyes, nose, throat and lungs, and may cause central nervous system depression. It stated ingestion may cause gastrointestinal upset, nausea, vomiting and diarrhea, may cause adverse kidney and liver effects.

Review of the MSDS for Ajax revealed it could cause eye irritation.

Review of the MSDS for Clorox revealed it may cause moderate eye irritation, inhalation of high concentrations may cause irritation of the respiratory tract, headaches, dizziness, nausea, vomiting and malaise.This deficiency demonstrates non-compliance investigated under Complaint Number 2623116, 1398691 and 1398689.

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Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

non-compliance investigated under Master Complaint Number 2624018, Complaint Number 2618783,

jeopardy to resident health or safety

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Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

Review of a nursing note dated 09/09/25 at 6:15 P.M. by Licensed Practical Nurse (LPN) #8 revealed Resident #8 admitted to the facility by ambulance with oxygen in place at 2 liter per minute (lpm).Review of a Minimum Data Set, dated [DATE] revealed Resident #8 received oxygen therapy.

Review of Resident #8's orders revealed there was no order in place for oxygen.Interview and observation on 09/22/25 at 3:57 P.M. with Resident #8 revealed she had an oxygen concentrator set to 2 liters per minute (lpm) and was wearing a nasal cannula. Resident #8 confirmed she had oxygen in place, and the tubing had just been changed the previous night.Interview on 09/23/25 at 8:48 A.M. with the Administrator revealed someone who has oxygen in place should have an order.Interview on 09/23/25 at 8:58 A.M. with Director of Nursing (DON) confirmed Resident #8 did not have an oxygen order in place but should have.Review of a policy titled Oxygen Administration dated 04/2023 revealed oxygen is administered under the orders of a physician except in the case of an emergency.This deficiency represents non-compliance investigated under Complaint Number 2623116 and 1398689.

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Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

Review of facility policy titled Pain Assessment and Management reviewed 08/2022 revealed pain management is based on a facility wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the residents' choices related to pain management.

This deficiency demonstrates non-compliance investigated under Complaint Number 2623116, and 1398689.

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Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

Observation on 09/24/25 from 7:29 A.M. until 7:41 A.M. revealed there

and were observed answering call lights and assisting residents.

There were no other staff members visualized or available. At 7:37 A.M., Resident #28 was seen self-propelling her wheelchair in the hallway and stated hey can you help me to CNA #86 who was passing by. CNA #86 replied just a minute, to which Resident #28 responded I thought this place was supposed to help you, they don't do nothing; I have an awful itch, I'm so thirsty, and I can't get my food open.

Review of the most recent facility wide assessment, page nine, for assistance with activities of daily living revealed the facility can care for five residents dependent on staff for dressing, five residents dependent on staff for bathing, five residents dependent on staff for transferring, and five residents dependent on staff for toileting.Review of facility wide assessment revealed the facility requires four full time registered nurses (RNs), four full time licensed practical nurses (LPNs), and fourteen full time certified nurse aides (CNAs), and one part time CNA to care for five residents dependent on staff for dressing, five residents dependent on staff for bathing, five residents dependent on staff for transferring, and five residents dependent on staff for toileting.Interview with the Director of Nursing (DON) confirmed full time direct resident care staff include five LPN's, one Registered Nurse, twelve CNAs, and part time direct care staff include one LPN and One CNA.Interview on 09/17/25 at 3:55 P.M. with the DON and Facility Administrator confirmed based on the current facility assessment the facility does not have an adequate amount of staff to care for the current resident population, and current resident needs, with timeliness, and quality.This deficiency demonstrates non-compliance investigated under Complaint Number 2618783, 1398691, 1398690, 1398689 and 1398688.

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Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

Review of a job description for the Activity Director dated 05/24/22 revealed the AD supervises an activity program appropriate to meet the physical, social, cultural, spiritual, emotional, and recreational needs and interests of each resident; provides the opportunity for residents to engage in normal pursuits; as well as promoting a successful and well-balanced leisure lifestyle.

The AD plans quality of life of each resident as well as maintaining an open working relationship with the resident's family.

The AD should plan, develop, organize, implement, evaluate and direct the activity program; assess individual and group needs and develop related meaningful morning, afternoon, evening and special programs; prepares and posts a monthly schedule of activities, and coordinates, directs and conducts all planned activities.

Review of a policy titled Dementia dated 04/28/25 revealed the staff and physician will review the current physical, functional and psychosocial status of individuals with dementia and will summarize the individual's condition, related complications, and functional abilities and impairments.

This deficiency demonstrates non-compliance investigated under Complaint Number 2623116, and 1398689.

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Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

stated when Resident #30 cannot go to AA, he is down in the dumps and assumes the facility staff

psychosocial functioning and independence; addressing difficulties with emotional adjustment to the

disciplines as appropriate; ensures that social services are coordinated with other facility services; coordinates behavior management programs with the assistance of other departments; provides timely and appropriate psychosocial intervention for residents as required and documents; assess the social, emotional, and spiritual needs of the residents and ensure the social services intervention is a part of the plan of care; ensure required social services interventions are provided directly through the department or outside referrals; and participates in mandatory in-services and annual conducts at least one in-service designed to increase the facility staff's awareness of the social and emotional needs of the residents.

This deficiency represents non-compliance investigated under Complaint Number 1398689.

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Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

Review of the facility policy tilted Administering Medications revised 04/28/25 revealed medications must be administered in accordance with orders, including any required time frame.

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Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

Observation revealed DC #23 placed an eight ounce (oz) scoop of sugar snapped peas and eight oz. of water into a blender, checked consistency and added one scoop of thickener.

Upon taste test after completion of pureeing sugar snap peas, the pea puree was stringy and had no flavor which was verified with DD #39.

Observation of pureeing of Resident #23's breaded fish revealed the fish was a very watery consistency with clumps.

One scoop of thickener was added and the consistency was still lumpy which was verified with DC #23 and DD #39.

Observation of pureeing of Resident #23's roasted potatoes revealed water was added and then blended.

The consistency was checked and revealed lumps in the mixture and upon taste test there was no flavor. It was confirmed at the time of the observations with DC #23 and DD #39 the pureed foods for Resident #23 were not not palatable. 2.

Record review of Resident #28 revealed an admission date of 12/14/23 with diagnoses including anxiety, obstructive sleep apnea, dementia, vitamin D deficiency, hypokalemia, and hyponatremia.Review of Resident #28's quarterly MDS assessment completed 07/03/25 revealed no displayed or exhibited behaviors during the review period except wandering.Review of Resident #28's care plan, revised on 09/08/25, for at potential nutrition/ hydration risk related to mild protein-calorie malnutrition, Body Mass Index (BMI) indicates an underweight status, and therapeutic diet in place to help meet estimated needs.

Interventions include assist with meals as needed, provide snacks, and diets as ordered per preference.On 09/16/25 at 12:35 P.M. Resident #28 was observed to be eating lunch in the dining room. Resident #28's meal contained Tex Mex casserole and black beans.

Interview with Resident # 28 revealed the lunch had no flavor, and they might as well eat dirt.This deficiency demonstrates non-compliance investigated under Complaint Number 1398690 and 1398688

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Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

Review of Resident #05's orders revealed an order placed 12/08/24 for a low concentrated sweets diet (LCS), with mechanical soft texture.Review of Resident #05's care plan revealed a plan of care revised on 09/15/25 stating Resident #05 was at risk for malnutrition/ alteration in nutritional status related to anemia, GERD, dysphagia, and barrettes esophagus.

Goals included the resident will maintain adequate nutritional status.

Interventions include to give medications as ordered, and provide diets as ordered.

Record review revealed no documentation Resident #05 had refused their modified texture diet.Observation on 09/11/25 at 12:20 P.M. revealed Resident #05's tray was plated with a whole hot dog on it.

The tray was then taken to the dining room and served to Resident #05 who was sitting at a table in the dining room.

After brought to the staff's attention, the whole hot dog was removed from Resident #05 so the mechanical soft texture could be provided. An interview with Dietary [NAME] (DC) #25 at the time of the observation confirmed Residnet #05 was a ordered a mechanical soft diet and was served a whole hot dog.2.

Record review revealed Resident #23 admitted to the facility 12/10/24 with diagnoses including osteoarthritis, chronic obstructive pulmonary disease (COPD) , anemia, heart failure, urinary tract infection, and adjustment disorder.

Record review of Resident #23 quarterly MDS completed 08/08/25 revealed severe cognitive impairment.

Record review of Resident #23 orders revealed an order placed on 09/01/25 for a pureed texture diet.Observation on 09/11/25 at 11:10 A.M. with Dietary Director (DD) #39 and Dietary [NAME] (DC) #35 revealed they were preparing pureed food for Resident #23. Resident #23's menu included sugar snapped peas, breaded fish, and roasted potatoes.

Observation revealed DC #23 placed an eight ounce (oz) scoop of sugar snapped peas and eight oz. of water into a blender, checked consistency and added one scoop of thickener.

Upon taste test after completion of pureeing sugar snap peas, the pea puree was stringy and had no flavor which was verified with DD #39.

Observation of pureeing of Resident #23's breaded fish revealed the fish was a very watery consistency with clumps.

One scoop of thickener was added and the consistency was still lumpy which was verified with DC #23 and DD #39.

Observation of pureeing of Resident #23's roasted potatoes revealed water was added and then blended.

The consistency was checked and revealed lumps in the mixture and upon taste test there was no flavor. It was confirmed at the time of the observations with DC #23 and DD #39 the pureed foods for Resident #23 were not at a smooth consistency for a pureed diet.

Review of undated facility policy dated 2023 titled Texture and Consistency Modified Diets revealed texture and consistency modified diets should be individualized with modifications made by the speech language pathologist (SLP) and physician in conjunction with a registered dietician.

This deficiency demonstrates non-compliance investigated under Complaint Number 1398690, and 1398689.

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Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

done yet.

the dietary department was not currently staffed according to the staffing plan in the facility

This deficiency demonstrates non-compliance investigated under Complaint Number 2618783 and

• 366448 09/30/2025

Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

Review of [NAME] Care Center Resident Analyzer and Resident Minimum Data Set (MDS) information revealed there were 14 residents (Residents #3 , #4, #5, #6, #9, #10, #22, #24, #25, #26, #30, #31, #33, and #34) who were dependent on staff for dressing .

Review of [NAME] Care Center Resident Analyzer and Resident Minimum Data Set (MDS) information revealed there were 14 residents (Residents #3, #5, #9, #10, #20, #22, #24, #25, #26, #29, #30, #31, #33, and #34) who were dependent on staff for showering/ bathing.Review of [NAME] Care Center Resident Analyzer and Resident Minimum Data Set (MDS) information revealed there were nine (9) residents who were dependent on staff for transferring (Residents #5, #25, #3, #23, #9, #31, #34, #24, and #30).

Review of the most recent facility wide assessment, page nine, for assistance with activities of daily living revealed the facility is able to care for five residents dependent on staff for dressing, five residents dependent on staff for bathing, five residents dependent on staff for transferring, and five residents dependent on staff for toileting.Review of facility wide assessment revealed the facility requires four full time registered nurses (RNs), four full time licensed practical nurses (LPNs), and fourteen full time certified nurse aides (CNAs), and one part time CNA to care for for five residents dependent on staff for dressing, five residents dependent on staff for bathing, five residents dependent on staff for transferring, and five residents dependent on staff for toileting.Interview with the Director of Nursing (DON) confirmed full time direct resident care staff include five LPN's, one Registered Nurse, twelve CNA's, and part time direct care staff include one LPN and One CNA.Review of the facility assessment revealed for dietary staff to meet the needs of the residents include three full dietary cooks, two full time dietary aides, and one part time dietary aide.Interview on 09/11/25 at 1:46 P.M. with Dietary Director revealed they currently had two full-time cooks and two full time aides.

Interview on 09/17/25 at 3:55 P.M. with the DON and Facility Administrator confirmed based on the current facility assessment the facility does not have an adequate amount of staff to care for the current resident population, and current resident needs, with timeliness, and quality.

Interview on 09/17/25 at 3:55 P.M with the DON and Facility Administrator revealed they did not accurately complete the facility wide assessment.

This deficiency is an incidental finding discovered during the complaint investigation.

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Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

and LPN #69 who stated they signed the catheter change as completed because they thought it was

09/25/25 at 7:50 A.M. revealed they have never personally switched Resident #05's suprapubic

knowledge it was never an order.

This deficiency demonstrates non-compliance investigated under Master Complaint Number 2624018, Complaint Number 1398691, and 1398689.

366448 09/30/2025

Stellar Care Center 47045 Moore Ridge Road Woodsfield, OH 43793

Review of an order dated 02/28/25 revealed Resident #9 had an indwelling catheter with 18 french and 30 cc balloon in place to be changed every 30 days and as needed.Review of a care plan dated 08/08/25 revealed Resident #9 had severely impaired cognition and was frequently incontinent of bladder.Observation on 09/16/25 at 9:38 A.M. revealed Resident #9 was resting with his bed in a low position and his catheter bag was laying on the floor.Observation on 09/16/25 at 10:15 A.M. revealed Resident #9 was resting in bed and his catheter bag remained on the floor.Observation on 09/18/25 at 1:09 P.M. revealed Resident #9 was resting in bed and his catheter bag was on the floor.Interview on 09/18/25 at 1:10 P.M. with Licensed Practical Nurse (LPN) #8 confirmed Resident #9's catheter bag was on the floor.