Cycle 1
Health 2024-06-24 · Fire 2024-06-24
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Mount Vernon, OH
Als Mount Vernon Inc
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
1135 Gambier Road, Mount Vernon, OH
(740) 392-1599
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
20
Certified beds
Average residents
19
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lionstone Care
Operator or chain grouping
Approved since
2013-08-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
22 facilities
Chain averages 3 overall / 2 health / 2 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
70%
Annual nurse turnover · state 50% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.81% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 36 · Observed rate 11.11% · Lower 95% interval 6.8% |
| Discharge to community | 35.34% |
50.57%
15.2 pts worse
|
Worse than the National Rate · Eligible stays 33 · Observed rate 24.24% · Lower 95% interval 21.63% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 14 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 47 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 74.2% |
92.4%
18.2 pts worse
|
93.4%
19.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 74.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.1% |
3.3%
2.8 pts worse
|
3.3%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
26.1%
23.6 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
6.2%
1.3 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.9% |
25.4%
13.5 pts better
|
19.6%
7.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.4% |
11.5%
4.1 pts better
|
16.7%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.5% |
6.2%
3.7 pts better
|
14.9%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.2%
0.2 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.5%
0.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.8% |
21.7%
4.1 pts worse
|
19.8%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.8% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
3.7%
2.8 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 69.8% |
78.1%
8.3 pts worse
|
81.7%
11.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 69.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 8.0% |
1.2%
6.8 pts worse
|
1.6%
6.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 8.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-04-21 · Fire 2022-04-21
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2019-06-27 · Fire 2019-06-27
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-06-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-06-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-19
F · Potential for more than minimal harm
2024-06-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-19
F · Potential for more than minimal harm
2022-04-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2022-06-17
F · Potential for more than minimal harm
2022-04-21
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-06-17
F · Potential for more than minimal harm
2022-04-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-04-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-06-17
E · Potential for more than minimal harm
2022-04-21
K922 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use and maintenance of medical gas equipment.
Corrected 2022-06-17
F · Potential for more than minimal harm
2019-06-27
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2019-08-09
F · Potential for more than minimal harm
2019-06-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-08-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-26
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-26
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-04-04
C · Minimal harm
2025-03-26
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-04-04
F · Potential for more than minimal harm
2024-06-24
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-07-19
E · Potential for more than minimal harm
2024-06-24
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-24
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-24
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-07-19
D · Potential for more than minimal harm
2024-06-24
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2024-07-19
D · Potential for more than minimal harm
2023-03-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-03-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-09
D · Potential for more than minimal harm
2022-04-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-06-17
F · Potential for more than minimal harm
2019-06-27
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2019-08-09
F · Potential for more than minimal harm
2019-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-09
D · Potential for more than minimal harm
2019-06-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-08-09
D · Potential for more than minimal harm
2019-06-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-08-09
D · Potential for more than minimal harm
2019-06-27
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2019-08-09
D · Potential for more than minimal harm
2019-06-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-08-09
C · Minimal harm
2019-06-27
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-08-09
Penalties and ownership
What sits behind the stars
Ownership
Lionstone Als Opco Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Kazarnovsky, Solomon
5% Or Greater Indirect Ownership Interest · Individual
Stein, Abba
5% Or Greater Indirect Ownership Interest · Individual
Cusner, Adam
Operational/Managerial Control · Individual
Cusner, Adam
Corporate Officer · Individual
Degyansky, Jeffrey
Operational/Managerial Control · Individual
Degyansky, Jeffrey
Corporate Officer · Individual
Goldish, Eliezer
Operational/Managerial Control · Individual
Goldish, Eliezer
Corporate Officer · Individual
Kazarnovsky, Solomon
Operational/Managerial Control · Individual
Stein, Abba
Operational/Managerial Control · Individual
Stein, Abba
Corporate Officer · Individual
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5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Country Club Retirement Center
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2-star overall rating with 2-star inspections with abuse icon flag with 13 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Country Court
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3-star overall rating with 2-star inspections with $15,593 in total fines with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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