Mount Vernon, OH

Country Club Retirement Center

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

1350 Yauger Road, Mount Vernon, OH

(740) 397-2350

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Country Club Rehabilitation Campus

Operator or chain grouping

Approved since

1990-12-20

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

7 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

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

0.55

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

0.75

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.08

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

3.38

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

1.30

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.03

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.36

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.04

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.59

CMS adjusted RN staffing hours

Adjusted total hours

3.64

CMS adjusted total nurse staffing hours

Case-mix index

1.27

Higher values indicate more complex resident acuity

RN turnover

14%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

50%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,447

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

23.62

Composite VBP score used to determine payment impact.

Payment multiplier

0.9832

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 19.67% · Performance 21.34% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

2.68

Baseline 6.69% · Performance 7.03% · Measure score 2.68 · Achievement 2.68 · Improvement 0

Total nurse turnover

6.77

Baseline 46.27% · Performance 36.00% · Measure score 6.77 · Achievement 6.77 · Improvement 4.29

Adjusted total nurse staffing

Baseline 3.29 hours · Performance 3.12 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.76%	10.72% About the same	No Different than the National Rate · Eligible stays 165 · Observed rate 10.91% · Lower 95% interval 7.42%
Discharge to community	54.06%	50.57% 3.5 pts better	No Different than the National Rate · Eligible stays 156 · Observed rate 51.28% · Lower 95% interval 45.14%
Medicare spending per beneficiary	1.05	1.02 About the same
Drug regimen review with follow-up	98.9%	95.27% 3.6 pts better	Numerator 90 · Denominator 91
Falls with major injury	3.3%	0.77% 2.5 pts worse	Numerator 3 · Denominator 91
Discharge self-care score	60%	53.69% 6.3 pts better	Numerator 36 · Denominator 60
Discharge mobility score	63.33%	50.94% 12.4 pts better	Numerator 38 · Denominator 60
Pressure ulcers or injuries, new or worsened	4.4%	2.29% 2.1 pts worse	Numerator 4 · Denominator 91 · Adjusted rate 4.43%
Healthcare-associated infections requiring hospitalization	7.04%	7.12% 0.1 pts better	No Different than the National Rate · Eligible stays 93 · Observed rate 6.45% · Lower 95% interval 4.03%
Staff COVID-19 vaccination coverage	1.05%	8.2% 7.1 pts worse	Numerator 1 · Denominator 95
Staff flu vaccination coverage	10.31%	42% 31.7 pts worse	Numerator 10 · Denominator 97
Discharge function score	68.33%	56.45% 11.9 pts better	Numerator 41 · Denominator 60
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 46 · Denominator 46
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 26 · Denominator 26
Resident COVID-19 vaccinations up to date	2.5%	25.2% 22.7 pts worse	Numerator 1 · Denominator 40

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	3.5	1.8 1.7 pts worse	1.9 1.6 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.5 · Observed 2.6 · Expected 1.4 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	3.0	1.8 1.2 pts worse	1.8 1.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.3 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	92.4% 7.6 pts better	93.4% 6.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	94.5% 5.5 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	5.3%	3.3% 2 pts worse	3.3% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 1.8% · Q3 5.2% · Q4 10.2% · 4Q avg 5.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.1%	26.1% 25 pts better	11.4% 10.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 2.2% · Q4 0.0% · 4Q avg 1.1%
Percentage of long-stay residents who lose too much weight	6.3%	6.2% 0.1 pts worse	5.4% 0.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 9.1% · Q3 6.5% · Q4 7.0% · 4Q avg 6.3%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	18.5%	25.4% 6.9 pts better	19.6% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 17.8% · Q3 21.3% · Q4 25.0% · 4Q avg 18.5%
Percentage of long-stay residents who received an antipsychotic medication	11.1%	11.5% 0.4 pts better	16.7% 5.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 10.8% · Q3 12.8% · Q4 8.1% · 4Q avg 11.1% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	0.0%	7.7% 7.7 pts better	16.3% 16.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	1.7%	6.2% 4.5 pts better	14.9% 13.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.4% · Q4 2.3% · 4Q avg 1.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.4%	0.2% 0.2 pts worse	1.0% 0.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 0.0% · 4Q avg 0.4% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	28.3%	21.7% 6.6 pts worse	19.8% 8.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 36.1% · Q2 25.4% · Q3 25.2% · Q4 26.6% · 4Q avg 28.3%
Percentage of long-stay residents with pressure ulcers	10.0%	3.7% 6.3 pts worse	5.1% 4.9 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 7.6% · Q3 17.8% · Q4 7.4% · 4Q avg 10.0% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	78.1% 21.9 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	15.9%	12.5% 3.4 pts worse	12.0% 3.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 17.7% · Expected 12.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.7%	1.2% 0.5 pts better	1.6% 0.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.7% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	100.0%	75.6% 24.4 pts better	79.7% 20.3 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.8%	25.1% 0.7 pts worse	23.9% 1.9 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.8% · Observed 30.6% · Expected 28.3% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-05-16 · Fire 2024-05-16

13 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

7 fire-safety deficiencies

Top issue: Miscellaneous (2 deficiencies)

Cycle 2 Health 2023-04-20 · Fire 2023-04-20

20 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2021-05-20 · Fire 2021-05-20

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-05-16

K711 · Miscellaneous Deficiencies

Fire Safety

Provide a written emergency evacuation plan.

Corrected 2024-06-06

F · Potential for more than minimal harm 2024-05-16

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2024-06-06

F · Potential for more than minimal harm 2024-05-16

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-06-06

E · Potential for more than minimal harm 2024-05-16

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2024-06-06

E · Potential for more than minimal harm 2024-05-16

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2024-06-06

E · Potential for more than minimal harm 2024-05-16

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-06-06

E · Potential for more than minimal harm 2024-05-16

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-06-06

F · Potential for more than minimal harm 2023-04-20

K131 · Construction Deficiencies

Fire Safety

Meet requirements for sections of health care facilities separated by fire resistive construction.

Corrected 2023-05-05

F · Potential for more than minimal harm 2023-04-20

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2023-05-05

F · Potential for more than minimal harm 2023-04-20

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-05-05

F · Potential for more than minimal harm 2023-04-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-05-05

F · Potential for more than minimal harm 2023-04-20

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2023-05-05

E · Potential for more than minimal harm 2023-04-20

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-05-05

E · Potential for more than minimal harm 2023-04-20

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2023-05-05

E · Potential for more than minimal harm 2023-04-20

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2023-05-05

E · Potential for more than minimal harm 2021-05-20

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2021-06-10

E · Potential for more than minimal harm 2021-05-20

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2021-06-10

E · Potential for more than minimal harm 2021-05-20

K344 · Smoke Deficiencies

Fire Safety

Have an alternate power supply for its alarm system.

Corrected 2021-06-10

E · Potential for more than minimal harm 2021-05-20

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2021-06-10

E · Potential for more than minimal harm 2021-05-20

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2021-06-10

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-06-10

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 2025-05-26

G · Actual harm 2024-10-03

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 2024-10-17

D · Potential for more than minimal harm 2024-10-03

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-10-17

D · Potential for more than minimal harm 2024-10-03

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2024-08-18

F · Potential for more than minimal harm 2024-05-16

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-06-06

E · Potential for more than minimal harm 2024-05-16

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2024-06-06

E · Potential for more than minimal harm 2024-05-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-16

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-16

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-16

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 2024-06-06

D · Potential for more than minimal harm 2024-05-16

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-16

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-16

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-16

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-16

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-05-16

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2024-06-06

D · Potential for more than minimal harm 2024-03-15

F568 · Resident Rights Deficiencies

Health

Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.

Corrected 2024-03-26

D · Potential for more than minimal harm 2024-03-15

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2024-03-26

D · Potential for more than minimal harm 2024-03-15

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-03-26

F · Potential for more than minimal harm 2023-11-07

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-11-21

D · Potential for more than minimal harm 2023-11-07

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-11-21

D · Potential for more than minimal harm 2023-11-07

F800 · Nutrition and Dietary Deficiencies

Health

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Corrected 2023-11-21

G · Actual harm 2023-08-29

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2023-09-18

F · Potential for more than minimal harm 2023-04-20

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-05-05

E · Potential for more than minimal harm 2023-04-20

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 2023-05-05

E · Potential for more than minimal harm 2023-04-20