7 health deficiencies
Top issue: Infection Control (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Mount Vernon, OH
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
1076 Coshocton Ave, Mount Vernon, OH
(740) 397-4125
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
92
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1971-08-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
0.61
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.71
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.27
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.72
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.62
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.34
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
38%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
12,475
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
0
Performance 9.05% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.06
Baseline 46.67% · Performance 51.16% · Measure score 3.06 · Achievement 3.06 · Improvement 0
Adjusted total nurse staffing
0.55
Baseline 3.47 hours · Performance 3.23 hours · Measure score 0.55 · Achievement 0.55 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.89% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 17.02% · Lower 95% interval 7.93% |
| Discharge to community | 52.99% |
50.57%
2.4 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 48.08% · Lower 95% interval 40.92% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 19 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | 9.05% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 25 · Observed rate 20% · Lower 95% interval 4.3% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 57 |
| Staff flu vaccination coverage | 21.43% |
42%
20.6 pts worse
|
Numerator 15 · Denominator 70 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · 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 12 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
92.4%
4.8 pts better
|
93.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.6% · Q3 95.3% · Q4 97.9% · 4Q avg 97.2% |
| 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 | 4.4% |
3.3%
1.1 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 8.9% · Q3 0.0% · Q4 0.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
26.1%
24.8 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.5% · Q3 0.0% · Q4 2.4% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
6.2%
1.4 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 5.0% · Q3 7.9% · Q4 10.0% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.6% |
25.4%
4.2 pts worse
|
19.6%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 32.5% · Q2 30.0% · Q3 28.2% · Q4 27.5% · 4Q avg 29.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.5% |
11.5%
10 pts worse
|
16.7%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 27.6% · Q3 21.2% · Q4 12.5% · 4Q avg 21.5% · 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 | 3.8% |
7.7%
3.9 pts better
|
16.3%
12.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 4.9% · Q3 4.0% · Q4 0.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.7% |
6.2%
3.5 pts better
|
14.9%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 7.9% · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.2%
0.3 pts worse
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
0.5%
0.1 pts worse
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.1% |
21.7%
0.4 pts worse
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 22.9% · Q3 23.8% · Q4 18.6% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 8.6% |
3.7%
4.9 pts worse
|
5.1%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 9.9% · Q3 7.6% · Q4 3.7% · 4Q avg 8.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.9% |
78.1%
12.8 pts better
|
81.7%
9.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.8% · Q2 92.5% · Q3 87.8% · Q4 86.1% · 4Q avg 90.9% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.8% |
1.2%
3.6 pts worse
|
1.6%
3.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 10.0% · Q3 0.0% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.3% |
75.6%
11.7 pts better
|
79.7%
7.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.3% |
Survey summary
Top issue: Infection Control (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (5 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (8 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-04-10
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-10
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-10
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-04-10
Fire Safety
Construct fire resistant interior walls.
Corrected 2025-04-10
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-04-10
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-04-10
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-09
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-09
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-09
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-02-09
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-02-09
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-02-04
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-02-04
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2020-02-04
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-02-04
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-02-04
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2020-02-04
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-02-04
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-02-04
Fire Safety
Provide family notifications of emergency plan.
Corrected 2020-02-04
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-10
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-10
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-04-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-10
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 2025-04-10
Health
Implement a program that monitors antibiotic use.
Corrected 2025-04-10
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-04-10
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-06
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-05
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-15
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-09-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-09
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-02-09
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 2023-02-09
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-02-09
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-02-09
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-02-09
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-02-09
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-02-09
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-02-09
Health
Respond appropriately to all alleged violations.
Corrected 2023-02-09
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-02-09
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-02-09
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-09
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-09
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-02-09
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-02-09
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-09
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 2023-02-09
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-02-09
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-02-09
Health
Provide and implement an infection prevention and control program.
Corrected 2020-02-04
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2020-02-04
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2020-02-04
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2020-02-04
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2020-02-04
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2020-02-04
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-02-04
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-02-04
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-02-04
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-02-04
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-02-04
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 2020-02-04
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2020-02-04
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 2020-02-04
Penalties and ownership
Fine · fine $15,593
Fine
Payment Denial · denial start 2023-09-02 · 13 days
13 day denial
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
5% Or Greater Security Interest · Organization
5% Or Greater Security Interest · Individual
Corporate Officer · Individual
5% Or Greater Security Interest · Individual
5% Or Greater Security Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Security Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Security Interest · Individual
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Mount Vernon, OH
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