17 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Mount Vernon, OH
2-star overall rating with 2-star inspections with 17 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
13 Avalon Road, Mount Vernon, OH
(740) 397-3200
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
99
Certified beds
Average residents
91
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ciena Healthcare/Laurel Health Care
Operator or chain grouping
Approved since
1978-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
84 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
RN hours / resident day
0.50
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.39
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.99
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.34
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
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.39
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
4,608
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9923
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
5.15
Baseline 24.30% · Performance 20.19% · Measure score 5.15 · Achievement 2.67 · Improvement 5.15
Healthcare-associated infections
4.06
Baseline 9.04% · Performance 7.20% · Measure score 4.06 · Achievement 2.13 · Improvement 4.06
Total nurse turnover
3.50
Performance 49.38% · Measure score 3.50 · Achievement 3.50 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
3.02
Baseline 2.23 hours · Performance 3.48 hours · Measure score 3.02 · Achievement 1.41 · Improvement 3.02
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.19% |
10.72%
1.5 pts worse
|
No Different than the National Rate · Eligible stays 96 · Observed rate 15.63% · Lower 95% interval 8.75% |
| Discharge to community | 46.47% |
50.57%
4.1 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 40.28% · Lower 95% interval 35.49% |
| Medicare spending per beneficiary | 1.03 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.61% |
95.27%
1.3 pts better
|
Numerator 57 · Denominator 59 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 59 |
| Discharge self-care score | 57.14% |
53.69%
3.5 pts better
|
Numerator 24 · Denominator 42 |
| Discharge mobility score | 40.48% |
50.94%
10.5 pts worse
|
Numerator 17 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 5.08% |
2.29%
2.8 pts worse
|
Numerator 3 · Denominator 59 · Adjusted rate 6.14% |
| Healthcare-associated infections requiring hospitalization | 7.2% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 7.41% · Lower 95% interval 4.4% |
| Staff COVID-19 vaccination coverage | 0.84% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 119 |
| Staff flu vaccination coverage | 7.43% |
42%
34.6 pts worse
|
Numerator 11 · Denominator 148 |
| Discharge function score | 40.48% |
56.45%
16 pts worse
|
Numerator 17 · Denominator 42 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 24 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 26.92% |
25.2%
1.7 pts better
|
Numerator 7 · Denominator 26 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.8
0.7 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.1% |
92.4%
3.7 pts better
|
93.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.5% · Q2 100.0% · Q3 96.3% · Q4 96.2% · 4Q avg 96.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
94.5%
4.3 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
3.3%
1.6 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 5.4% · Q3 4.9% · Q4 5.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.2% |
26.1%
17.9 pts better
|
11.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 7.3% · Q3 11.1% · Q4 6.5% · 4Q avg 8.2% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
6.2%
0.9 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 10.4% · Q3 2.6% · Q4 2.8% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.2% |
25.4%
0.8 pts worse
|
19.6%
6.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.3% · Q2 29.9% · Q3 22.1% · Q4 23.6% · 4Q avg 26.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.9% |
11.5%
2.4 pts worse
|
16.7%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 9.3% · Q3 12.7% · Q4 16.9% · 4Q avg 13.9% · 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 | 6.1% |
7.7%
1.6 pts better
|
16.3%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 11.6% · Q3 5.0% · Q4 2.4% · 4Q avg 6.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.5% |
6.2%
3.3 pts worse
|
14.9%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.6% · Q2 10.6% · Q3 1.3% · Q4 2.9% · 4Q avg 9.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.2%
0.1 pts worse
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · 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 | 20.1% |
21.7%
1.6 pts better
|
19.8%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 18.2% · Q3 16.9% · Q4 23.5% · 4Q avg 20.1% |
| Percentage of long-stay residents with pressure ulcers | 10.5% |
3.7%
6.8 pts worse
|
5.1%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 11.9% · Q3 7.1% · Q4 9.8% · 4Q avg 10.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.9% |
78.1%
9.8 pts better
|
81.7%
6.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.3% · Q2 91.5% · Q3 89.4% · Q4 79.2% · 4Q avg 87.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.0% |
12.5%
11.5 pts worse
|
12.0%
12 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 27.0% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.2%
0.1 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.7% |
75.6%
15.1 pts better
|
79.7%
11 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.5% |
25.1%
1.4 pts worse
|
23.9%
2.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.5% · Observed 29.7% · Expected 26.7% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (7 deficiencies)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-07
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-07
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-07
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-03-07
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-24
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-11-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-20
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-20
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-11-20
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-20
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2023-11-20
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-11-20
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2021-12-13
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-12-13
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-12-13
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-12-13
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-12-13
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2021-12-13
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 2021-12-13
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-12-13
Inspection history
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-08-29
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-08-29
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-29
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 2025-08-29
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-29
Health
Have policies on smoking.
Corrected 2025-03-07
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-07
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-03-07
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-03-07
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-07
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-03-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-07
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-07
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-07
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-07
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-03-07
Health
Provide or obtain dental services for each resident.
Corrected 2025-03-07
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-04-14
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-11-20
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-11-20
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-20
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-20
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 2023-11-20
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-20
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-11-20
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-11-20
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-20
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 2023-11-20
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-11-20
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 2021-12-13
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-12-13
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2021-12-13
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-12-13
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 2021-12-13
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Officer · Individual
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