Cycle 1
Health 2024-05-02 · Fire 2024-05-02
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Mount Vernon, OH
Ohio Eastern Star Hlth Care Ctr The
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1451 Gambier Road, Mount Vernon, OH
(740) 397-1706
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
86
Certified beds
Average residents
76
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1996-07-25
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
Hours and turnover
RN hours / resident day
0.76
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.56
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
3.17
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
5.48
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.32
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
4.79
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.72
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
6.50
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,383
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9898
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.03
Baseline 18.12% · Performance 20.03% · Measure score 3.03 · Achievement 3.03 · Improvement 0
Healthcare-associated infections
2.14
Baseline 6.59% · Performance 7.20% · Measure score 2.14 · Achievement 2.14 · Improvement 0
Total nurse turnover
5.6
Baseline 50.00% · Performance 40.79% · Measure score 5.6 · Achievement 5.6 · Improvement 3.16
Adjusted total nurse staffing
3.79
Baseline 5.72 hours · Performance 4.16 hours · Measure score 3.79 · Achievement 3.79 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.69% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 15.15% · Lower 95% interval 9.04% |
| Discharge to community | 62.44% |
50.57%
11.9 pts better
|
Better than the National Rate · Eligible stays 81 · Observed rate 61.73% · Lower 95% interval 53.92% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.3% |
95.27%
2 pts better
|
Numerator 72 · Denominator 74 |
| Falls with major injury | 1.35% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 74 |
| Discharge self-care score | 52.94% |
53.69%
0.8 pts worse
|
Numerator 27 · Denominator 51 |
| Discharge mobility score | 47.06% |
50.94%
3.9 pts worse
|
Numerator 24 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 6.76% |
2.29%
4.5 pts worse
|
Numerator 5 · Denominator 74 · Adjusted rate 5.77% |
| Healthcare-associated infections requiring hospitalization | 7.2% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 6.33% · Lower 95% interval 4.05% |
| Staff COVID-19 vaccination coverage | 1.33% |
8.2%
6.9 pts worse
|
Numerator 3 · Denominator 225 |
| Staff flu vaccination coverage | 9.29% |
42%
32.7 pts worse
|
Numerator 25 · Denominator 269 |
| Discharge function score | 52.94% |
56.45%
3.5 pts worse
|
Numerator 27 · Denominator 51 |
| Transfer of health information to provider | 95.74% |
95.95%
0.2 pts worse
|
Numerator 45 · Denominator 47 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 28.57% |
25.2%
3.4 pts better
|
Numerator 10 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
92.4%
5.6 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 98.4% · Q3 98.4% · Q4 96.7% · 4Q avg 98.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.1% |
94.5%
2.6 pts better
|
95.5%
1.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.2% |
3.3%
3.9 pts worse
|
3.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 6.5% · Q3 9.4% · Q4 11.5% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.2% |
26.1%
20.9 pts better
|
11.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 3.6% · Q3 3.4% · Q4 10.5% · 4Q avg 5.2% |
| Percentage of long-stay residents who lose too much weight | 2.5% |
6.2%
3.7 pts better
|
5.4%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 0.0% · Q3 0.0% · Q4 5.0% · 4Q avg 2.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.4% |
25.4%
5 pts better
|
19.6%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 21.1% · Q3 21.4% · Q4 17.1% · 4Q avg 20.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.8% |
11.5%
2.7 pts better
|
16.7%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 11.4% · Q3 8.3% · Q4 8.3% · 4Q avg 8.8% · 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 | 24.6% |
7.7%
16.9 pts worse
|
16.3%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q4 14.8% · 4Q avg 24.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.8% |
6.2%
13.6 pts worse
|
14.9%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 16.2% · Q3 21.4% · Q4 10.3% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.6% |
0.2%
3.4 pts worse
|
1.0%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.8% · Q3 4.5% · Q4 6.7% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.5% |
0.5%
4 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.3% · Q3 3.1% · Q4 6.7% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.2% |
21.7%
2.5 pts worse
|
19.8%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 22.6% · Q3 23.3% · Q4 30.2% · 4Q avg 24.2% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
3.7%
0.4 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 3.2% · Q3 5.5% · Q4 2.7% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.6% |
78.1%
14.5 pts better
|
81.7%
10.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.7% · Q2 91.8% · Q3 95.5% · Q4 94.3% · 4Q avg 92.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.8% |
12.5%
4.3 pts worse
|
12.0%
4.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.8% · Observed 15.9% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.2%
0.3 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 1.5% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.2% |
75.6%
12.6 pts better
|
79.7%
8.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.0% |
25.1%
4.9 pts worse
|
23.9%
6.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.0% · Observed 27.0% · Expected 21.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-07 · Fire 2023-03-07
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2020-01-09 · Fire 2020-01-09
11 health deficiencies
Top issue: Resident Rights (5 deficiencies)
9 fire-safety deficiencies
Top issue: Miscellaneous (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-05-02
K222 · Egress Deficiencies
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 2024-05-20
E · Potential for more than minimal harm
2024-05-02
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-05-20
E · Potential for more than minimal harm
2024-05-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-05-20
F · Potential for more than minimal harm
2023-03-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-04-24
F · Potential for more than minimal harm
2023-03-07
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-20
F · Potential for more than minimal harm
2023-03-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-24
F · Potential for more than minimal harm
2020-01-09
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2020-01-31
F · Potential for more than minimal harm
2020-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-31
F · Potential for more than minimal harm
2020-01-09
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2020-01-31
F · Potential for more than minimal harm
2020-01-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-01-31
E · Potential for more than minimal harm
2020-01-09
K222 · Egress Deficiencies
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 2020-01-31
E · Potential for more than minimal harm
2020-01-09
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2020-01-31
C · Minimal harm
2020-01-09
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2020-01-31
C · Minimal harm
2020-01-09
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2020-01-31
C · Minimal harm
2020-01-09
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-01-31
Inspection history
Recent health citations
G · Actual harm
2025-02-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-21
D · Potential for more than minimal harm
2025-01-03
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-02-27
D · Potential for more than minimal harm
2024-09-04
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 2024-09-17
F · Potential for more than minimal harm
2024-05-02
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 2024-05-20
D · Potential for more than minimal harm
2024-05-02
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 2024-05-20
F · Potential for more than minimal harm
2023-03-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-21
F · Potential for more than minimal harm
2023-03-07
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 2023-04-21
D · Potential for more than minimal harm
2023-03-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-03-07
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-04-21
G · Actual harm
2020-01-09
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 2020-01-31
F · Potential for more than minimal harm
2020-01-09
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 2020-01-31
F · Potential for more than minimal harm
2020-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-01-31
E · Potential for more than minimal harm
2020-01-09
F761 · Pharmacy Service Deficiencies
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 2020-01-31
D · Potential for more than minimal harm
2020-01-09
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2020-01-31
D · Potential for more than minimal harm
2020-01-09
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2020-01-31
D · Potential for more than minimal harm
2020-01-09
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 2020-01-31
D · Potential for more than minimal harm
2020-01-09
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 2020-01-31
D · Potential for more than minimal harm
2020-01-09
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 2020-01-31
C · Minimal harm
2020-01-09
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 2020-01-31
C · Minimal harm
2020-01-09
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2020-01-31
Penalties and ownership
What sits behind the stars
Ownership
Engelbach, Michele
Corporate Officer · Individual
Engelbach, Michele
W-2 Managing Employee · Individual
Hardesty, Ronald
Corporate Director · Individual
Nearby options
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#2
Als Mount Vernon Inc
Mount Vernon, OH
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 4 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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