Cycle 1
Health 2022-08-01 · Fire 2022-08-01
8 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (10 deficiencies)
Monroe, OH
Ohio Living Mount Pleasant
4-star overall rating with 3-star inspections with 8 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
225 Britton Lane, Monroe, OH
(513) 539-7391
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
32
Certified beds
Average residents
29
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ohio Living Communities
Operator or chain grouping
Approved since
1977-11-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
11 facilities
Chain averages 5 overall / 4 health / 4 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
0.97
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
1.46
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.50
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.93
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
2.43
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.40
Weekend registered nurse coverage · state 0.41 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,456
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9873
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.66% · Performance 23.36% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.65
Baseline 4.85% · Performance 6.45% · Measure score 4.65 · Achievement 4.65 · Improvement 0
Total nurse turnover
6.07
Baseline 51.81% · Performance 38.89% · Measure score 6.07 · Achievement 6.07 · Improvement 4.29
Adjusted total nurse staffing
2.40
Baseline 4.16 hours · Performance 3.76 hours · Measure score 2.40 · Achievement 2.40 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.28% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 124 · Observed rate 13.71% · Lower 95% interval 9.01% |
| Discharge to community | 64.25% |
50.57%
13.7 pts better
|
Better than the National Rate · Eligible stays 115 · Observed rate 61.74% · Lower 95% interval 55.53% |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 68 · Denominator 68 |
| Falls with major injury | 1.47% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 68 |
| Discharge self-care score | 76.09% |
53.69%
22.4 pts better
|
Numerator 35 · Denominator 46 |
| Discharge mobility score | 63.04% |
50.94%
12.1 pts better
|
Numerator 29 · Denominator 46 |
| Pressure ulcers or injuries, new or worsened | 1.47% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 68 · Adjusted rate 1.51% |
| Healthcare-associated infections requiring hospitalization | 6.45% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 71 · Observed rate 4.23% · Lower 95% interval 3.22% |
| Staff COVID-19 vaccination coverage | 0.93% |
8.2%
7.3 pts worse
|
Numerator 1 · Denominator 108 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 73.91% |
56.45%
17.5 pts better
|
Numerator 34 · Denominator 46 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 41 · Denominator 41 |
| 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 | 51.61% |
25.2%
26.4 pts better
|
Numerator 16 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
92.4%
5.5 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 96.0% · Q4 95.5% · 4Q avg 97.9% |
| 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 | 2.1% |
3.3%
1.2 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 6.4% |
26.1%
19.7 pts better
|
11.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 9.1% · Q3 4.0% · Q4 13.6% · 4Q avg 6.4% |
| Percentage of long-stay residents who lose too much weight | 3.3% |
6.2%
2.9 pts better
|
5.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.7% |
25.4%
13.3 pts worse
|
19.6%
19.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.5% |
11.5%
1 pts worse
|
16.7%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.5% · 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 | 13.4% |
7.7%
5.7 pts worse
|
16.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.1% |
6.2%
1.9 pts worse
|
14.9%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.1% · 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 · 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 a urinary tract infection | 5.3% |
0.5%
4.8 pts worse
|
1.7%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 13.0% · Q3 4.0% · Q4 0.0% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.8% |
21.7%
2.9 pts better
|
19.8%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.3% · Q2 23.6% · Q3 12.1% · Q4 14.3% · 4Q avg 18.8% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
3.7%
0.4 pts worse
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 2.4% · Q3 2.0% · Q4 5.0% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.6% |
78.1%
4.5 pts better
|
81.7%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.0% · Q2 89.1% · Q3 76.0% · Q4 70.9% · 4Q avg 82.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
12.5%
2.9 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 9.1% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.2%
0.2 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
75.6%
20.1 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 38.1% |
25.1%
13 pts worse
|
23.9%
14.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 38.1% · Observed 31.8% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-06-27 · Fire 2019-06-27
0 health deficiencies
No concentrated health issue counts in this cycle.
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-05-17 · Fire 2018-05-17
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2022-08-01
E29 · Emergency Preparedness Deficiencies
Fire Safety
Develop a communication plan.
Corrected 2022-09-13
F · Potential for more than minimal harm
2022-08-01
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2022-09-13
F · Potential for more than minimal harm
2022-08-01
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2022-09-13
F · Potential for more than minimal harm
2022-08-01
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-09-13
F · Potential for more than minimal harm
2022-08-01
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 2022-09-24
F · Potential for more than minimal harm
2022-08-01
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Not marked corrected
F · Potential for more than minimal harm
2022-08-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-13
F · Potential for more than minimal harm
2022-08-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-09-24
F · Potential for more than minimal harm
2022-08-01
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2022-09-13
F · Potential for more than minimal harm
2022-08-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-24
E · Potential for more than minimal harm
2022-08-01
K132 · Construction Deficiencies
Fire Safety
Meet requirements for outpatient facilities located next to inpatient facilities separated by fire resistive construction.
Corrected 2022-09-13
E · Potential for more than minimal harm
2022-08-01
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 2022-09-24
E · Potential for more than minimal harm
2022-08-01
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 2022-09-13
E · Potential for more than minimal harm
2022-08-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-13
E · Potential for more than minimal harm
2022-08-01
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2022-09-13
E · Potential for more than minimal harm
2022-08-01
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-09-13
E · Potential for more than minimal harm
2022-08-01
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-09-13
E · Potential for more than minimal harm
2022-08-01
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-09-13
E · Potential for more than minimal harm
2022-08-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-24
E · Potential for more than minimal harm
2022-08-01
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-09-13
E · Potential for more than minimal harm
2022-08-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2022-09-13
F · Potential for more than minimal harm
2019-06-27
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 2019-08-23
F · Potential for more than minimal harm
2019-06-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-08-23
F · Potential for more than minimal harm
2019-06-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2019-08-23
F · Potential for more than minimal harm
2019-06-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-08-23
F · Potential for more than minimal harm
2019-06-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-08-23
F · Potential for more than minimal harm
2018-05-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-06-27
E · Potential for more than minimal harm
2018-05-17
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 2018-06-27
E · Potential for more than minimal harm
2018-05-17
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2018-06-27
E · Potential for more than minimal harm
2018-05-17
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-06-27
E · Potential for more than minimal harm
2018-05-17
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2018-06-27
E · Potential for more than minimal harm
2018-05-17
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 2018-06-27
E · Potential for more than minimal harm
2018-05-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2018-06-27
Inspection history
Recent health citations
G · Actual harm
2022-08-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2022-09-13
F · Potential for more than minimal harm
2022-08-01
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 2022-09-13
F · Potential for more than minimal harm
2022-08-01
F803 · Nutrition and Dietary Deficiencies
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 2022-09-13
F · Potential for more than minimal harm
2022-08-01
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 2022-09-13
E · Potential for more than minimal harm
2022-08-01
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 2022-09-13
E · Potential for more than minimal harm
2022-08-01
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-09-13
D · Potential for more than minimal harm
2022-08-01
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 2022-09-13
D · Potential for more than minimal harm
2022-08-01
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-09-13
Penalties and ownership
What sits behind the stars
Ownership
Adam, Sandra
Corporate Director · Individual
Gumina, Laurence
Operational/Managerial Control · Individual
Gumina, Laurence
Corporate Officer · Individual
Joyce, James
Corporate Director · Individual
Stillman, Robert
Corporate Officer · Individual
White, Terry
Corporate Director · Individual
Nearby options
Other facilities in reach
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3-star overall rating with 4-star inspections with 4 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#2
Majestic Care Of Middletown LLC
Middletown, OH
2-star overall rating with 1-star inspections with $108,164 in total fines with 6 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
#3
The Laurels Of Middletown
Middletown, OH
4-star overall rating with 3-star inspections with 14 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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