Mount Gilead, OH
4-star overall rating with 3-star inspections with 14 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
841 W Marion Rd, Mount Gilead, OH
(419) 947-2015
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
75
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Atrium Centers
Operator or chain grouping
Approved since
1995-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
26 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
0.78
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.96 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.14 · national 2.35
Total nurse hours
3.24
All reported nurse hours · state 3.72 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.59 · national 1.54
Weekend hours
2.70
Weekend nurse staffing · state 3.29 · national 3.43
Weekend RN hours
0.45
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
0.83
CMS adjusted RN staffing hours
Adjusted total hours
3.46
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 47% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
2,927
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
46.89
Composite VBP score used to determine payment impact.
Payment multiplier
1.0003
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.89
Baseline 24.09% · Performance 20.99% · Measure score 3.89 · Achievement 0.96 · Improvement 3.89
Healthcare-associated infections
4.46
Baseline 10.19% · Performance 7.61% · Measure score 4.46 · Achievement 0.74 · Improvement 4.46
Total nurse turnover
8.67
Baseline 23.81% · Performance 28.26% · Measure score 8.67 · Achievement 8.67 · Improvement 0
Adjusted total nurse staffing
1.74
Baseline 2.59 hours · Performance 3.31 hours · Measure score 1.74 · Achievement 0.81 · Improvement 1.74
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.58% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 58 · Observed rate 6.9% · Lower 95% interval 6.07% |
| Discharge to community | 59.52% |
50.57%
9 pts better
|
No Different than the National Rate · Eligible stays 35 · Observed rate 54.29% · Lower 95% interval 46.88% |
| Medicare spending per beneficiary | 1.24 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 21 · Denominator 21 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 21 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 21 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.61% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 28 · Observed rate 10.71% · Lower 95% interval 3.81% |
| Staff COVID-19 vaccination coverage | 3.85% |
8.2%
4.3 pts worse
|
Numerator 3 · Denominator 78 |
| Staff flu vaccination coverage | 19.75% |
42%
22.2 pts worse
|
Numerator 16 · Denominator 81 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.3 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 82.1% |
92.4%
10.3 pts worse
|
93.4%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 64.8% · Q2 64.3% · Q3 98.2% · Q4 100.0% · 4Q avg 82.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.2% |
94.5%
3.7 pts better
|
95.5%
2.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.2% |
3.3%
1.1 pts better
|
3.3%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.6% · Q3 1.8% · Q4 0.0% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
26.1%
25.2 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 0.0% · Q4 1.9% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
6.2%
3.8 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 0.0% · Q3 4.8% · Q4 0.0% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.4% |
25.4%
1 pts better
|
19.6%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 24.4% · Q3 27.9% · Q4 22.2% · 4Q avg 24.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.1% |
11.5%
6.4 pts better
|
16.7%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 5.7% · Q3 8.8% · Q4 0.0% · 4Q avg 5.1% · 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 | 4.9% |
7.7%
2.8 pts better
|
16.3%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 10.3% · Q4 3.8% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.7% |
6.2%
1.5 pts worse
|
14.9%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 7.5% · Q3 7.1% · Q4 13.6% · 4Q avg 7.7% · 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 | 0.5% |
0.5%
About the same
|
1.7%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.9% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 7.4% |
21.7%
14.3 pts better
|
19.8%
12.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 0.0% · Q3 16.7% · Q4 11.0% · 4Q avg 7.4% |
| Percentage of long-stay residents with pressure ulcers | 4.0% |
3.7%
0.3 pts worse
|
5.1%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 6.5% · Q4 8.1% · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 61.5% |
78.1%
16.6 pts worse
|
81.7%
20.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 34.6% · Q3 74.1% · Q4 98.4% · 4Q avg 61.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.0% |
12.5%
1.5 pts worse
|
12.0%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.0% · Observed 13.8% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.7% |
1.2%
3.5 pts worse
|
1.6%
3.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 6.5% · Q3 3.3% · Q4 0.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 48.1% |
75.6%
27.5 pts worse
|
79.7%
31.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 48.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 35.0% |
25.1%
9.9 pts worse
|
23.9%
11.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 35.0% · Observed 31.0% · Expected 21.2% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Resident Assessment and Care Planning (3 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
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 2025-02-28
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-28
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-28
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-02-28
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-28
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-28
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-28
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-08
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-08
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-08
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-08
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-09-03
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2021-09-03
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-18
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-18
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-18
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-02-28
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-02-28
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 2025-02-28
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-02-28
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-02-28
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-02-28
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-02-28
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2025-02-25
Health
Implement a program that monitors antibiotic use.
Corrected 2025-02-28
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-02-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-19
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-12-08
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-12-08
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-12-08
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 2023-12-08
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-08
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 2023-12-08
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-08
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-09-03
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2021-09-03
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 2021-09-03
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2021-09-03
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 2021-09-03
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-09-03
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 2021-09-03
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Corporate Director · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
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