Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Laurels Of Mt Vernon The during CMS and state inspections, most recent first.
A cognitively intact resident with mood and anxiety disorders was subjected to frequent 15‑minute visual checks and removal of personal belongings despite no physician order, no documented concerning behaviors, and a psychiatric recommendation to discontinue such monitoring. Staff initiated and continued these checks over several days, visually confirming the resident’s presence and safety, while documentation showed the resident remained behaviorally stable and expressed frustration about the monitoring and lack of access to belongings. Facility leadership and nursing staff later acknowledged there was no clear documentation or clinical justification for starting or prolonging the checks, and that the resident’s belongings were not returned in a timely manner, infringing on the resident’s right to privacy and dignity.
Two residents did not receive comprehensive dementia care services due to inadequate staffing, resulting in missed personal hygiene assistance and scheduled activities. Residents were left unsupervised, and planned activities were not conducted as listed, with staff confirming challenges in providing care and supervision due to limited personnel.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the plan was not prepared, reviewed, and revised by a team of health professionals as required.
A resident with severe cognitive impairment and multiple neurological and psychiatric diagnoses experienced two falls with injury, including one resulting from being pushed by another resident. After hospital evaluation and return to the facility, required neurological checks were not completed or documented, despite orders for continued monitoring. This deficiency was identified during a complaint investigation.
The facility failed to maintain the smoking area in a clean and safe manner, affecting all 89 residents. Observations revealed numerous cigarette butts scattered on the ground instead of in designated ashtrays. The Administrator confirmed the poor condition of the smoking area, and the facility did not effectively implement its Smoking Policy.
The facility failed to date and discard medications properly, affecting six residents and potentially impacting all 89 residents. Observations revealed undated Morphine Sulfate bottles and a Cromolyn ophthalmic solution not discarded after 30 days. An LPN confirmed these findings, highlighting improper medication storage practices.
The facility failed to maintain a clean and sanitary environment for four residents, as observed during a survey. A resident's privacy curtain was found with black marks and blue stains, confirmed by a CNA. An environmental tour with the Administrator revealed that the rooms of three other residents also had stained privacy curtains. The housekeeping schedule indicated that resident rooms are scheduled for deep cleaning every 30 to 45 days, suggesting a lapse in maintaining cleanliness standards.
The facility failed to notify the guardians of two residents about falls, as required by policy. One resident with Alzheimer's and major depression experienced multiple falls without guardian notification. Another resident with severe cognitive impairment also had a fall without notification to the power of attorney. The DON confirmed the lack of notifications.
A facility failed to ensure accurate dental assessments for a resident with multiple health issues, including dementia and malnutrition. The resident's admission MDS inaccurately reported no dental issues, while observations showed broken, missing, and decayed teeth. The DON confirmed the MDS error, and the Social Service Assistant was unaware of the dental issues, with the resident not having seen a dentist since admission.
A facility failed to create a comprehensive dental care plan for a resident with multiple health issues, including dementia and malnutrition. The resident had broken and decayed teeth, but no dental care plan was documented. The Social Service Assistant was unaware of the dental issues and believed nursing was responsible for the dental plan, which was not in place.
A facility failed to ensure pressure reduction interventions were in place for a resident at risk for impaired skin integrity. The resident, with moderately impaired cognition and a surgical wound, had orders for heel elevation boots while in bed. However, during an observation, the resident was not wearing the boots, as confirmed by an LPN. This was contrary to the facility's skin management policy.
A resident with a history of falls and medical conditions was not provided with necessary fall interventions, such as non-skid strips and visual cues, as observed during a facility survey. The resident, who required assistance for daily activities, had experienced previous falls, one with a major injury. An LPN confirmed the absence of these interventions, indicating a deficiency in the facility's supervision and accident prevention measures.
The facility failed to properly store and manage respiratory equipment for three residents, leading to deficiencies in care. A resident with COPD had oxygen tubing on the floor, contrary to policy. Another resident's nebulizer and oxygen mask tubing were improperly stored, and a third resident used respiratory devices without physician orders. Staff confirmed these issues, highlighting lapses in adherence to facility policies.
A facility failed to implement non-pharmacological pain interventions for a resident with multiple diagnoses, including acute kidney failure and bipolar disorder. Despite physician orders for Oxycodone and a revision to include non-pharmacological interventions, the resident's MAR showed repeated administration of Oxycodone without documentation of such interventions. The DON confirmed the lack of documentation, which was contrary to the facility's pain management policy.
A resident with multiple diagnoses, including bacteremia and acute kidney failure, did not receive ordered laboratory tests (CBC and BMP) due to a failure in the facility's process. The tests were not completed or rescheduled, as confirmed by interviews with an LPN and the DON.
A facility failed to provide routine dental services for a resident with multiple health issues, including alcoholic cirrhosis and dementia. The resident's admission MDS inaccurately reported no dental issues, but observations revealed broken, missing, and decayed teeth. Interviews confirmed the resident had not been referred to the dentist, and the Social Service Assistant was unaware of any dental problems. The resident confirmed not seeing a dentist since admission, despite the facility's quarterly dental visits.
A resident with severe cognitive impairment and dementia was verbally and physically abused by an LPN, who yelled profanities and forcibly placed the resident back into a wheelchair. The incident was witnessed by two STNAs and reported to the ADON. The resident had a history of aggressive behaviors and was being treated for a urinary tract infection at the time.
Unwarranted 15‑Minute Checks and Delayed Return of Belongings Compromise Resident Privacy
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to privacy and dignity by placing the resident on frequent visual checks without a physician order or clear clinical justification. The resident, who was cognitively intact and had diagnoses including borderline personality disorder, major depressive disorder, anxiety, and insomnia, had a care plan that called for one-to-one monitoring and suicide protocol only if he expressed a desire to harm himself or others. Psychiatry documentation showed that the resident had recently expressed frustration about staff monitoring and feeling targeted and harassed by 15‑minute checks, and the psychiatric provider noted there were no recent threats, no suicidal or homicidal ideation, and recommended discontinuing the 15‑minute checks. After a subsequent pink‑slip and hospital evaluation, the resident was cleared and returned to the facility the same day, with no physician order written for 15‑minute checks and no documented concerning behaviors. Despite the absence of an order and the lack of documented behaviors such as crying, yelling, hitting, threatening, or rejection of care, staff initiated and continued 15‑minute visual checks over multiple days, and removed the resident’s potentially harmful belongings, delaying their return. Guest location visual check forms showed that checks were conducted nearly continuously overnight and then reinitiated the following afternoon and continued into subsequent days. Progress notes documented that the resident exhibited no behaviors during this period and expressed frustration about not having access to personal belongings. Interviews with the DON, Administrator, interim Administrator, and nursing staff confirmed there was no physician order, no consistent documentation supporting why the checks were started or continued, that the resident had been cleared from the pink‑slip and was not considered a safety risk, and that the checks and restriction of belongings continued longer than necessary, which could understandably feel annoying or excessive to the resident.
Failure to Provide Comprehensive Dementia Care and Activities Due to Inadequate Staffing
Penalty
Summary
The facility failed to provide comprehensive, resident-centered services to meet the dementia care needs of residents on the specialty memory care unit. Observations and schedule reviews revealed that staffing was inadequate, with only one CNA and one nurse scheduled on several days. This resulted in residents not receiving timely assistance with personal hygiene, as evidenced by a resident remaining with oatmeal smeared on her sweater sleeve for an extended period. Additionally, scheduled activities intended to promote resident well-being, such as morning stretches, coffee and daily chronicle, and coloring, were not conducted as listed on the activity calendar. Residents were left unsupervised in the dining/activity room, and activity staff did not arrive until later in the day, confirming that planned activities were not provided as scheduled. Further, the lack of staff supervision led to safety concerns, such as a resident entering another resident's room without staff awareness, which was only addressed after being brought to the attention of the nurse. Interviews with staff confirmed the challenges posed by insufficient staffing, including difficulty providing care for residents requiring two-person assistance and the inability to carry out scheduled activities. The administrator acknowledged ongoing staffing shortages due to staff unavailability and training, which contributed to the lack of adequate supervision and activity provision on the memory care unit.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Complete Neurological Checks After Resident Falls with Injury
Penalty
Summary
The facility failed to complete neurological checks for a resident following two separate falls with injuries. The resident, who had diagnoses including dementia, degenerative disease of the nervous system, major depressive disorder, and generalized anxiety disorder, experienced a fall on 06/05/25 and another incident on 06/06/25 in which she was pushed by another resident, resulting in her hitting the back of her head and sustaining a laceration. After the second incident, the resident was transferred to the hospital, where she was found to have a 2.5-centimeter contusion to the left posterior occiput and received medical glue for the wound. Upon the resident's return to the facility, there was no evidence that neurological checks were performed as required, despite the resident likely having a concussion and orders for continued monitoring. The deficiency was confirmed through record review and interview with the Licensed Nursing Home Administrator, who verified the absence of documentation for neurological checks after the resident's return from the hospital. This issue was identified during a complaint investigation and affected one resident out of six reviewed for incidents with injuries.
Improper Maintenance of Smoking Area
Penalty
Summary
The facility failed to maintain the smoking area in a clean and safe manner, which had the potential to affect all 89 residents. During an observation on February 3rd, 2025, at 12:03 P.M., the smoking area in the courtyard was found to be improperly maintained, with numerous cigarette butts scattered on the ground instead of being disposed of in designated ashtrays. A subsequent observation on February 6th, 2025, at 9:18 A.M., conducted with the Administrator, revealed approximately 25 cigarette butts around the courtyard and a pile of cigarette butts that appeared to have been dumped from an ashtray onto the ground. An interview with the Administrator at the same time confirmed the poor condition of the smoking area. A review of the facility's undated Smoking Policy indicated that smoking was permitted in designated areas outside the facility, in compliance with state regulations, but the facility failed to implement this policy effectively.
Medication Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that medications were properly dated and discarded according to professional guidelines, affecting six residents and potentially impacting all 89 residents in the facility. During an observation of the medication storage area for the 300-400 hall, it was found that two residents had opened bottles of Morphine Sulfate solution that were not dated when opened, despite being dispensed in late January. A Registered Nurse confirmed that these medications were not dated upon opening. Further observations in the medication storage area for the 200 hall revealed an opened bottle of Cromolyn ophthalmic solution that was not discarded 30 days after opening, as required by the manufacturer's instructions. Additionally, a multi-vial of Tuberculin purified protein derivative was not dated when opened, although it should be discarded 30 days after opening. An LPN confirmed these findings, and it was noted that three residents were admitted since the Tuberculin was dispensed, indicating potential exposure to improperly stored medication.
Facility Fails to Maintain Clean Environment for Residents
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for four residents, as observed during a survey. On February 3rd, Resident #73's privacy curtain was found to have black marks and blue stains, which was confirmed by a CNA. An environmental tour conducted with the Administrator on February 6th revealed that the rooms of Residents #15, #16, and #27 also had privacy curtains stained by unknown substances. These findings were verified by the Administrator. The housekeeping schedule indicated that resident rooms are scheduled for deep cleaning every 30 to 45 days, suggesting a lapse in maintaining cleanliness standards.
Failure to Notify Guardians of Resident Falls
Penalty
Summary
The facility failed to notify the guardians of two residents about falls that occurred, as required by their policy. Resident #76, who was admitted with diagnoses including encephalopathy, Alzheimer's Dementia, and major depression, experienced multiple falls between August 2024 and January 2025. Despite being at risk for falls and having impaired cognition, there was no documentation that her guardian was notified of any of these incidents. The Director of Nursing confirmed the lack of notification. Similarly, Resident #39, who had severe cognitive impairment and was dependent on assistance for daily activities, experienced a fall in October 2024. The fall investigation revealed that no notifications were made to the power of attorney. The Director of Nursing verified that the notification was not given. The facility's policy required that changes in a resident's status, such as falls, should be communicated to the resident's representative, which was not adhered to in these cases.
Inaccurate Dental Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of assessments for Resident #47, affecting their dental care. Resident #47, who was admitted with multiple diagnoses including alcoholic cirrhosis, alcohol-induced persisting dementia, and severe protein-calorie malnutrition, was noted in the admission Minimum Data Set (MDS) assessment to have no obvious or likely cavities or broken natural teeth. However, observations on two separate occasions revealed that the resident had broken, missing, and decayed teeth. The Director of Nursing confirmed that the admission MDS was incorrect regarding the resident's dental status. Additionally, the Social Service Assistant indicated that the resident had not been referred to the dentist, who visits the facility quarterly, and was unaware of any dental issues. The resident confirmed that they had not seen a dentist since their admission.
Failure to Develop Dental Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident's dental needs. The resident, who was admitted with multiple diagnoses including alcoholic cirrhosis of the liver, alcohol dependence with alcohol-induced persisting dementia, acute kidney failure, viral hepatitis C, severe protein-calorie malnutrition, and anxiety, was found to have broken and decayed lower teeth. Despite the resident's need for supervision or assistance with oral hygiene, there was no evidence in the medical record of a dental care plan. An observation confirmed the dental issues, and an interview with the Social Service Assistant revealed that the resident had not been referred to the dentist, who visits the facility quarterly. The Social Service Assistant was unaware of the dental issues and believed that nursing was responsible for the dental plan of care, confirming that no such plan existed for the resident.
Failure to Implement Pressure Reduction Interventions
Penalty
Summary
The facility failed to ensure that pressure reduction interventions were consistently in place for a resident identified as being at risk for impaired skin integrity. The resident, who had moderately impaired cognition and required assistance with activities of daily living, was admitted with a surgical wound and had diagnoses including injury of the left Achilles tendon, muscle wasting, and bradycardia. The care plan included interventions such as encouraging the resident to float heels while in bed and assisting as needed. Additionally, physician's orders specified the use of heel elevation boots for both feet while the resident was in bed. However, during an observation, it was noted that the resident was not wearing the prescribed elevation boots, a fact confirmed by an LPN present at the time. The facility's policy on skin management, which mandates appropriate interventions for residents with skin impairments, was not adhered to in this instance.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident, identified as Resident #60, who was at risk for fall-related injuries. Resident #60 had a medical history that included end-stage renal disease, obstructive uropathy, chronic kidney disease stage four, osteoarthritis, major depressive disorder, and paroxysmal atrial fibrillation. The resident was assessed to be at risk for falls due to muscle weakness, limited mobility, and the use of psychoactive medications. Interventions to prevent falls included keeping the call light and commonly used items within reach, moving the resident closer to the nurses' station, and using non-skid strips and visual cues to remind the resident to ask for assistance. However, during an observation on February 5, 2025, it was noted that the non-skid strips were not in place, and there were no visual signs posted to remind the resident to ask for help. An interview with an LPN confirmed the absence of these interventions. The resident had previously experienced two falls since admission, one resulting in a major injury. The facility's fall policy required the interdisciplinary team to review all resident falls within 24-72 hours and modify the plan of care to minimize repeat falls, but the necessary interventions were not maintained, leading to a deficiency in providing adequate supervision and accident prevention measures.
Improper Storage and Management of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage and management of respiratory equipment for three residents, leading to deficiencies in respiratory care. Resident #8, who has a history of acute respiratory failure, COPD, and sleep apnea, was observed with oxygen tubing laying on the floor, contrary to the facility's policy that requires tubing to be kept off the floor. The Director of Nursing confirmed this observation, acknowledging that the tubing should have been secured in a bag. Resident #78, diagnosed with Down syndrome and pulmonary embolism, was found with respiratory equipment improperly stored. Observations revealed that the nebulizer and oxygen mask tubing were left in a chair without a bag, and the oxygen nasal cannula was on the floor. Both a CNA and the Director of Nursing confirmed that the equipment should have been stored in a bag, as per facility policy. Resident #286, with diagnoses of influenza A and pneumonia, had an Aerobika device and incentive spirometer in use without corresponding physician orders or inclusion in the plan of care. The Assistant Director of Nursing confirmed the absence of these orders and was unaware of the resident's use of these devices. This oversight indicates a failure to implement and document necessary respiratory interventions for the resident.
Failure to Implement Non-Pharmacological Pain Interventions
Penalty
Summary
The facility failed to implement non-pharmacological pain interventions for a resident who required such services. Resident #237, who was admitted with diagnoses including acute kidney failure, pulmonary emboli, alcohol abuse, bipolar disorder, and weakness, was affected by this deficiency. The resident had intact cognition and required assistance with activities of daily living. The resident's physician orders included a prescription for Oxycodone for pain management, with a revision to include documentation of non-pharmacological interventions such as massage, meditation, and positioning. However, the Medication Administration Record (MAR) showed that the resident was administered Oxycodone multiple times without any documentation of non-pharmacological interventions being attempted or provided prior to the administration of the medication. The Director of Nursing confirmed that there were no non-pharmacological interventions documented on the initial pain medication order and that the revised order included these interventions, but they were marked as nonapplicable on the MAR. The facility's policy on pain management emphasized the inclusion of both pharmacological and non-pharmacological interventions, yet this was not adhered to in the case of Resident #237. The failure to document and attempt non-pharmacological interventions before administering pain medication led to the deficiency identified in the report.
Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory testing was completed for a resident, which was identified during a review of medical records and interviews. The resident, who had a range of diagnoses including bacteremia, acute kidney failure, and bipolar disorder, was admitted with intact cognition and required assistance with activities of daily living. The facility's medical director had requested laboratory tests, specifically a Complete Blood Count (CBC) and Basic Metabolic Panel (BMP), to be completed on a specified date. However, there were no orders for these tests in the resident's physician orders, and the tests were not marked as completed in the Treatment Administration Record. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the laboratory tests were not completed as ordered and were not rescheduled. The LPN explained the process for ordering and completing laboratory tests, which involves faxing the order and laboratory form to the laboratory, with results then faxed back to the facility. Despite this process, the tests for the resident were neither completed nor rescheduled, as confirmed by the Director of Nursing.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure routine dental services were provided for Resident #47, who was admitted with multiple diagnoses including alcoholic cirrhosis of the liver, alcohol dependence with alcohol-induced persisting dementia, acute kidney failure, viral hepatitis C, severe protein-calorie malnutrition, and anxiety. The admission Minimum Data Set (MDS) assessment inaccurately reported the resident's dental status as having no obvious or likely cavities or broken natural teeth. However, observations on two separate occasions revealed that the resident had broken, missing, and decayed teeth. Interviews with the Director of Nursing and a Social Service Assistant confirmed that the resident had not been referred to the dentist, and the Social Service Assistant was unaware of any dental issues. The resident confirmed that he had not seen a dentist since his admission, despite the facility having a dentist who visits quarterly.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect Resident #87, who exhibited severe cognitive impairment and had diagnoses of unspecified dementia and cognitive communication deficit, from verbal and physical abuse. On 04/12/24, LPN #655 was witnessed yelling profanities at Resident #87 and forcibly placing her back into her wheelchair. This incident was observed by STNAs #486 and #499, who reported the abusive behavior to the ADON. Resident #87 had a history of aggressive behaviors and was being treated for a urinary tract infection at the time of the incident. The medical record review revealed that Resident #87 required assistance for activities of daily living and used a wheelchair for mobility. The comprehensive care plan indicated that Resident #87 was incontinent and at risk for cognitive decline and mood fluctuations. On the day of the incident, Resident #87 was exhibiting aggressive behaviors and had been transferred to the hospital for evaluation, returning with a diagnosis of a urinary tract infection and an order for antibiotics. The facility's investigation included statements from multiple staff members who witnessed the abuse. The ADON conducted interviews and assessed Resident #87 for injuries, finding none. The investigation confirmed that LPN #655 had yelled at and forcibly placed Resident #87 into the wheelchair. The incident was reported to the Ohio Board of Nursing, and LPN #655 was terminated from employment at the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mount Vernon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whispering Hills Rehabilitation And Nursing Center | 0.6 mi | ★★★★★ | 13 | 0 |
| Country Court | 1.2 mi | ★★★★★ | 9 | 1 |
| Country Club Retirement Center | 1.3 mi | ★★★★★ | 2 | 0 |
| Als Mount Vernon Inc | 1.8 mi | ★★★★★ | 15 | 0 |
| Ohio Eastern Star Hlth Care Ctr The | 2.1 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.