Inspection visit
Inspection
14 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 14 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0553
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Allow resident to participate in the development and implementation of his or her person-centered plan of
care.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of
Resident #9's medical record revealed admission date of 04/01/21 with diagnoses including Huntington's
Disease, chronic obstructive pulmonary disease (COPD), depression, and anxiety. Resident #9 required
assistance from staff to complete activities of daily living (ADL) and had severely impaired cognition.
Review of Resident #9's IPOC summary dated 02/01/23 revealed the IPOC summary was marked for an
annual review and a quarterly review care conference. The only people in attendance for the care
conference included Resident #9's power of attorney (POA) and the SSD designee #412. There were no
completed IPOC summary review care conferences available to review from 03/01/23 to 06/24/24.
Review of Resident #9's progress notes dated 02/01/23 to 02/20/23 revealed no documentation reflecting
the IPOC care conference completed on 02/10/23. Further review of progress notes dated 03/01/23 to
06/24/24 revealed no documentation for any type of care conference, annual or quarterly, since the care
conference completed on 02/10/23.
Interview on 06/20/24 at 10:20 A.M. with SSD #412 confirmed there were no completed IPOC summary
review care conferences since the IPOC summary care conference dated 02/10/23. SSD #412 further
confirmed the only people in attendance for the care conference dated 02/10/23 was Resident #9's POA
and SSD #412. SS #412 stated there should at least be a nurse, dietary representative, and therapy
representative in attendance for a care conferences. SSD #412 confirmed there should be documentation
in the progress notes to reflect the completion of care conferences.
3. Review of Resident #13's medical record revealed admission date of 11/18/20 with diagnoses including
traumatic brain injury (TBI), stroke, and hemiplegia to left side. Resident #13 required assistance from staff
for ADL tasks and had moderately impaired cognition.
Review of Resident #13's IPOC summary review care conference form dated 04/20/23 revealed the care
conference marked as a quarterly IPOC summary review care conference. The attendees included
Resident #13's family members, the Director of Nursing (DON), the Assistant Director of Nursing (ADON)
#402, and SSD #412. There were no completed annual or quarterly IPOC summary review care
conferences dated from 05/01/23 to 06/24/24 available to review.
Review of Resident #13's progress notes dated 04/01/23 to 05/01/23 revealed no documentation to reflect
the completion of the IPOC summary review care conference dated 04/20/23. Further review of Resident
#13's progress notes dated 05/01/23 to 06/24/24 revealed no documentation was available for review to
reflect an annual or quarterly IPOC summery review care conference completion.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 18
Event ID:
366412
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0553
Level of Harm - Minimal harm
or potential for actual harm
Interview on 06/20/24 at 10:20 A.M. with SSD #412 confirmed Resident #13 only had a quarterly care
conference completed on 04/20/23, and there were no further care conferences completed from 05/01/23
to 06/24/24. SSD #412 stated Resident #13's family requested to only have annual care conferences
instead of quarterly care conferences. SSD #412 confirmed there should be documentation in the progress
notes to reflect the completion of care conferences.
Residents Affected - Some
4. Review of Resident #15's medical record revealed admission date of 05/21/24 with diagnoses including
high blood pressure, anxiety, and bipolar disorder. Resident #15 required minimal assistance from staff for
ADL tasks and had intact cognition. Resident #15 was receiving therapy services in anticipation for
discharge to previous living conditions.
Review of Resident #15's IPOC summary review care conference form dated 06/13/24 revealed the care
conference was marked as a discharge care conference. There was no previous IPOC summary review
care conference forms to review or reflect the completion of an initial care conference completed for
Resident #15.
Review of Resident #15's progress notes dated 05/21/24 to 06/24/24 revealed no documentation available
to review for completed IPOC review care conferences.
Interview on 06/20/24 at 10:20 A.M. with SSD #412 confirmed Resident #15 did not have an initial IPOC
summary review care conference completed upon admission to the facility. SSD #412 stated Resident #15
should have had an initial care conference completed within seven days of admission to the facility. SSD
#412 confirmed there should be documentation in the progress notes to reflect the completion of care
conferences.
Review of the facility's policy titled, Nursing Home Resident's Rights revealed, Nursing home residents
have the right to participate in planning your care and treatment or changes in your care and treatment.
Based on record review, interview, and facility policy review the facility failed to ensure residents and/or
their representatives were invited to participate in initial and quarterly care plan meetings. This affected four
residents (#10, #9, #13, and #15) of five residents reviewed for care plan meetings. The facility census was
19.
Findings include:
1. Review of Resident #10's medical record revealed an admission date of 01/24/23. Medical diagnoses
included chronic obstructive pulmonary disease, unsteadiness on feet, and muscle weakness. Resident
#10 was hospitalized from [DATE] to 05/03/24.
Review of Resident #10's Minimum Data Set (MDS) 3.0 significant change assessment, dated 05/14/24,
revealed a brief interview for mental status (BIMS) score of 02, indicating severely impaired cognition. The
resident was recorded to have an impairment on one side of his upper extremities. Resident #10 required
set up assistance for eating and substantial/maximum assistance for other activities of daily living and
mobility tasks. An additional review of the MDS 3.0 discharge return anticipated, dated 04/29/24, revealed
the resident had one fall with a minor injury.
Review of Resident #10's interdisciplinary progress notes revealed a note dated 05/06/24 which indicated
the resident had pain, edema, and bruising to his right upper extremity. An additional note
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366412
If continuation sheet
Page 2 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0553
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
dated 05/06/24 indicated the facility Nurse Practitioner had ordered an x-ray examination of his right
clavicle. The interdisciplinary progress notes revealed no mention of a care plan meeting being held,
scheduled, or Resident #10's family being invited to such a meeting since the resident admitted to the
facility on [DATE].
Review of an x-ray report, completed at the facility on 05/07/24, revealed Resident #10 had an acute
fracture of the right mid clavicle, with moderate displacement and fracture overlap.
Review of Resident #10's physician's orders revealed orders dated 05/07/24 for the resident to wear a sling
to his right upper extremity and for the resident to be referred to an orthopedic specialist.
Review of Resident #10's Interdisciplinary Plan of Care (IPOC) Summary form, dated 05/04/24, revealed
the reason the IPOC meeting was held was Annual, admission and Significant Change. The form indicated
Resident #10 recently had a fall which resulted in injury with the family choosing to not see an orthopedic
specialist. The summary of the meeting indicated Resident #10's child and Social Services Designee (SSD)
#412 were the only two attendees. Resident #10's child's name was handwritten on the form which did not
include a signature.
A telephone interview conducted on 06/20/24 at 9:00 A.M. with a family member of Resident #10 revealed
knowledge of Resident #10's fall and resulting clavicle fracture at the facility. The family member of Resident
#10 denied ever being informed or refusing an orthopedic consult and indicated the family had previously
transported the resident to all outside appointments via their personal vehicles. The family member of
Resident #10 stated they had never been offered, nor attended, a care conference since the resident
admitted to the facility approximately a year and a half ago.
An interview conducted on 06/20/24 at 10:18 A.M. with SSD #412 revealed she coordinated the care plan
meetings at the facility. SSD #412 stated only she and the daughter of Resident #10 were present for the
care conference dated 05/04/24 and the date on the form indicated the date the care conference was held.
The surveyor informed SSD #412 that the documentation on the form stated the family refused an
orthopedic consult days before Resident #10's x-ray examination was ordered, completed, or revealed a
fracture. SSD #412 verified the documentation was incorrect and stated that the correct date for the care
plan meeting was 05/24/24. SSD #412 confirmed there was no documentation of scheduling or notices
provided to coordinate a care plan meeting, and the IPOC Summary dated 05/04/24 contained no evidence
that a nurse or other department representative was present at the care plan meeting. SSD #412 stated
documentation should be completed in the resident's electronic medical record reflecting a care conference
was scheduled, held and afterwards, a summary contained in the resident's electronic medical record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366412
If continuation sheet
Page 3 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on observation, interview, and facility policy review the facility failed to maintain a clean home like
environment in resident rooms. This deficient practice affected one resident (#17) out of 19 residents
reviewed for environment. The facility census was 19.
Findings include:
Observation on 06/17/24 at 8:45 A.M. revealed Resident #17's outer doorframe was noted to have missing
paint and dry wall covering. The area was observed on the wall surrounding the doorframe. The
appearance of having had plastic covering taped around the doorframe and doorway was evident. The
largest area was approximately four inches wide with paint and dry wall covering missing exposing the dry
wall backing paper. Further observation inside Resident #17's room revealed the wall to the left side of the
bed with multiple vertical large, long (approximately 12 inches long) gouges running the length of the bed.
The gouges were deep enough for the dry wall material to be visible, approximately one-half inch deep,
with torn dry wall covering hanging loosely on the wall. Resident #17's bed was against the wall with
Resident #17's left side being towards the damaged wall.
Interview on 06/24/24 at 9:35 A.M. with Maintenance Staff #416 confirmed the gouges being deep enough
for the dry wall material to be visible, approximately one-half inch deep, with torn dry wall covering hanging
loosely on the wall to the left side of the bed and the outer doorframe areas of missing dry wall and
non-painted areas.
Review of the facility's policy titled Resident Environmental Quality, dated 08/22, revealed, It is the policy of
this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary,
and comfortable environment for residents, staff, and the public.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366412
If continuation sheet
Page 4 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, staff interview, and record review the facility failed to accurately code the Minimum
Data Set (MDS) 3.0 assessment for Residents #10 and #11. This affected two residents (#10 and #11) of
11 residents reviewed for accuracy of assessments. The facility census was 19.
Residents Affected - Few
Findings include:
1. Review of Resident #10's medical record revealed an admission date of 01/24/23. Medical diagnoses
included chronic obstructive pulmonary disease, unsteadiness on feet, and muscle weakness.
Review of Resident #10's MDS 3.0 significant change assessment, dated 05/14/24, revealed a brief
interview for mental status (BIMS) score of 02, indicating severely impaired cognition. The resident was
recorded to have an impairment on one side of his upper extremities. Resident #10 required set up
assistance for eating and substantial/maximum assistance for other activities of daily living (ADL) and
mobility tasks. An additional review of the MDS 3.0 discharge return anticipated assessment, dated
04/29/24, revealed the resident had one fall with a minor injury, and no falls with a major injury.
Review of Resident #10's progress notes revealed a note dated 04/29/24 at 12:25 A.M. indicating a thud
was heard from the resident's room. When staff entered the room, the resident was observed on the floor
underneath his bedside table. The resident reported he had been attempting to change clothes when he
fell. The resident complained of pain to his right arm and head, with a knot noted near his right clavicle.
Resident #10 was transferred and admitted to a local hospital.
Review of a facility incident report, dated 04/29/24, revealed Resident #10 sustained a fall and was noted
with a quarter sized knot near his right clavicle. The report indicated that Resident #10 was transferred and
admitted to a local hospital.
Review of hospital records for Resident #10, dated 04/29/24, revealed an x-ray examination of the right
humerus was completed on 04/29/24 which showed no definitive fracture. The hospital records revealed no
indication that a right clavicle x-ray examination had been completed while the resident was at the hospital.
Review of Resident #10's vitals and pain assessment, dated 05/07/24, revealed the resident complained of
pain rated at 7/10 on a 01-10 scale. The pain was described as aching and stiffness, worse with movement.
Resident #10 was additionally observed to have edema (swelling) to his right upper extremity.
Review of an x-ray report, completed at the facility on 05/07/24, revealed Resident #10 had an acute
fracture of the right mid clavicle, with moderate displacement and fracture overlap.
An interview conducted on 06/18/24 at 2:12 P.M. with the Director of Nursing (DON) revealed Resident #10
sustained a fall resulting in injury on 04/29/24 and was transported to the hospital, where he was admitted .
The injury was a knot on his right clavicle, and the resident complained of arm pain. The DON stated she
believed the hospital would have completed an x-ray examination of the clavicle, but the hospital only
x-rayed the humerus (upper arm bone) which was not fractured. After the resident returned to the facility
and was still having pain, the facility obtained an order to x-ray the clavicle. The DON confirmed the fracture
to Resident #10's clavicle was a result of the fall
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366412
If continuation sheet
Page 5 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0641
sustained on 04/29/24.
Level of Harm - Minimal harm
or potential for actual harm
An interview conducted on 06/18/24 at 10:21 A.M. by phone with MDS Nurse #250 revealed she was
unaware of Resident #10's fall on 04/29/24 resulted in a fractured clavicle. MDS Nurse #250 stated
although the fracture was not noted at the time of the hospital transfer, she should have modified the MDS
assessment once it was determined Resident #10 sustained a fracture, as that would be considered a
major injury. MDS Nurse #250 stated the assessment was incorrect and stated she would complete a
modification of Resident #10's MDS assessment to reflect one fall with major injury.
Residents Affected - Few
Review of the Resident Assessment Instrument (RAI) Manual, revised October 2023, revealed an injury
related to a fall included any documented injury that occurred as a result of, or was recognized within a
short period of time after the fall and attributed to the fall. The RAI Manual identified a major injury included
bone fractures and joint dislocations.
2. Observation on 06/17/24 at 9:05 A.M. revealed Resident #11 sitting in a recliner chair receiving
continuous two liters of oxygen therapy from an oxygen concentrator via a nasal canula tubing.
Review of Resident #11's medical record revealed an admission date of 05/03/24 with diagnoses including
pneumonia, high blood pressure, heart failure, and rib fractures. Resident #11 required assistance from
staff to complete ADL tasks and had moderately impaired cognition with a score of seven out of fifteen on
Brief Interview of Mental Status (BIMS) score.
Review of Resident #11's at risk for altered respiratory status care plan dated 05/14/24 revealed an
intervention for the use of oxygen as ordered.
Review of Resident #11's admission MDS 3.0 assessment, dated 05/07/24, revealed Section O - Special
Treatments, Procedures, and Programs C1 Oxygen therapy was marked as being used on admission and
while being a resident.
Review of Resident #11's significant change MDS 3.0 assessment, dated 05/15/24, revealed Section O
Special Treatments, Procedures, and Programs C1 Oxygen therapy was marked as not being used while
being a resident.
Interview on 06/24/24 at 10:25 A.M. with the MDS Registered Nurse (RN) #450 confirmed Resident #11's
significant change MDS 3.0 assessment, dated 05/15/24, was coded incorrectly to reflect Resident #11 did
not use oxygen therapy.
Review of the RAI 3.0 User's Manual, dated October 2023, revealed the steps for assessment include,
Review the resident's medical record to determine whether or not the resident received or performed any of
the treatments, procedures, or programs within the assessment period defined for each column.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366412
If continuation sheet
Page 6 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, staff and resident interview, record review, and facility policy review, the facility failed to
complete a physician-ordered orthopedic consult for Resident #10, and failed to ensure dressings were
changed as ordered for Resident #5. This affected two residents (#10 and #5) of 11 residents reviewed for
quality of care. The facility census was 19.
Residents Affected - Few
Findings include:
1. Review of Resident #10's medical record revealed an admission date of 01/24/23. Medical diagnoses
included chronic obstructive pulmonary disease, unsteadiness on feet, and muscle weakness. Resident
#10 was hospitalized from [DATE] to 05/03/24.
Review of Resident #10's Minimum Data Set (MDS) 3.0 significant change assessment, dated 05/14/24,
revealed a brief interview for mental status (BIMS) score of 02, indicating severely impaired cognition. The
resident was recorded to have an impairment on one side of his upper extremities. Resident #10 required
set up assistance for eating and substantial/maximum assistance for other activities of daily living (ADL)
tasks and mobility tasks. An additional review of the MDS 3.0 discharge return anticipated, dated 04/29/24,
revealed the resident had one fall with a minor injury.
Review of an x-ray report, completed at the facility on 05/07/24, revealed Resident #10 had an acute
fracture of the right mid clavicle, with moderate displacement and fracture overlap.
Review of Resident #10's physician's orders revealed orders dated 05/07/24 for the resident to wear a sling
to his right upper extremity, and for the resident to be referred to an orthopedic specialist.
Review of Resident #10's interdisciplinary progress notes revealed a note dated 05/06/24 which indicated
the resident had pain, edema, and bruising to his right upper extremity. An additional note dated 05/06/24
indicated the facility Nurse Practitioner had ordered an x-ray examination of his right clavicle. Subsequent
progress notes contained no evidence that Resident #10's referral to an orthopedic specialist had been
completed or that a discussion had taken place with Resident #10's family regarding the orthopedic
consultation.
An observation and interview on 06/18/24 at 8:38 A.M. with Resident #10 revealed him seated on the edge
of the bed. The resident denied pain when asked and denied any recent falls or hospitalizations, stating he
could not remember. The resident was not wearing a sling and was observed to feed himself breakfast.
An interview on 06/18/24 at 2:12 P.M. with the Director of Nursing (DON) revealed Resident #10 had a fall
on 04/29/24 with a documented injury to his right clavicle, described as a quarter-sized knot. The DON
stated the resident was transported to the hospital and admitted , and upon the return to the facility, the
facility obtained an x-ray of the resident's clavicle as he was having ongoing pain. The resident's x-ray
indicated a fracture to the right clavicle on 05/07/24, which the DON stated she attributed as being related
to the fall on 04/29/24. The DON stated she thought the hospital would have x-rayed the resident's clavicle,
but they only obtained x-ray imaging for the humerus (upper arm bone). The DON stated the facility Nurse
Practitioner ordered an orthopedic consultation and a sling on 05/07/24 and verified there was no evidence
in the medical record of the orthopedic
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366412
If continuation sheet
Page 7 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
consult being completed. The DON stated the resident's family possibly refused the orthopedic consult but
verified there were also no refusals recorded in Resident #10's medical record but there should have been.
An interview on 06/18/24 at 3:54 P.M. with Registered Nurse (RN) #413 revealed Resident #10 recently had
a fracture identified to his right clavicle. Nursing staff had provided pain management, and over a few weeks
the pain decreased, and the resident was gradually able to regain his range of motion. RN #413 stated he
believed the family possibly did not want the resident to go to any outside providers.
A telephone interview on 06/20/24 at 9:00 A.M. with a family member of Resident #10 revealed knowledge
of the resident's recent fall at the facility on 04/29/24 and his return to the hospital. The family member
indicated the fall on 04/29/24 resulted in a broken collarbone that the facility identified upon the resident's
return from the hospital. The family member stated they were never notified of the resident being referred to
an orthopedic specialist, and stated she would have been aware as they previously transported the resident
to all outside appointments.
Review of the facility policy titled Provision of Physician Ordered Services, dated 10/2023, revealed
qualified nursing personnel will submit timely requests for physician ordered services (including
consultations) to the appropriate entity. Documentation of consultations will be maintained in the resident's
clinical record.
2. Review of Resident #5's medical record revealed an admission date of 02/03/23. Medical diagnoses
included diabetes mellitus, a history of a myocardial infarction, and dementia with unspecified severity.
Review of Resident #5's MDS 3.0 quarterly assessment, dated 04/17/24, revealed a BIMS score of 09,
indicating moderately impaired cognition.
Review of Resident #5's incident report revealed the resident sustained a fall on 06/15/24 when he was
ambulating without his assistive device. The fall resulted in a skin tear to the resident's left outer forearm.
The listed intervention included education on the use of proper footwear.
Review of Resident #5's physician's orders revealed an order dated 06/18/24 to treat a recently obtained
skin tear. The order called for staff to replace border foam to the resident's left outer forearm every three
days, and check steri-strip placement. The order instructed staff to not remove steri-strips, as they will fall
off on their own. The order was scheduled to be completed on day shift between 7:00 A.M. and 7:00 P.M. on
the designated days.
Review of Resident #5's June 2024 Treatment Administration Record (TAR) revealed the dressing was
documented as being completed on 06/18/24 and 06/21/24.
An observation on 06/24/24 at 8:06 A.M. revealed Resident #5 seated at the dining room table. He had
eaten all of his breakfast and was observed coloring. The resident was observed with a dressing on his left
elbow dated 06/18/24.
An interview on 06/24/24 at 8:59 A.M. with the DON verified Resident #5's dressing was still dated 06/18/24
and was not completed as documented on 06/21/24. The DON stated the dressing needed to be changed.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366412
If continuation sheet
Page 8 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0684
Level of Harm - Minimal harm
or potential for actual harm
Review of the facility policy titled Wound Care, dated 08/2023, revealed treatments should be completed
per physician's orders. Following the completion of the treatment, the nurse should document in the
resident's electronic medical record.
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366412
If continuation sheet
Page 9 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
Based on observation, record review, interview, and facility policy review the facility failed to ensure safety
interventions were implemented and were appropriate for residents assessed to be at high risk for falls. This
deficient practice affected two residents (#6 and #9) out of five residents reviewed for accidents. The facility
census was 19.
Findings include:
Observation on 06/24/24 at 8:07 A.M. revealed Resident #9 sitting at the dining room table eating breakfast.
Resident #9 was wearing light blue non-skid socks on his feet. The right foot sock was halfway on the foot
with the toe of sock was folded under the foot and dragging on the floor. Resident #9's four wheeled walker
was located behind the dining room chair approximately two feet out of Resident #9's reach. Resident #9
stood up from the table when State Tested Nursing Assistant (STNA) #421 came over to the table to assist
Resident #9. Resident #9 reached for the four wheeled walker, grabbed hold of the handles and then lost
balance tipping the walker over to the left side, Resident #9 regained his balance and began to ambulate
through the dining room. STNA #412 did not attempt to assist Resident #9 with bringing the four wheeled
walker to within his reach, regaining his balance or attempting to readjust the right sock that was dragging
on the floor.
Review of Resident #9's medical record revealed admission date of 04/01/21 with diagnoses including
Huntington's Disease, chronic obstructive pulmonary disease (COPD), depression, anxiety, and history of
falls. Resident #9 required assistance from staff to complete activities of daily living (ADL) and had severely
impaired cognition. Resident #9 used a four wheeled walker for assistance with independent ambulation,
and severely impaired balance and gait due to the diagnosis of Huntington's Disease.
Review of Resident #9's recent fall investigations dated 09/04/23, 10/16/23, 12/23/23, 12/25/24, 01/11/24,
and 06/06/24 revealed the falls occurred in the dining room during mealtime and involved Resident #9
attempting to sit in a chair or standing up from the table following the completion of the meal. Safety
measures implemented for these falls include the following:
09/04/23 - Resident #9 encouraged to ask staff for help during transfers and sitting.
10/16/23 - Resident #9 educated to use walker when out of bed.
12/23/23 - Resident #9 to notify staff if stuck behind chair and needing assistance
12/25/23 - Staff educated to assist Resident #9 to the chair when coming into the dining room for meals.
01/11/24 - Staff educated to continue with current fall prevention interventions.
06/06/24 - Resident #9 educated to ask for help when transferring or sitting.
Review of Resident #9's at risk for falls care plan dated 06/13/21 revealed other safety measures including
providing staff assistance as needed, to wear non-skid footwear when ambulating, and implement fall
prevention devices as ordered by the physician.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366412
If continuation sheet
Page 10 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Interview on 06/24/24 at 8:58 A.M. with STNA #438 confirmed Resident #9's right sock was folded under
his foot and was dragging on the floor. STNA #438 stated Resident #9 should have shoes on instead of the
non-skid socks.
Interview on 06/24/24 at 9:20 A.M. with the Director of Nursing (DON) confirmed Resident #9's fall
interventions were repetitive and ineffective safety measures due to Resident #9's impaired cognition. The
DON stated it has been challenging to implement safety measures for Resident #9 due to diagnosis and
impaired cognition.
2. Review of Resident #6's medical record revealed an admission date of 09/07/23. Medical diagnoses
included dementia without behavioral disturbances, anemia in chronic kidney disease, and diabetes.
Review of Resident #6's MDS 3.0 quarterly assessment, dated 05/28/24, revealed Resident #6 was
recorded to have a Brief Interview for Mental Status score of 00, indicating severely impaired cognition. The
resident was recorded as requiring set-up assistance for eating and was dependent on staff for all other
ADL and mobility tasks.
Review of Resident #6's fall risk assessment, dated 06/01/24, revealed the resident scored a 9, indicating
she was at risk for falls.
Review of Resident #6's interdisciplinary progress notes revealed a note dated 06/01/24 which indicated
Resident #6 fell out of bed. The resident was assessed for injury and transferred to the local hospital for
evaluation in the emergency department. Resident #6 returned to the facility later that date after all x-rays
and scans returned negative for injury. Resident #6's listed interventions included implementation of a
perimeter mattress and a padded mat to the floor to the open side of the bed.
Review of Resident #6's care plan, revised 06/02/24, revealed the resident was at risk for falls and potential
injury related to weakness and dementia. Listed interventions included a bed with a perimeter mattress, a
floor mat to the exit side of bed, and keeping commonly used articles within easy reach.
An observation on 06/24/24 at 8:09 A.M. revealed Resident #6 in bed with the head of bed elevated. Her
breakfast tray was in front of her. The padded mat was in a folded position leaning against the wall,
approximately six feet from the resident's bed.
An observation and interview on 06/24/24 at 8:14 A.M. with STNA #438 revealed Resident #6 remained in
bed, awake and alert, feeding herself a sausage link. STNA #438 verified Resident #6's padded fall mat
was not in place and should have been. STNA #438 replaced the fall mat during the interview.
Review of the policy titled Managing Falls and Fall Risk, reviewed 08/2023, revealed based on previous
evaluations and current data, staff will identify interventions related to the resident's risks and causes to try
to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input
of the attending physician/ nurse practitioner (NP) as needed, will implement a resident-centered fall
prevention plan to reduce the specific risk factors of falls for each resident. Staff will monitor residents'
response to interventions intended to reduce falling.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366412
If continuation sheet
Page 11 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, record review, interview, and review of the facility policy the facility failed to obtain a
physician's order for the administration of oxygen therapy. This deficient practice affected one resident (#11)
out of one resident reviewed for respiratory care. The facility census was 19.
Residents Affected - Few
Findings include:
Observation on 06/17/24 at 8:23 A.M. revealed Resident #11 sitting in a recliner chair receiving continuous
two liters of oxygen therapy from an oxygen concentrator via a nasal canula tubing.
Review of Resident #11's medical record revealed an admission date of 05/03/24 with diagnoses including
pneumonia, high blood pressure, heart failure, and rib fractures. Resident #11 required assistance from
staff to complete activities of daily living (ADL) tasks and had moderately impaired cognition with a score of
seven out of fifteen on Brief Interview of Mental Status (BIMS) score.
Review of Resident #11's at risk for altered respiratory status care plan dated 05/14/24 revealed
intervention for the use of oxygen as ordered.
Review of Resident #11's hospice progress notes dated 05/09/24 revealed a physician order for oxygen two
to five liters continuous via nasal cannula tubing.
Review of Resident #11's physician orders dated 06/01/24 revealed no order transcribed for oxygen two to
five liters continuous via nasal cannula tubing.
Interview on 06/17/24 at 4:17 P.M. with Licensed Practical Nurse (LPN) #475 confirmed Resident #11 did
not have physician's order for oxygen two to five liters continuous via nasal cannula tubing. LPN #475
stated Resident #11 has always been using oxygen since admission.
Review of the facility's policy titled, Oxygen Administration dated 04/01/23 revealed, Oxygen is
administered under orders of a physician.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366412
If continuation sheet
Page 12 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
Based on record review and staff interview, the facility failed to ensure there was a registered nurse (RN)
on duty for at least eight consecutive hours a day, seven days a week as required. This had the potential to
affect all 19 residents currently residing in the facility.
Findings include:
Review of the staff schedule for June 2024 revealed there was no RN scheduled in the building on 06/01/24
(Saturday), 06/02/24 (Sunday), 06/05/24, 06/06/24, 06/07/24, 06/10/24, 06/11/24, 06/14/24, 06/15/24
(Saturday), 06/16/24 (Sunday), 06/17/24, 06/19/24, 06/20/24, 06/21/24, 06/24/24, 06/25/24, 06/28/24,
06/29/24 (Saturday) and 06/30/24 (Sunday).
Interview on 06/19/24 2:45 P.M. with Licensed Practical Nurse (LPN) #402 confirmed the schedule does not
have an RN listed for at least eight hours a day, seven days a week. LPN #402 stated The director of
nursing (DON) is here the days the RN is not. I can fix the schedule to reflect that. When asked about the
weekend RN coverage no explanation was given, and no evidence was provided there was an RN in the
facility every Saturday and Sunday.
Interview on 06/20/24 10:43 A.M. with RN #600 confirmed there is no RN on the schedule for eight hours a
day, seven days a week.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366412
If continuation sheet
Page 13 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0757
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Level of Harm - Minimal harm
or potential for actual harm
Based on staff interview, record review, and facility policy review, the facility failed to ensure
physician-ordered medication parameters were followed for Residents #4 and #5. This affected two (#4 and
#5) of six residents reviewed for unnecessary medications. The facility census was 19.
Residents Affected - Few
Findings include:
1. Review of Resident #4's medical record revealed an admission date of 09/06/19. Medical diagnoses
included cerebrovascular accident (stroke), atrial fibrillation, coronary artery disease, and hypertension.
Review of Resident #4's Minimum Data Set (MDS) 3.0 quarterly assessment, dated 06/03/24, revealed the
resident had a Brief Interview for Mental Status score of six, indicating severely impaired cognition.
Review of Resident #4's physician's orders revealed an order dated 05/13/24 for Carvedilol (an
antihypertensive medication to lower blood pressure and/or heart rate) 3.125 milligram (mg) one tablet
twice daily, with instructions to hold the medication for a systolic blood pressure less than 90 or for a resting
heart rate less than 60. Resident #4 also had an order dated 05/13/24 for lisinopril (an antihypertensive
medication to lower blood pressure) 5 mg once daily with instructions to hold the medication if the systolic
blood pressure is less than 110.
Review of Resident #4's May 2024 Medication Administration Record (MAR) revealed the resident was
administered the dose of Carvedilol when his heart rate was recorded as being less than 60 beats per
minute. These administrations occurred on 05/01/24, 05/02/24, 05/06/24, 05/11/24, 05/12/24, 05/16/24,
05/25/24, 05/28/24, 05/29/24, and 05/30/24. Additionally, Resident #4 was administered the dose of
lisinopril when his systolic blood pressure was less than 110 on 05/01/24 and 05/30/24.
Review of Resident #4's June 2024 MAR revealed the resident was administered the dose of Carvedilol
when his heart rate was less than 60 beats per minute on 06/04/24, 06/08/24, 06/09/24, and 06/18/24.
Resident #4 was administered his ordered dose of lisinopril on 05/13/24 when his systolic blood pressure
was recorded as less than 110.
2. Review of Resident #5's medical record revealed an admission date of 02/03/23. Medical diagnoses
included diabetes mellitus, a history of a myocardial infarction, and dementia with unspecified severity.
Review of Resident #05's MDS 3.0 quarterly assessment, dated 04/17/24, revealed a BIMS score of nine,
indicating moderately impaired cognition.
Review of Resident #5's physician's orders revealed an order dated 11/02/23 for Midodrine (a medication
used to raise blood pressure) 5 mg once daily, with instructions to hold the medication if the systolic blood
pressure was greater than 120.
Review of Resident #5's May 2024 and June 2024 MAR revealed no correlating blood pressure
documented prior to medication administration.
An interview conducted on 06/17/24 at 8:23 A.M. with Resident #5 revealed he had a recent fall and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366412
If continuation sheet
Page 14 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0757
reported sometimes he felt dizzy.
Level of Harm - Minimal harm
or potential for actual harm
An interview conducted on 06/20/24 at 10:42 A.M. with Assistant Director of Nursing (ADON) #402 verified
Resident #4's medications had been administered outside of parameters when the medication should have
been held. ADON #402 additionally verified Resident #5 should have had correlating blood pressure
documented prior to medication administration but did not.
Residents Affected - Few
Review of the policy titled Medication Administration - General Guidelines, dated 07/01/21, revealed
medications are administered as prescribed in accordance with good nursing principles and practices.
Medications are administered in accordance with written orders of the prescriber.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366412
If continuation sheet
Page 15 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0758
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on record review, interview, and facility policy review the facility failed to complete routine
assessments for monitoring of psychotropic medication side effects. This deficient practice affected one
resident (#9) out of five residents reviewed for unnecessary medications. The facility census was 19.
Findings include:
Review of Resident #9's medical record revealed admission date of 04/01/21 with diagnoses including
Huntington's Disease, chronic obstructive pulmonary disease (COPD), depression, anxiety, and history of
falls. Resident #9 required assistance from staff to complete activities of daily living (ADL) and had severely
impaired cognition. Resident #9 used a four wheeled walker for assistance with independent ambulation
and had severely impaired balance and gait due to the diagnosis of Huntington's Disease.
Review of Resident #9's physician orders revealed an order with revised date of 06/12/24 for antipsychotic
medication Olanzapine oral tablet 7.5 milligrams (mg) give one tablet by mouth one time a day related to
Huntington's Disease.
Review of Resident #9's completed routine assessments revealed a completed Abnormal Involuntary
Movement Scale (AIMS) dated 10/04/21 with the results of minimal/normal severity of abnormal
movements at a score of ten out of 28. The next completed AIMS for Resident #9 was dated 01/24/24 with
the results of moderate severity of abnormal movements for Resident #9 with a score of 18 out of 28.
Interview on 06/24/24 at 9:16 A.M. with the Director of Nursing (DON) confirmed Resident #9 was receiving
the anti-psychotic medication Olanzapine for some time and there were not any AIMS assessments
completed prior to 01/24/24, and there had not been an AIMS completed since 01/24/24. The DON stated
the AIMS assessments should be completed when an anti-psychotic medication is initiated and at least
quarterly for routine monitoring of side effects with the use of anti-psychotic medications.
Review of the facility's policy titled, Medication Monitoring and Management, dated 07/14/21, revealed, In
order to optimize the therapeutic benefits of medication therapy and minimize or prevent potential adverse
consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform
ongoing monitoring for appropriate, effective, and safe medication use.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366412
If continuation sheet
Page 16 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0790
Provide routine and 24-hour emergency dental care for each resident.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, staff and resident interview, and record review, the facility failed to recognize Resident #5's
bottom dentures were missing and failed to timely refer him to a dental provider. This affected one resident
(#5) of one resident reviewed for dental services. The facility census was 19.
Residents Affected - Few
Findings include:
Review of Resident #5's medical record revealed an admission date of 02/03/23. Medical diagnoses
included diabetes mellitus, a history of a myocardial infarction, and dementia with unspecified severity. The
record contained no evidence Resident #5 had seen a dental provider since admission on [DATE].
Review of Resident #5's Minimum Data Set (MDS) 3.0 quarterly assessment, dated 04/17/24, revealed a
Brief Interview for Mental Status (BIMS) score of nine, indicating moderately impaired cognition. The
assessment indicated the resident required set-up assistance for eating and did not have any broken or
loosely fitting dental appliance. The assessment additionally revealed the resident had no reported difficulty
with chewing.
Review of Resident #5's physician's orders revealed an order dated 02/03/23 for the resident to see
podiatrist, dentist, and optometrist as needed.
Review of Resident #5's care plan, revised 12/11/23, revealed Resident #5 had the potential for alteration in
nutrition and hydration related to multiple medical diagnoses and the presence of upper and lower dentures
with no chewing or swallowing disorders.
Review of Resident #5's interdisciplinary progress notes revealed a note dated 04/24/24 indicating the
resident was edentulous (missing all natural teeth), had upper and lower dentures, and tolerated his
recommended diet without chewing or swallowing difficulty or pain. Previous progress notes dated 01/31/24
and 11/03/23 also reflected Resident #5 as being edentulous and using both upper and lower dentures.
An observation and interview on 06/17/24 at 8:26 A.M. with Resident #5 revealed he was finishing
breakfast. Resident #5 was alert, feeding himself, and answered questions appropriately. Resident #5
stated he had been missing his bottom dentures for approximately four months and had not seen a dentist.
Resident #5 stated he had told about everyone awhile back about his missing bottom dentures but no one
ever found his dentures. Resident #5 smiled and revealed a full set of top dentures and no natural teeth or
presence of a dental appliance present on the bottom.
Interviews conducted on 06/18/24 between 10:24 A.M. and 10:30 A.M. with State Tested Nurse Aide
(STNA) #421 and STNA #438 revealed they were unaware what type of dentures Resident #5 utilized.
An interview conducted on 06/18/24 at 1:22 P.M. with Registered Nurse (RN) #413 revealed he was unsure
if Resident #5 had both upper and lower dentures, or only upper dentures. RN #413 indicated he had never
received information that Resident #5 had been missing dentures.
An interview on 06/18/24 at 2:12 P.M. with the Director of Nursing (DON) and Assistant Director of Nursing
(ADON) #402 revealed Resident #5 should have both his top and bottom dentures and stated
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
366412
If continuation sheet
Page 17 of 18
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
366412
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/24/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Als Mount Vernon Inc
1135 Gambier Road
Mount Vernon, OH 43050
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0790
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
they were unaware the dentures were missing. The DON stated she coordinated ancillary services and
would be sure Resident #5 saw the dentist upon the dentist's next visit to the facility.
An interview on 06/24/24 at 11:24 A.M. with Regional Nurse #600 revealed a list of all residents scheduled
to see the dentist on the next visit, scheduled for 07/02/24. Resident #5 was present on the list to see the
dentist, which listed the resident's primary insurance and stated Dental New Patient Exam. Dental full
mouth x-ray. Regional Nurse #600 verified the list contained no mention of Resident #5's missing dentures
and the reason or cause for the dental examination. The surveyor discussed concern of the dentures
previously being reported missing to facility staff on 06/18/24, and Resident #5's medical record still
contained no mention of the missing dentures, or what the facility had done to ensure the resident was able
to eat or drink appropriately. Regional Nurse #600 stated she would have the speech therapist evaluate
Resident #5 upon their next visit to the facility.
Event ID:
Facility ID:
366412
If continuation sheet
Page 18 of 18
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Back to topCitations
14 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F757 - Unnecessary Drugs—General
Ensure each resident’s drug regimen must be free from unnecessary drugs.
F758 - Medication Errors
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.
F790 - Dental services
Provide routine and 24-hour emergency dental care for each resident.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0324GeneralS&S Fpotential for harm
Provide properly protected cooking facilities.
- 0353GeneralS&S Fpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
F761 - Labeling of Drugs and Biologicals
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
F918 - Bathroom Facilities
Have generator or other power source capable of supplying service within 10 seconds.
F553 - The right to participate in the development and implementation of his or her
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
F584 - Safe Environment
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.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the June 24, 2024 survey of ALS MOUNT VERNON INC?
This was a inspection survey of ALS MOUNT VERNON INC on June 24, 2024. The surveyor cited 14 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at ALS MOUNT VERNON INC on June 24, 2024?
Yes, 14 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives an accurate assessment."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.