Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Axiom Gardens Of Mount Vernon during CMS and state inspections, most recent first.
The facility failed to provide sufficient nursing staff and supervision to meet residents’ documented needs during ADLs and meals. A resident with hemiplegia and significant transfer and self-care deficits, who required supervision with eating, was repeatedly left in bed or in a chair for extended periods and observed eating alone in his room without supervision, while reporting that staff were unavailable due to staffing shortages and the need for two-person transfers. Another behaviorally complex resident with traumatic brain injury, blindness, wandering, and high fall risk was not adequately supervised; he was repeatedly observed taking food from other residents’ plates and trays, eating from used dishes and cups, removing multiple plates to his room, climbing over the nurses’ station counter into a supply closet, and entering the kitchen through serving and dirty dish windows, often when no staff were present in the dining room, hallways, or at the nurses’ station. Staff interviews and facility policies confirmed that adequate staffing and supervision were required but not consistently provided.
Insufficient nursing staff and supervision led to residents being unattended during meals and throughout the unit. One resident with hemiplegia, debility, and transfer dependence was repeatedly observed eating alone in his room without supervision and stated staff often said there were not enough staff for transfers. Another resident with wandering and aggressive behaviors was observed taking food from other residents, entering rooms, and getting behind the nurses’ station and into a locked closet while staff were not present in nearby areas.
A resident with cerebral atherosclerosis and bilateral blindness, care planned as high risk for falls and needing assistance with toileting, activated a call light requesting help to use the restroom. A CNA responded, stated she was alone on the hall and that the resident currently required two-person assistance, then turned off the call light and left without providing toileting care. The resident had last been toileted earlier that morning and was not assisted again until a later call light was answered by another CNA. Staff interviews revealed that the hall was sometimes staffed with fewer CNAs than preferred, even though some residents required two-person assistance, and leadership acknowledged that such a prolonged wait for toileting was not acceptable under the facility’s dignity policy.
A resident with cerebral atherosclerosis and bilateral blindness had a care plan calling for staff to anticipate needs, keep the call light within reach, and be aware of her blindness. Staff observed the resident’s call light on, but a CNA told the family member the resident was a two-assist and it would be a minute, then turned off the light and left without toileting her. Later, the resident’s call light was answered and she was toileted, and the DON stated a 40-minute wait for toileting was not acceptable.
A resident admitted with multiple right leg fractures and end-stage renal disease reported severe pain and had an order for oxycodone 5 mg PO q4h PRN, along with PRN acetaminophen for mild pain. Despite a care plan identifying pain as a focus and multiple documented pain scores, including high levels, staff did not obtain or administer oxycodone for several days, relying instead on acetaminophen and repositioning, which provided limited relief. Interviews revealed confusion and inaction regarding use of the emergency medication bank and emergency runs, inconsistent understanding of whether oxycodone was available on-site, and delays in securing an active prescription, while pharmacy and emergency bank representatives reported that oxycodone 5 mg IR was stocked and that no emergency access or run was requested. CNAs and family described the resident as frequently yelling out and crying in pain, while nurses documented and reported ongoing pain but did not effectively utilize available systems to ensure timely access to the ordered opioid.
A resident admitted with multiple fractures and ESRD had severe pain on arrival, but ordered oxycodone was not available for several days. Staff gave Tylenol and made repeated calls to the pharmacy and providers, yet the opioid was still delayed, and interviews showed confusion about prescriptions, emergency medication bank access, and whether an emergency run was requested. The resident continued to report significant pain, with staff and family describing crying, yelling out, and discomfort during care.
A resident admitted with multiple fractures and end stage renal disease, who was cognitively intact and documented with severe right leg pain, did not receive ordered oxycodone for several days after admission. The admission assessment and care planning identified oxycodone and acetaminophen for pain management, but staff relied primarily on Tylenol, which the resident and family reported did not relieve the pain. Nursing staff made multiple calls to the pharmacy and providers, yet the first documented prescription request for oxycodone was not sent until two days after admission, and the pharmacy did not deliver the medication until the following day. Despite having an emergency medication bank and the ability to request STAT deliveries and on-call provider orders, staff did not successfully access oxycodone from the emergency kit or arrange an emergency run, and pharmacy and emergency bank records showed no such requests. This resulted in a delay in providing the resident’s necessary controlled pain medication, contrary to facility and pharmacy policies for controlled substances and emergency medication access.
A resident admitted with multiple fractures and severe right leg pain did not receive ordered oxycodone in a timely manner. Staff documented repeated calls to the pharmacy and provider, but the prescription was not promptly obtained, the emergency med bank was not used for oxycodone, and the resident was given Tylenol instead while continuing to report significant pain.
Two residents with severe cognitive impairment were involved in a physical altercation, resulting in one sustaining a nasal fracture. Despite care plans addressing behavioral risks and monitoring needs, one resident with a history of aggression entered another's room and caused injury. Staff and a housekeeper observed the aftermath, and both residents were sent to hospitals for evaluation. The facility's failure to prevent this incident led to physical harm.
Resident-to-resident physical abuse occurred when one resident was punched by another resident on a locked dementia unit, resulting in a nasal fracture. The injured resident had severe cognitive impairment and later stated that a man hit him in the nose, while the other resident had dementia with a history of physical aggression and was seen going into the injured resident’s room before the altercation. Staff separated the residents after the incident, but the event resulted in documented injury and hospital evaluation.
Two residents with dementia and cognitive impairments, sharing a room, became involved in a physical altercation resulting in injuries. One resident had a history of behavioral issues and had previously expressed discomfort with his roommate, while the other had difficulty communicating needs. Staff and care plans noted these challenges, but the facility did not prevent the incident, leading to a failure to protect residents from abuse.
The facility failed to follow CDC guidelines for PPE use and floor sanitation during a COVID outbreak, affecting all 53 residents. Housekeeping used a cleaner ineffective against COVID, and staff wore only surgical masks instead of N95 masks and eye protection. The DON was unaware of the improper PPE use despite staff training.
The facility failed to serve meals simultaneously to residents at the same table, causing distress and inappropriate behaviors. Residents with severe cognitive impairments were left waiting for their meals while others were served, leading to incidents of food being taken from others. The issue arose from dietary staff rearranging meal cards by diet type rather than by table, resulting in delays and resident dissatisfaction.
The facility failed to provide necessary nutritional supplements to residents with a history of weight loss or at risk for nutritional problems. Observations revealed that several residents did not receive their prescribed health shakes or nutritional ice cream with meals. Staff interviews confirmed that the facility had run out of the necessary nutritional products and had not provided any substitutes, despite policy requirements.
The facility failed to ensure that a physician conducted comprehensive evaluations within 30 days post-admission for five residents with complex medical conditions. The medical director had not been physically present since mid-January, and the residents were only seen by a nurse practitioner, not meeting the required physician evaluation.
The facility failed to provide person-centered care for residents with dementia, leading to incidents where residents consumed food from others' plates and invaded personal space. Staff lacked training and individualized care plans, resulting in inadequate supervision and management of residents' behaviors.
The facility failed to manage and dispose of expired medications for several residents, including expired inhalation solutions and vaccines. Despite regular pharmacy checks, expired medications were found in the medication refrigerator, indicating a lapse in following the facility's policy on medication disposal.
The facility did not follow the approved menu for portion sizes and items, serving smaller portions of ground chicken and omitting margarine from meals, affecting several residents. Residents expressed a preference for butter, and the facility's policy requires adherence to the menu spreadsheet for portion control.
The facility failed to conduct proper assessments and obtain physician's orders for lap restraints for two residents, despite their use being observed during meals. One resident had no documented order or care plan for a lap cushion, while the other had an order but lacked an assessment. The facility's policy requires restraint assessments and periodic reviews, which were not followed.
A resident with Alzheimer's and dementia experienced multiple falls without timely fall risk assessments or effective interventions. The facility's outdated care plan and inappropriate interventions contributed to the deficiency, as confirmed by the MDS Coordinator and DON.
The facility failed to clean and sanitize dining tables before residents sat down to eat, leading to instances where residents with severe cognitive impairments ate from soiled tables. Despite staff acknowledging the need for cleaning, tables were not sanitized between uses, violating the facility's dining service policy.
The facility failed to implement Enhanced Barrier Precautions for three residents with chronic wounds, as required by professional standards. Observations confirmed the absence of precautionary signage and PPE near the residents' rooms. Interviews with staff revealed a lack of awareness and understanding of these precautions, leading to a deficiency in infection prevention and control practices.
The facility failed to maintain or offer influenza vaccinations for a resident with multiple diagnoses, including Parkinson's disease and dementia. The resident's medical record lacked documentation of receiving the influenza vaccination in 2024, nor was there evidence that the vaccine was offered or refused. The DON confirmed the absence of information regarding the resident's vaccination for 2024, despite most residents receiving it in October.
The facility failed to protect residents from staff abuse, as multiple staff members reported witnessing a CNA, V6, physically and verbally abusing residents with severe cognitive impairments. Incidents included yelling, shoving, and inappropriate language, with staff initially hesitant to report due to fear of retaliation. The abuse involved residents with dementia and other cognitive disorders, highlighting a significant deficiency in resident safety.
The facility failed to immediately report abuse allegations involving four residents. A CNA was observed hitting, grabbing, and pushing residents, but staff delayed reporting these incidents. The facility's policy mandates immediate reporting to the administrator, which was not followed.
A facility failed to investigate an abuse allegation involving a CNA and a resident with dementia and other medical conditions. The Dietary Manager reported the incident, but the Administrator did not complete the required investigation, missing the allegation on the Facility Incident Investigation Form.
A resident with dementia and anxiety disorders physically attacked another resident, despite being on multiple medications and having a care plan in place. The incident was witnessed by staff, who intervened to separate the residents. The facility's abuse prevention policy failed to prevent this altercation.
A resident with a history of aggressive behavior pushed another resident to the floor and threatened her, resulting in physical injuries. Despite interventions in place to manage aggression, the facility failed to prevent the incident, which was witnessed by a housekeeper who called for help. The facility's investigation confirmed the incident but inaccurately reported no injuries.
The facility failed to maintain a safe and sanitary shower environment for 20 residents on the west side, with mold and dirt accumulation observed. Staff cited a non-functional vent and a malfunctioning pump as contributing factors, leading to a consistently warm and damp environment. The facility's policy requires routine maintenance, but these issues persisted, compromising resident safety.
The facility failed to prevent resident-to-resident abuse, resulting in multiple altercations causing injuries. Incidents were often unwitnessed, and investigations could not substantiate claims of physical contact. Care plans lacked personalized interventions for aggressive behaviors, relying on generic program-generated solutions.
A resident with severe dementia fell out of bed and sustained a wrist injury. The LPN on duty failed to notify the physician and did not send the resident to the ER. The injury was not properly addressed until two days later when an x-ray confirmed fractures. The facility lacked a policy for such situations.
A resident with severe dementia and high fall risk fell out of bed and sustained wrist fractures. Despite the facility's fall prevention policy, no fall mat was provided, and the care plan was not updated with fall interventions. Staff acknowledged the oversight but had not taken corrective action.
Insufficient Nursing Staff and Supervision During ADLs and Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to supervise and attend to residents’ needs in a timely manner, as required by facility policy and regulatory standards. One resident with a history of cerebral infarction, hemiplegia/hemiparesis, and age-related physical debility was care planned as cognitively intact, with bilateral lower extremity impairment, requiring substantial to maximum assistance with transfers and supervision or touching assistance with eating. His care plan also documented an ADL self-care deficit and the need for assistance or dependence in transfer, dressing, and toilet use, as well as supervision with meal consumption. Despite these documented needs, the resident reported that staff told him they needed two people to transfer him and that someone was always on break or there was not enough staff, resulting in him remaining either in bed or in his chair for prolonged periods. On multiple observations over several days, this resident was repeatedly found lying in bed at various times of day, including during mealtimes, and was observed eating alone in his room without supervision. He stated that if he got up into his chair, he should expect to stay there all day, and if he stayed in bed in the morning, he would remain there. He also reported that when he asked to get out of bed in the morning, staff told him it was fine but that he should not expect to return to bed until after lunch. On another day, he stated he did not ask to get out of bed because he anticipated being left in the chair all day and reported that he started hurting after a couple of hours of being in the chair. These statements and observations demonstrate that his care-planned needs for supervised meals and assistance with transfers were not consistently met due to staffing limitations. A second resident, newly admitted with diagnoses including cerebral atherosclerosis and bilateral blindness, had a care plan identifying high fall risk with interventions such as anticipating and meeting needs, ensuring the call light was within reach, encouraging its use, and being aware of blindness. Another resident with traumatic brain injury was care planned as an elopement risk and wanderer, at risk for falls/injury related to wandering and poor safety awareness, and having behavior problems such as entering other residents’ rooms and taking their items. Interventions included frequent observation of whereabouts, redirection when entering other residents’ rooms or beds, and use of diversional activities. A psychiatry note documented additional concerning behaviors for this resident, including pacing, inappropriate sexual behaviors, stealing other residents’ belongings and food, digging in and eating from trash, and becoming physically aggressive with redirection. However, the care plan did not initially address abuse or potential for abuse or the full scope of these behaviors. Over several days, surveyors observed this behaviorally complex resident repeatedly taking food from other residents’ plates and trays in the dining room, eating from plates and cups that other residents had already used, and removing multiple plates and trays to his room without effective staff intervention. Staff reported having to remove up to 15 plates from his room on some days. During multiple observation periods, there were no staff present in the dining room or hallways to supervise him, and a CNA stated there were no staff on the hallways to supervise him. The resident was also observed climbing over the nurses’ station countertop, moving a locked treatment cart, and entering a closet containing snacks, activity supplies, personal staff items, and medical supplies, with no staff present. He was seen entering the locked nurses’ station on more than one occasion, opening bags and boxes in the closet, and staff later acknowledged that he had climbed over the nurses’ station multiple times to obtain snacks. Dietary staff and CNAs reported that this resident had climbed into the kitchen through the serving and dirty dish windows, which were approximately three feet off the ground, and that he had entered the kitchen several times in the past to obtain food. Staff described him as very agile and hard to redirect. During one observation, a laundry staff member had to seek out a CNA from the dining room because there were no staff around the nurses’ station when the resident climbed over the counter. These repeated incidents of unsupervised wandering, access to restricted areas, and taking of other residents’ food occurred in the context of documented staffing gaps, including periods when no staff were observed in the dining room or hallways. Facility policies required adequate staffing levels and sufficiently trained or supervised staff to deliver services necessary to attain or maintain each resident’s highest practicable well-being, but the observed lack of staff presence and supervision contributed directly to the identified deficiency.
Insufficient Nursing Staff and Inadequate Supervision
Penalty
Summary
The facility failed to provide enough staff to supervise and attend to residents’ needs in a timely manner, and failed to have sufficient nursing staff available on each shift. The report states this affected all 70 residents in the facility. Facility policy required adequate staffing levels and sufficient licensed and unlicensed nursing staff on each shift to meet residents’ physical, mental, and psychosocial needs. One resident, admitted with diagnoses including cerebral infarction with hemiplegia/hemiparesis and age-related physical debility, had an MDS showing intact cognition, substantial to maximum assistance needed for transfers, and supervision or touching assistance needed for eating. The care plan documented supervision with meal consumption and assistance or dependence with transfers, dressing, and toileting. The resident stated staff often said two people were needed for transfers and that someone was always on break or going on break, or there were not enough staff. The resident was repeatedly observed lying in bed and eating alone in his room without supervision, and stated that if he stayed in bed he always ate alone and did not have supervision when eating. Another resident had behaviors documented in the record including wandering, entering other residents’ rooms, taking items and food, and becoming physically aggressive with redirection. During observations, this resident took food from other residents’ plates in the dining room, entered other residents’ rooms, removed items, and was seen behind the nurses’ station and inside a locked closet containing snacks, activity supplies, personal staff items, and medical supplies. Staff were observed redirecting the resident at times, but there were also multiple periods when no staff were observed in hallways or around the nurses’ station. Staff statements included that there were no staff on the hallways to supervise the resident and that the resident had climbed over the nurses’ station multiple times and entered the kitchen through serving windows. The administrator stated the resident was very agile and hard to redirect.
Failure to Timely Respond to Call Light for Toileting, Affecting Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to respond to a visually impaired resident’s call light in a timely manner to provide toileting assistance, as required to maintain dignity and self-determination. The resident was admitted with diagnoses including cerebral atherosclerosis and category 5 blindness in both eyes, and her care plan identified her as high risk for falls with interventions to anticipate and meet her needs, ensure her call light was within reach, and encourage its use for assistance. On one observed occasion, the resident’s call light was on and a CNA (V9) responded promptly. The resident’s family member stated the resident needed to use the restroom. V9 stated she was the only aide on the hall, that the resident required two staff for assistance at that time, then turned off the call light and left the room without toileting the resident. Subsequent interviews and observations documented that the resident had last been toileted after breakfast and then laid down, and had not been toileted again until later that morning. Continuous observation of the room began, and when the call light came on again, another CNA (V10) answered and toileted the resident. Staff interviews indicated that the hallway was sometimes staffed with only two CNAs instead of the preferred three, despite having residents who required two-person assistance. Staff reported that when only two aides were present, they could request help from a nurse or a CNA from another hall. The DON stated that a 40-minute wait time for toileting due to needing a second staff member was not acceptable and that staffing should never prevent a resident from getting out of bed. The facility’s dignity policy states that care shall be provided in a manner that maintains or enhances each resident’s dignity and respect.
Delayed Response to Call Light and Toileting Need
Penalty
Summary
The facility failed to answer a resident’s call light in a timely manner to support dignity and self-determination. The resident had an admission date of 3/13/26 and discharge date of 3/18/26, with diagnoses including cerebral atherosclerosis and blindness in both eyes. Her care plan identified her as high risk for falls and directed staff to anticipate and meet her needs, keep her call light within reach, encourage her to use it for assistance, and be aware of her blindness. On 3/16/26 at 10:01 AM, the resident’s call light was observed on. A CNA responded, and the resident’s family member stated the resident needed to use the restroom. The CNA said she was the only one on the hall, the resident was a two-assist, and it would be a minute; she then shut off the call light and left the room without toileting the resident. Later that morning, staff stated the resident had been toileted after breakfast and then laid down, but had not been toileted again. Continuous observation began at 10:24 AM, and when the resident’s call light came on again at 10:41 AM, another CNA answered and toileted the resident at 10:42 AM. Staff and the DON stated that if a resident needed toileting and another staff member was needed for transfer, a 40-minute wait was not acceptable and staffing should not prevent the resident from getting out of bed.
Failure to Obtain and Administer Ordered Opioid Resulting in Prolonged Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and effective pain management for a newly admitted resident with multiple right lower extremity fractures. The resident was admitted with a right femur fracture, displaced trimalleolar and bimalleolar fractures of the right lower leg, cellulitis of the right lower limb, and end-stage renal disease. On admission assessment, the resident was cognitively intact, oriented to person, place, time, and situation, and reported a pain level of 8/10 in the right leg. The care planning documentation identified pain as a focus area, with goals and interventions that included administering analgesia per orders, anticipating the resident’s need for pain relief, responding immediately to complaints of pain, monitoring pain characteristics, and notifying the physician if interventions were unsuccessful or if pain represented a significant change. The resident had an order dated 02/14 for oxycodone 5 mg PO every 4 hours PRN for pain and an order for Tylenol 325 mg, two tablets PO every 4 hours PRN for mild pain starting 02/15. However, the Medication Administration Record shows that oxycodone was not administered until 02/19, while Tylenol was given on several occasions between 02/15 and 02/19 for pain levels ranging from 3 to 5. Vital records document multiple pain scores during this period, including scores of 5 on 02/14 and 02/16, and scores of 3–5 on subsequent days, with a pain score of 7 on 02/19 prior to oxycodone administration. A family member reported that the resident arrived in horrible pain, remained alert and able to state she was in pain, and did not receive oxycodone for approximately two days, during which Tylenol was given but did not relieve the pain. Staff interviews and pharmacy information show that the facility did not effectively secure the ordered oxycodone or utilize available emergency medication resources in a timely manner. The DON stated the pharmacy was problematic and that oxycodone was not in the emergency medication bank, and also stated she did not know why staff did not call her when they had difficulty obtaining the medication. The ADON and agency LPN described attempts to contact the pharmacy and confusion about whether oxycodone was available in the emergency medication bank, with the agency LPN reporting she lacked access to the bank and only had Tylenol to give despite the resident being in significant pain. A staff RN reported calling the pharmacy and providers multiple times on 02/16, stated the resident was in a lot of pain and crying with pain rated 10/10, and believed there was no excuse for not trying to obtain pain medication over the weekend. In contrast, the pharmacy and emergency medication bank representatives stated that oxycodone 5 mg IR was stocked in the emergency medication bank, that no emergency run or emergency bank access was requested by facility staff, and that an active prescription for oxycodone was not received until 02/16, with the medication delivered on 02/17. CNAs reported the resident frequently yelled out and appeared to be in a lot of pain, especially with repositioning, while nurses lacked the ordered pain medication and relied on repositioning and Tylenol, which only helped somewhat or not much at all. The facility’s own pain management policy states its purpose is to effectively manage pain to remove adverse physiologic effects of unrelieved pain and promote comfort, but the documented actions and omissions resulted in prolonged, significant pain for this resident due to the unavailability and delayed provision of the ordered oxycodone.
Delayed Pain Medication for Resident With Multiple Fractures
Penalty
Summary
The facility failed to ensure effective pain management and timely treatment for a resident admitted with a right femur fracture, displaced trimalleolar and bimalleolar fractures of the right lower leg, cellulitis of the right lower limb, and end stage renal disease. The resident’s admission assessment documented severe right leg pain rated 8 out of 10, with pain affecting sleep and mood. The care plan identified pain as a focus area and included interventions to administer analgesia as ordered, give medication before treatments or care, and respond immediately to complaints of pain. The resident arrived at the facility later in the evening after discharge from a hospital, and family reported that the resident was in horrible pain on arrival. The resident had an order for oxycodone 5 mg every 4 hours as needed for pain, along with Tylenol 325 mg every 4 hours as needed for mild pain. However, the resident did not receive oxycodone until several days after admission. The MAR showed Tylenol was given on multiple occasions while oxycodone was not administered until 02/19/26, and pain records documented repeated pain scores ranging from 0 to 7 during the period when the resident was waiting for the opioid medication. Staff interviews showed confusion and delay in obtaining the oxycodone. Nursing staff reported calling the pharmacy multiple times, contacting providers, and attempting to obtain an emergency run, but the medication was still not available. The DON, ADON, administrator, and pharmacy representative gave differing accounts about whether the prescription had been received and whether the emergency medication bank was used. The emergency medication bank representative stated no staff requested oxycodone from the bank, and the pharmacy customer service representative stated the resident did not receive oxycodone until three days after admission and that no emergency run was requested. Staff also stated the resident was crying and in significant pain, and CNA interviews confirmed the resident was yelling out in pain and remained uncomfortable during repositioning and care.
Failure to Timely Obtain and Provide Ordered Controlled Pain Medication
Penalty
Summary
The deficiency involves the facility’s failure to obtain and provide ordered controlled pain medication (oxycodone) in a timely manner for a newly admitted resident with multiple fractures and end stage renal disease. The resident was admitted on 02/14/26 with diagnoses including a right femoral neck fracture, displaced trimalleolar and bimalleolar fractures of the right lower leg, cellulitis of the right lower limb, and end stage renal disease. The resident’s MDS and admission/re-admission observation documented that she was cognitively intact, dependent for most mobility and transfer tasks, and experiencing significant pain, with an admission pain score of 8/10 in the right leg. The admission assessment and pain care planning documentation identified oxycodone and acetaminophen as treatments, with PRN oxycodone noted as a coping measure for pain and interventions directing staff to administer analgesia per orders, anticipate pain needs, and respond immediately to complaints of pain. Despite this documentation, the facility did not have the resident’s oxycodone available for several days after admission. Progress notes from 02/16/26 show that nursing staff called the pharmacy three times that day to check on the oxycodone prescription and also contacted the physician provider company multiple times, with a note that the request was sent to a nurse practitioner at 3:35 PM and that the pharmacy cutoff was 6:00 PM. Interviews revealed conflicting and incomplete actions: the DON stated the new pharmacy was problematic, that oxycodone was not in the emergency medication bank kit, and that the resident arrived after the pharmacy cutoff, but also acknowledged she did not know why staff did not call her and admitted they “dropped the ball” on obtaining the medication. The ADON reported attempts to contact the pharmacy and believed the resident’s allergy to hydrocodone limited use of other narcotics, while also stating she told a nurse to request an emergency run and was under the impression oxycodone was not in the emergency kit. Additional interviews and pharmacy records further demonstrated that the facility did not timely secure the controlled medication. The administrator and vice president of operations stated that staff could have contacted on-call providers for a prescription and used the emergency medication bank or an emergency run, but this was not done. The family member reported that the resident arrived from the hospital in horrible pain and did not receive oxycodone for about two days, receiving only Tylenol, which the family member stated did not relieve the pain. Nursing staff described repeated calls to the pharmacy and providers, the resident crying with pain rated 10/10, and reliance on Tylenol because oxycodone was not available. Pharmacy representatives stated that an active prescription for oxycodone 5 mg was not received until 02/16/26 and that the medication was not delivered until 02/17/26, with no record of any emergency run request or request to access oxycodone from the emergency medication bank, which they confirmed contained oxycodone 5 mg IR. The resident’s MAR showed oxycodone administration only beginning on 02/19/26. Facility and pharmacy policies required that when a medication is not available, staff must call the pharmacy and notify the physician, and that STAT/emergency medications, including controlled substances, can be obtained via emergency kits and STAT delivery within four hours, but the documented actions and interviews show these processes were not effectively used to ensure timely access to the resident’s ordered controlled pain medication. The facility’s own staff accounts were inconsistent regarding the availability of oxycodone in the emergency medication bank and the steps taken to access it. One agency LPN reported being told by the ADON that the medication could be pulled from the emergency medication bank but stated she did not have access as an agency nurse and instead gave Tylenol after being shown standing orders. Another RN believed she had requested an emergency run and possibly removed oxycodone from the emergency kit, but pharmacy and emergency bank representatives reported no such requests or withdrawals. The provider group confirmed that the first request for an oxycodone prescription from the facility occurred on 02/16/26 at 3:49 PM, with the prescription sent to the pharmacy at 4:47 PM, and no earlier requests documented. Collectively, the records and interviews show that from admission on 02/14/26 until at least 02/16/26–02/17/26, the resident with documented severe pain and an identified need for opioid therapy did not receive the ordered controlled pain medication because the facility did not timely secure a valid prescription, did not effectively use available emergency medication systems, and did not coordinate with the pharmacy and providers in accordance with facility and pharmacy policies for controlled substances and STAT/emergency medication access.
Delayed Access to Ordered Oxycodone
Penalty
Summary
The facility failed to obtain and provide necessary controlled prescription pain medication in a timely manner for a resident admitted with a fractured right femur, displaced fractures of the right lower leg, cellulitis of the right lower limb, and end stage renal disease. The resident’s records showed she was alert and oriented, had significant dependence for transfers and toileting, and had pain documented as an 8 out of 10 on admission with right leg pain. Her admission assessment also documented that oxycodone and acetaminophen were part of her pain treatment plan, and the care plan directed staff to administer analgesia as ordered and respond promptly to complaints of pain. After the resident arrived later in the evening, staff documented repeated attempts to obtain oxycodone from the pharmacy. A progress note stated the pharmacy was called three times and the physician provider company was called three times because the prescription was not in yet. Staff and leadership later stated the resident missed the pharmacy cutoff because she arrived after 5:00 PM, and the facility did not have oxycodone in the emergency medication bank kit. The DON, ADON, administrator, and vice president of operations all stated that staff should have contacted a physician for a prescription and used available emergency medication processes, but those steps were not completed in time. Multiple staff and pharmacy representatives confirmed the delay. The family member stated the resident was in horrible pain and did not receive oxycodone until about two days later, with Tylenol not relieving the pain. A nurse stated she gave Tylenol because that was all available and that the resident did not receive oxycodone on the day she was trying to obtain it. Pharmacy staff stated the active prescription was not received until two days after admission and that no staff requested an emergency run or accessed the emergency medication bank for oxycodone. The resident’s pain remained documented during this period, and staff described difficulty obtaining the controlled medication despite the resident’s known pain needs and the facility’s stated processes for emergency and stat medications.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect residents from resident-to-resident physical abuse, resulting in one resident sustaining a nasal fracture during an altercation with another resident. Both residents involved had severe cognitive impairment and resided on a locked dementia unit. One resident had a history of physical aggression and was care planned for monitoring when approached by confused residents and for entering other residents' rooms. Despite these interventions, the aggressive resident was observed entering the other resident's room prior to the incident. On the day of the incident, a housekeeper observed the aggressive resident entering the other resident's room. Shortly after, the injured resident approached the nurse's station with a bleeding and crooked nose, stating he had been hit. The aggressive resident was seen walking behind the injured resident and had blood on his hand. Staff interviews confirmed that both residents were ambulatory and that the aggressive resident was known to wander into other residents' rooms, requiring redirection. The incident was witnessed by staff, and both residents were sent to separate hospitals for evaluation. Medical records and interviews documented that the injured resident sustained an acute nasal bone fracture with associated swelling and bruising. Both residents were evaluated by psychiatry following the incident, and no medication changes were made. The facility's abuse prevention policy affirms the right of residents to be free from abuse, but the failure to prevent this altercation resulted in physical harm to a resident.
Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure residents were free from resident-to-resident physical abuse for 2 of 4 residents reviewed for abuse. The deficiency involved two residents on the locked dementia unit, both with severe cognitive impairment and both able to ambulate independently. One resident had diagnoses including encephalopathy, unspecified dementia with behavioral disturbances, agitation, and convulsions, with a BIMS score of 2. The other resident had vascular dementia without behavioral disturbance, psychotic or mood disturbance, anxiety, and insomnia, with a BIMS score of 99. Both residents had care plans addressing behavior or abuse risk, and the second resident’s plan noted physical aggression and monitoring when approached by confused residents. On 8/1/2025, the first resident went to the nurse’s station with blood coming from his nose and an apparent crooked nose. Staff reported that the resident said the other resident had hit him, and the residents were separated and sent to different hospitals. The first resident’s hospital record documented that he had been punched by another resident and had an obvious deformity of the nasal bones. X-ray findings showed an acute transverse fracture through the mid nasal bone with minimal depression and overlying soft tissue swelling. The first resident later stated that a man hit him in his nose, but he did not know why or know the man’s name. Interviews and records showed the second resident had been seen going into the first resident’s room before the altercation, and a housekeeper stated the second resident later said, “got him back.” The nurse stated he did not see either resident strike the other because he was trying to separate them, but he observed blood on the second resident’s hand and between his fingers. The DON stated the second resident sometimes wandered into other residents’ rooms and was monitored for redirection. Psychiatry notes for both residents described the incident as a recent peer altercation, and both were described as confused and poor historians due to dementia.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident physical abuse, as evidenced by an incident involving two residents with cognitive impairments. One resident, diagnosed with unspecified dementia and a BIMS score indicating moderate impairment, had a documented history of behavioral issues, including physical altercations with a roommate. The other resident, with vascular dementia and unable to complete a BIMS interview, was noted to have impaired cognitive function and difficulty expressing needs. Both residents were sharing a room at the time of the incident. On the date of the incident, a CNA discovered the two residents entangled on the floor during routine checks, with one resident sustaining skin tears on both hands and the other presenting with a swollen nose. Interviews with staff revealed that the resident with a history of behavioral issues had previously expressed dissatisfaction with his roommate, citing rummaging through personal belongings and a desire for a different room. Staff also noted that the resident often felt threatened and was territorial, while the other resident was generally not known for aggressive behavior but could become frustrated due to communication difficulties. The care plans for both residents included interventions for their respective cognitive and behavioral challenges, such as monitoring for agitation and arranging compatible roommate placements. However, despite these interventions, the facility did not prevent the altercation, and the residents' ongoing conflicts and behavioral cues were not adequately addressed to ensure their safety and prevent abuse.
Inadequate PPE Use and Floor Sanitation During COVID Outbreak
Penalty
Summary
The facility failed to adhere to CDC guidelines for proper PPE use and effective floor sanitation during a COVID outbreak, potentially affecting all 53 residents. Housekeeping staff used a lavender all-purpose neutral cleaner for mopping, which was confirmed by a manufacturer representative to have zero kill time for COVID. Both the Housekeeping Supervisor and a Housekeeper were unaware of the cleaner's ineffectiveness against COVID. The facility administrator was also unaware that the cleaner did not kill COVID. Additionally, staff members, including an Activity Assistant Aide, Social Services Director, and several CNAs, reported wearing only surgical masks when entering rooms of COVID-positive residents, despite CDC guidelines requiring N95 masks, gowns, gloves, and eye protection. The Social Services Director and CNAs noted the absence of N95 masks and eye protection, with PPE supplies reportedly unavailable. Two residents confirmed that staff wore only regular masks during the outbreak. The Director of Nurses was unaware of the improper PPE use, despite staff training on proper PPE protocols.
Inconsistent Meal Service Leads to Resident Distress
Penalty
Summary
The facility failed to provide a respectful dining service by not serving residents at the same table simultaneously, leading to several incidents where residents were left without food while their tablemates were served. For instance, one resident, who had severe cognitive impairment and was at risk for nutritional problems, expressed frustration and distress after waiting over 30 minutes for his meal while others at his table were served. Another resident with severe dementia and a history of behavioral disturbances took food from a tablemate due to not being served on time, and staff failed to intervene appropriately. In another case, a resident with severe cognitive impairment and bipolar disorder was observed eating food remains off a table and touching another resident's food, causing the other resident to stop eating. This occurred because the resident was not served her meal in a timely manner. Additionally, a resident with dementia and a history of traumatic brain injury took another resident's plate and ate from it while waiting for his meal, which was served significantly later than his tablemates'. The issue stemmed from the dietary staff rearranging dietary cards by diet type rather than by table, resulting in inconsistent meal service times. This led to residents becoming upset, leaving the dining area, or taking food from others. A CNA noted that the dietary cards were initially grouped by table to ensure simultaneous service, but the kitchen staff altered this order, causing the delays and subsequent resident dissatisfaction.
Failure to Provide Nutritional Supplements
Penalty
Summary
The facility failed to provide necessary nutritional supplements to residents with a history of weight loss or at risk for nutritional problems. Observations on two consecutive days revealed that several residents did not receive their prescribed health shakes or nutritional ice cream with their meals. Specifically, residents identified as R7, R12, R17, R19, R23, and R35 were affected by this deficiency, as they did not receive the supplements as ordered by their physicians. Resident R23, for instance, had a documented history of significant weight loss and was prescribed health shakes three times a day and nutritional ice cream twice a day. Despite these orders, R23 did not receive the supplements during the observed meal times. Similarly, R12, R19, R7, R17, and R35 had physician orders for nutritional supplements, which were not provided during the observed periods. The lack of these supplements was confirmed by staff interviews, which indicated that the facility had run out of the necessary nutritional products and had not provided any substitutes. The facility's policy requires that nutritional supplements be provided per clinician orders and that any shortages should be addressed with appropriate substitutions. However, staff interviews revealed that no substitutes were provided during the shortage, and the facility had been without nutritional ice cream for at least two days. The administrator and registered dietician both acknowledged that substitutes should have been provided, but this was not done, leading to the deficiency in care for the affected residents.
Failure to Conduct Timely Physician Evaluations
Penalty
Summary
The facility failed to ensure that a physician performed a comprehensive evaluation within 30 days post-admission for five residents. These residents included individuals with complex medical histories such as chronic obstructive pulmonary disease, type 2 diabetes mellitus, heart failure, liver cell carcinoma, anxiety disorder, major depressive disorder, anemia, hereditary and idiopathic neuropathy, neurocognitive disorder with Lewy bodies, dementia, metabolic encephalopathy, acute systolic heart failure, chronic kidney disease, chronic atrial fibrillation, depression, hyperlipidemia, gastro-esophageal reflux disease, peripheral vascular disease, hypothyroidism, bipolar disorder, hypertension, aortic aneurysm, and diaphragmatic hernia. The facility's administrator confirmed that the medical director had not been physically present in the building since January 15, 2025, and had not conducted in-person comprehensive admission assessments for these residents. Instead, the residents were seen by a nurse practitioner, which did not fulfill the requirement for a physician's comprehensive evaluation within the specified timeframe.
Deficiency in Dementia Care and Supervision
Penalty
Summary
The facility failed to provide person-centered care and services to residents with dementia, as evidenced by multiple incidents involving five residents. These residents, diagnosed with various forms of dementia and other cognitive impairments, were not adequately supervised during meals, leading to situations where they consumed food from other residents' plates. For instance, one resident ate off another's plate before being served their own meal, and another resident consumed two desserts belonging to a fellow resident without staff intervention. These incidents highlight a lack of supervision and timely meal service, contributing to confusion and inappropriate behaviors among residents. Additionally, the facility did not implement individualized care plans for residents with dementia, as confirmed by staff interviews. The MDS Coordinator admitted that dementia care plans were not individualized, and the Activity Director acknowledged that all residents participated in the same activities, regardless of their cognitive abilities. This lack of personalized care planning and activity programming failed to address the unique needs and behaviors of residents with dementia, resulting in repeated incidents of residents invading each other's personal space and consuming food from others' plates. Staff members, including CNAs and LPNs, reported a lack of special training in dementia care and an absence of one-on-one interventions for residents exhibiting challenging behaviors. The facility's policy on dementia care emphasized a person-centered approach, yet staff interviews revealed that interventions were limited to redirection, with no structured activities or individualized plans in place. This deficiency in care planning and staff training contributed to an environment where residents' behaviors were not effectively managed, compromising their safety and well-being.
Deficiency in Medication Management and Disposal
Penalty
Summary
The facility failed to properly manage the storage and disposal of expired medications for four residents, leading to a deficiency in pharmaceutical services. Resident R32 had an expired box of Ipratropium Bromide and Albuterol Sulfate inhalation solution in the medication room refrigerator, which had expired in February 2025. Resident R156 had a Shingrix vaccine vial in the medication refrigerator with an expiration date of October 2023, despite not having received the vaccine. Residents R16 and R12 both had Shingrix vaccine vials in the medication refrigerator that had expired in October 2023, even though they had received their first doses in September 2022. Additionally, the medication refrigerator contained expired stock medications, including Vaxneuvance syringes, Pneumovax 23 vials, and Prevnar 20 syringes. The Director of Nursing (V2) and a Licensed Practical Nurse (V20) both stated that the pharmacy regularly checks for expired medications, but the last audit from January 2025 did not indicate any expired refrigerated medications. The facility's policy on the disposal of expired or discontinued medications was not followed, as expired medications were not removed or destroyed in a timely manner, contributing to the deficiency.
Failure to Follow Approved Menu and Portion Sizes
Penalty
Summary
The facility failed to adhere to the approved menu for portion sizes and items to be served, affecting eight residents out of a sample of 21 reviewed for dining. During the observation of the lunch meal service, it was noted that residents were served a smaller portion of ground chicken than specified in the facility's diet spreadsheet. The spreadsheet indicated a portion size of 4 ounces using a #8 dipper, but residents received only 2 2/3 ounces with a #12 scoop. This discrepancy was observed for residents on mechanical soft diets, as documented in their physician orders. Additionally, the facility did not serve margarine with meals over several days, despite it being listed on the diet spreadsheet for various types of bread and cornbread. Multiple residents expressed their preference for butter with their meals, indicating they were alert and oriented or moderately cognitively intact. The facility's policy on portion control requires serving portions according to the menu spreadsheet, using appropriate tools to ensure correct portion sizes. The administrator acknowledged that residents should receive the portion sizes indicated on the spreadsheet.
Failure to Assess and Document Restraint Use
Penalty
Summary
The facility failed to ensure that two residents, R12 and R19, had proper assessments and physician's orders for the use of lap restraints, which were observed during a survey. R12, diagnosed with Alzheimer's disease, dementia, and other conditions, had no documented order or care plan focus area for a lap cushion, despite hospice notes indicating its use to prevent falls. Similarly, R19, with diagnoses including cerebral atherosclerosis and moderate dementia, had an order for a lap cushion for positioning, but no assessment was conducted. The care plan mentioned the use of a lap cushion, but it was not adequately assessed or documented. During observations, both residents were seen with lap restraints during meals, and a CNA noted that R19 could not remove the restraint independently. The facility's policy requires restraint assessments and periodic reviews to minimize restraint use, but these were not conducted for R12 and R19. The administrator acknowledged the lack of assessments, indicating the restraints were intended as fall interventions, but failed to comply with the facility's restraint policy.
Failure to Implement Timely Fall Interventions
Penalty
Summary
The facility failed to perform timely fall risk assessments and implement effective interventions to prevent falls for a resident diagnosed with Alzheimer's disease and unspecified dementia. The resident's admission record and Minimum Data Set (MDS) indicated a high risk for falls, yet the most recent fall risk assessment was outdated, lacking a documented year, and the care plan had not been updated with new interventions since May of the previous year. Despite multiple falls occurring in February, no new interventions were documented, and the interventions listed in the fall investigation report from December were deemed inappropriate by the MDS/Care Plan Coordinator. The Director of Nurses confirmed the absence of documented interventions for the falls in February and expressed uncertainty about the five interventions dated in March, which appeared without a clear reason. The facility's policy on fall prevention requires a fall risk assessment at least quarterly and after any fall incident, but this was not adhered to. The lack of timely assessments and appropriate interventions contributed to the deficiency in ensuring the resident's safety and preventing further falls.
Failure to Clean and Sanitize Dining Tables
Penalty
Summary
The facility failed to ensure proper cleaning and sanitization of dining tables before residents sat down to eat, as observed in three specific cases. Resident R32, who has severe cognitive impairment due to unspecified dementia, was observed eating leftover food from another resident's plate on a soiled table. Despite the presence of staff, the table was not cleaned or sanitized before R32 was served his meal. Similarly, Resident R44, with severe cognitive impairment and bipolar disorder, was brought to a table that had not been cleaned after another resident had eaten there. R44 was observed eating food remains directly from the table with her fingers before being served her meal on the same uncleaned surface. Resident R41, also with severe cognitive impairment, sat at a table that had not been cleaned after another resident had used it. R41 attempted to eat from a plate left by the previous occupant, and although the plate was removed, the table was not cleaned before R41's meal was served. Staff members, including a CNA, an Activity Assistant, and a Dietary Aide, acknowledged that tables should be cleaned and sanitized before a resident sits down to eat, yet this protocol was not followed in these instances. The facility's policy on Resident Dining Services also mandates that tables be cleaned and sanitized after a resident leaves, which was not adhered to in these cases.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions for three residents with chronic wounds, as required by professional standards of practice. Resident 38, who was admitted with diagnoses including local infection of the skin and necrotizing fasciitis, had active treatment orders for wound care but lacked enhanced barrier precautions in their medical record and care plan. Observations over several days confirmed the absence of precautionary signage and PPE near the resident's room. Similarly, Resident 22, admitted with idiopathic aseptic necrosis, and Resident 13, with atherosclerosis and post-amputation care, also had active wound treatment orders but no enhanced barrier precautions documented or implemented. Interviews with facility staff, including an LPN, the Administrator, and the Director of Nursing, revealed a lack of awareness and understanding of Enhanced Barrier Precautions. The LPN was unsure about the appropriate disposal of wound trash and stated that no residents were on enhanced barrier precautions. The Administrator and Director of Nursing both admitted to not knowing about the necessity of these precautions for residents with wounds and other conditions requiring special precautions. This lack of knowledge and implementation led to the deficiency in infection prevention and control practices at the facility.
Failure to Administer or Offer Influenza Vaccination
Penalty
Summary
The facility failed to maintain or offer influenza vaccinations for one resident, identified as R34, out of five residents reviewed for immunizations in a sample of 39. R34's admission record indicates diagnoses of Parkinson's disease, dementia, major depressive disorder, anxiety disorder, and cognitive communication deficit. The Minimum Data Set for R34, dated with an unspecified date, shows a mental status score of 99, indicating the resident was unable to complete the interview. The physician's orders for R34, dated 03/17/25, include an order for an annual flu vaccine with consent unless contraindicated, but no start or end date is noted. R34's electronic medical record lacks documentation of receiving the influenza vaccination in 2024, nor is there evidence that the vaccine was offered or refused. The Director of Nursing, identified as V2, confirmed the absence of information regarding R34's influenza vaccination for 2024, noting that most residents received the vaccination in October 2024, but she was unaware of why R34 did not receive it then.
Failure to Protect Residents from Staff Abuse
Penalty
Summary
The facility failed to protect residents from staff-to-resident physical and verbal abuse, as evidenced by multiple incidents involving a Certified Nurse Assistant (CNA), identified as V6. The abuse was reported by various staff members, including housekeepers and an occupational therapy assistant, who witnessed V6 yelling at and shoving residents. Despite these observations, staff members were initially reluctant to report the abuse due to fear of retaliation from V6. The incidents involved residents with severe cognitive impairments, including those with unspecified dementia and other behavioral disturbances, who were unable to effectively communicate or defend themselves. One resident, R1, who has severe cognitive impairment and a history of dementia, was reportedly hit and verbally abused by V6. A cook, V13, witnessed V6 hitting and shoving R1 while using inappropriate language. Although R1 later stated that V6 yelled at her, she did not confirm being hit or shoved, likely due to her cognitive limitations. Another resident, R2, who also suffers from severe dementia and is rarely understood, was reportedly pushed by V6 out of the dining room. This incident was witnessed by a housekeeper, V9, who delayed reporting it due to fear of V6. Additionally, R3, who has a diagnosis of bipolar disorder and severe cognitive impairment, was also reportedly grabbed and pushed by V6. A housekeeper, V11, observed V6's aggressive behavior towards R3 and R2. Furthermore, an incident involving R11, who was unable to complete an interview due to cognitive issues, was reported where a CNA, V12, used inappropriate language in response to R11's behavior. The facility's failure to promptly address and report these incidents of abuse highlights a significant deficiency in ensuring a safe and respectful environment for residents.
Failure to Immediately Report Allegations of Abuse
Penalty
Summary
The facility failed to immediately report allegations of abuse involving four residents. A cook witnessed a Certified Nurse Assistant (CNA) hitting and grabbing a resident at the kitchen window, but delayed reporting the incident until the following day. The cook was unaware of the requirement to report immediately. Another staff member from housekeeping observed the same CNA pushing a resident and reported it to social services instead of the administrator, leading to a delay in the investigation. Additionally, another housekeeping staff member witnessed the CNA grabbing and raising her voice at two residents but did not report it immediately due to fear of job loss. The Social Services Director was informed of the incident by housekeeping but did not report it to the administrator, assuming someone else had already done so. Furthermore, the Dietary Manager noted an incident where a CNA made a sarcastic remark to a resident urinating on the floor but only documented it on an investigation form without immediate reporting. The facility's policy requires all staff to report any allegations of abuse, neglect, or mistreatment to the administrator immediately, which was not adhered to in these cases.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to initiate an investigation into an allegation of abuse involving a resident and a Certified Nurse Assistant (CNA). The incident was reported by the Dietary Manager, who witnessed the CNA making a sarcastic remark to the resident after finding them urinating on the floor. Despite the report being documented on the Facility Incident Investigation Form, the Administrator admitted to missing the allegation and did not complete an abuse investigation. The resident involved in the incident has a medical history that includes unspecified dementia, psychotic disturbance, mood disturbance, anxiety, and Type 2 Diabetes Mellitus. The resident's Minimum Data Set (MDS) indicated a Brief Interview of Mental Status (BIMS) score of 99, suggesting the interview could not be completed. The facility's Abuse Prevention and Reporting policy requires immediate protection of residents and prompt investigation of all abuse allegations, which was not adhered to in this case.
Resident-to-Resident Altercation Due to Inadequate Monitoring
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving two residents. One resident, who has a history of dementia, major depressive disorder, and generalized anxiety disorder, was found with their hands around the neck of another resident, who also has similar diagnoses. The incident was witnessed by a Certified Nurse Assistant (CNA) and a Registered Nurse (RN), who intervened to separate the residents. The resident who initiated the altercation was described as generally confused but had not previously exhibited such behavior towards others. The resident involved in the altercation was on multiple medications, including antidepressants, anxiolytics, and medications for dementia. Despite these interventions, the resident displayed physical and verbal behaviors several days a week, as documented in their Minimum Data Set (MDS). The facility's care plan for this resident included monitoring for risk of harm to self and others, but the incident suggests that these measures were insufficient to prevent the altercation. The facility's policy on abuse prevention and reporting emphasizes the right of residents to be free from abuse and the facility's commitment to creating a secure environment. However, the incident indicates a lapse in ensuring resident safety, as the altercation occurred despite the presence of staff and existing care plans. The report does not mention any specific triggers for the resident's behavior, and the facility's response involved sending the resident to a psychiatric hospital for medication regulation.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident abuse involving two residents, identified as R1 and R2. R1, who has a history of dementia with aggressive behavior, pushed R2 to the floor and verbally threatened her, causing R2 to be fearful. R1's care plan included interventions to manage aggressive behavior, but these were not effectively implemented to prevent the incident. R1's medical records indicate severe cognitive impairment and a history of physical aggression. On the day of the incident, R1 exhibited aggressive behavior towards R2, resulting in R2 sustaining physical injuries, including contusions and pain in her right arm and leg. Despite R1's documented aggressive tendencies, the facility's behavior tracking record did not reflect any incidents of aggression prior to the event. The incident was witnessed by a housekeeper who intervened and called for help. The facility's investigation report confirmed the occurrence of the incident but concluded that no injuries resulted, despite medical documentation to the contrary. The facility's abuse policy emphasizes the prevention of abuse and neglect, yet the measures in place were insufficient to prevent this incident.
Unsanitary Shower Conditions Affect Resident Safety
Penalty
Summary
The facility failed to provide a safe and sanitary environment for residents to shower, affecting 20 residents on the west side of the building. During an inspection, mold was observed in the shower room, specifically between the floor and the wall, and along the wall for approximately eight tiles. Additionally, there was a significant accumulation of dirt and debris around the bottom of the toilet in the attached toilet room. These conditions were noted during a survey conducted on two separate occasions. Interviews with facility staff revealed that the shower stall's cleanliness was compromised due to a non-functional vent, which resulted in a consistently warm and damp environment. The maintenance staff confirmed the presence of black accumulation in the caulk and grout, attributing it to the need to keep the hot water running constantly due to a malfunctioning pump. The facility's policy mandates routine maintenance and compliance with relevant codes, but these issues persisted, affecting the residents' right to a safe and homelike environment.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in multiple incidents of resident-to-resident altercations. One resident, diagnosed with dementia, sustained a fractured rib after an altercation with another resident who mistakenly entered his room. The incident was not directly witnessed by staff, but it was observed on a monitor, and the residents were separated and assessed. The facility's investigation concluded that the altercation was due to confusion caused by cognitive impairment, but the measures to prevent such incidents, like visual cues, were not consistently implemented. Another incident involved a resident with severe cognitive impairment who sustained a skin tear after an altercation with a peer in the dining room. The resident reported being verbally abused and physically attacked, but the incident was unwitnessed by staff. The facility's investigation could not substantiate the claim of an attack, although the injury was acknowledged. The care plans were updated, but the lack of staff presence during the incident highlights a gap in supervision. Additional incidents involved residents with dementia and agitation, where altercations led to minor injuries such as discoloration and scrapes. These incidents were often unwitnessed, and the facility's investigations were unable to substantiate claims of physical contact. The care plans for the involved residents lacked personalized interventions to address aggressive behaviors, and the facility's response relied on generic program-generated interventions. The repeated nature of these incidents indicates a systemic issue in managing resident interactions and ensuring adequate supervision.
Failure to Notify Physician and Delay in Treatment for Resident's Injury
Penalty
Summary
The facility failed to notify a resident's physician in a timely manner following a fall that resulted in an injury. The resident, who has severe dementia and other mental health conditions, fell out of bed and sustained a bruised and swollen right wrist. Despite the visible injury, the LPN on duty was unable to reach the resident's doctor and did not send the resident to the emergency room for evaluation. The LPN only informed the resident's family about the fall and injury. The following day, the day shift LPN was not informed about the fall and injury during the shift change report. The resident showed the injured wrist to the day shift LPN, but the LPN did not understand the resident's communication. It was not until the Social Service Director noticed the injury during the noon meal that the Director of Nursing was informed, and an x-ray was ordered. The x-ray confirmed fractures in the resident's right wrist and forearm. The Director of Nursing and Assistant Director of Nursing acknowledged that the physician was not notified in a timely manner and that the resident should have been sent to the emergency room immediately after the injury was discovered. The facility lacked a policy on what actions to take if a resident's doctor could not be reached, contributing to the delay in treatment.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to implement fall interventions to prevent future falls after a resident with severe dementia and high fall risk fell out of bed and sustained injuries. The resident, who was admitted with severe dementia and other mental health conditions, was found on the floor by a CNA after a loud thump was heard. The resident's right wrist was bruised and swollen, and subsequent medical evaluation confirmed fractures in the wrist and forearm. Despite the resident's high fall risk, no fall mat was observed in the resident's room during multiple checks by surveyors, and staff confirmed that no fall mats were used in the dementia unit. The resident's care plan, which included various focus areas such as cognitive loss, ADL function, and nutrition, did not include a plan of care for the fall with injury or interventions to prevent future falls. The facility's fall prevention policy mandates the implementation of appropriate interventions and updating care plans for residents identified at risk of falls. However, the care plan was not updated after the fall, and the promised fall mat was not provided. Interviews with facility staff, including the Administrator, DON, and Assistant DON, revealed that the facility acknowledged the need for a fall mat but had not yet obtained one. The staff admitted that the care plan should have been updated with fall interventions but failed to do so. This lack of action and failure to follow the facility's fall prevention policy contributed to the deficiency identified by the surveyors.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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Illustrative
What surveyors actually found near you
We read the 99 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Nature Trail Health And Rehab | 0.4 mi | ★★★★★ | 8 | 0 |
| Mount Vernon Countryside Manor | 1.5 mi | ★★★★★ | 1 | 0 |
| Axiom Healthcare Of Mount Vernon | 1.5 mi | ★★★★★ | 5 | 0 |
| Centralia Manor | 18.7 mi | ★★★★★ | 19 | 1 |
| Fireside House Of Centralia | 18.7 mi | ★★★★★ | 0 | 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.