Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mount Vernon Countryside Manor during CMS and state inspections, most recent first.
Unlocked Medication Cart Left Unattended: An LPN left a med cart unlocked while away from it and out of visual control, including while entering a resident room and while talking with a resident near the nurse's station. The cart remained unlocked until the Administrator locked it. The LPN stated she knew the cart was supposed to be locked when she walked away, and the facility policy requires the cart to be closed and locked when out of sight of the med nurse or aide.
Kitchen Sanitation and Storage Deficiencies: Surveyors observed a dirty and unsanitary kitchen during meal service, including crumb-covered clean plate carts, dusty shelves with food and drink residue, grease buildup on the convection oven, litter under cabinets, gnats throughout the kitchen, dried juice under the juice machine, and a sticky floor. In dry storage, corn meal was left open to air and boxes remained on the floor and stacked in the area for hours. The ADM acknowledged the areas needed more thorough cleaning.
A resident with severe cognitive impairment, Alzheimer’s disease, and dysphagia was routinely placed at a table by the nurses station for meals, often facing a wall or corner, because staff said she was too loud or disruptive in the dining room. Family members and a personal sitter reported the resident wanted socialization and was eating without staff companionship, and observations confirmed her seated away from the dining room during lunch. The administrator acknowledged the arrangement may not have been the best option and stated staff are expected to treat all residents with dignity and respect.
Failure to maintain resident mobility and restorative walking program: A resident with severe cognitive impairment, muscle weakness, gait abnormalities, and impaired ROM had PT discharge recommendations for restorative nursing and a walking program to prevent functional decline and maintain gains. Family reported staff were supposed to walk the resident to the dining room with a walker, but staff gave conflicting accounts, including that the resident could not walk safely, was not walked, and had never had a walking program. Records showed inconsistent walking documentation and MDS entries with 0 restorative walking days.
A resident with severe cognitive impairment, Parkinson's disease, and limited ROM after a femur fracture did not receive appropriate restorative services to prevent further decline in ROM. Therapy and restorative referrals recommended passive ROM, active ROM, and bed mobility, but staff were unclear about the order and documentation, and an observation showed the resident was unable to follow commands or participate in the ROM activity.
Failure to Obtain Ordered Daily Weights: A resident with dementia, epilepsy, and CKD had a documented history of significant wt loss, and the care plan noted recent wt loss. Although the MD ordered daily weights, the chart showed only two weights recorded during the month. The RD stated the resident's intake had improved and wt was stabilizing, but the facility did not carry out the ordered daily wt monitoring.
Failure to maintain dialysis weights and communication: A resident with ESRD on hemodialysis had physician orders for daily weights and for post-dialysis weights to be obtained from the dialysis provider, but the resident was not weighed on multiple days and the chart lacked documentation of post-dialysis weights from the dialysis center. The DON stated the facility did not have a dialysis communication book, while the dialysis RN stated the resident is weighed after every dialysis session and that she had repeatedly told the facility a communication book should be sent with the resident.
Infection control practices were not followed for 2 residents. An LPN performed a fingerstick blood glucose check on a resident with DM and other significant diagnoses, then returned the glucometer to the cart without disinfecting it with the required wipe between uses; the LPN later said she used an alcohol prep pad, and the Administrator stated that was not the correct method. Another resident with DM, vascular dementia, malnutrition, and a wound order for Silvadene to the intergluteal cleft was also included in the infection control review.
A resident with multiple medical conditions who required a wheelchair was injured when her wheelchair tipped inside a facility van due to improper securing by transport staff. The staff member had not been properly trained on the correct procedure for securing wheelchairs, leading to the resident sustaining a skin tear and significant bruising. Facility policy required safe securing of wheelchairs, but this was not followed, resulting in the incident.
The facility failed to follow CDC guidelines for PPE use when interacting with COVID-19 positive residents. Staff, including a CNA and a housekeeper, were observed wearing surgical masks instead of N95 respirators and sometimes not wearing gowns, despite clear signage and instructions. This non-compliance involved residents with conditions like Parkinson's and Dementia, who were under isolation due to positive COVID-19 tests.
The facility failed to provide dietary supplements as ordered for four residents, resulting in significant weight loss for one resident with severe cognitive impairment. Despite recommendations for health shakes and vitamin C, the dietary manager was not informed, and the orders were not implemented. Other residents with severe protein-calorie malnutrition also did not receive the necessary supplements due to communication failures within the facility.
The facility failed to provide the correct physician-ordered diets for three residents. One resident, requiring a mechanically altered diet, was served inappropriate food. Another resident with diabetes and renal disease did not receive prescribed nutritional supplements for wound healing. A third resident with malnutrition did not have dietary recommendations implemented. The dietary manager was not informed of necessary dietary changes, leading to these deficiencies.
A resident with multiple health conditions, including chronic respiratory failure and diabetes, did not receive consistent range of motion exercises as prescribed. Despite being cognitively intact and having a care plan that included active and passive range of motion exercises, the resident reported not receiving these services, and staff confirmed the lack of consistent care. The facility's failure to provide these exercises as per their policy resulted in a deficiency.
A facility failed to ensure a resident was free from unnecessary psychotropic medications. Despite being cognitively intact and having no documented behaviors justifying an increase in bupropion, the resident's medication was increased. Staff interviews confirmed the absence of symptoms like crying or irritability, which were cited for the medication change. The facility did not effectively implement behavior tracking as per its policy.
A resident with severe cognitive impairment and mobility dependence was injured after being placed in a bariatric shower chair that was too large for her. During the shower, she slid through the chair's opening, resulting in an acute impacted fracture of the left femoral neck. The resident's medical history included dementia and other conditions, and she required substantial staff assistance. Staff noted her tendency to move and slide in the chair, which contributed to the incident.
A facility failed to report an alleged abuse incident involving a cognitively impaired resident to the IDPH. The resident's family claimed a housekeeper shoved the resident in a wheelchair and yelled at her. Despite the facility's policy requiring such incidents to be reported, the administrator did not investigate or report it, believing the situation was resolved and not abusive.
A facility failed to investigate an alleged abuse incident involving a resident with severe cognitive impairment. The resident was reportedly shoved by a housekeeper, but the administrator did not conduct an investigation, treating it as a grievance instead. This action violated the facility's Abuse Prevention Program, which mandates immediate reporting and documentation of all abuse allegations.
Unlocked Medication Cart Left Unattended
Penalty
Summary
The facility failed to ensure a medication cart was kept locked when it was out of staff visual control. On 03/25/2026 at 8:16 AM, an LPN prepped medications, left the cart unlocked, and went down the hallway to a resident room while the cart remained out of her visual control; when she returned at 8:22 AM, the cart was still unlocked. Later that day at 12:02 PM, the same LPN was observed at the end of 300 hall near the nurse's station talking with a resident while her medication cart for 300 hall was in the middle of the hallway and unlocked. At 12:05 PM, the Administrator was observed walking down 300 hall, stopping at the medication cart, and locking it. At 12:11 PM, the LPN stated she realized she had left the cart unlocked after walking away and entering the resident's room, and said she knew the policy required the cart to be locked when she walked away. The facility's medication administration policy states the medication cart is to be kept closed and locked when out of sight of the medication nurse or aide, and the census documented 83 residents.
Kitchen Sanitation and Storage Deficiencies
Penalty
Summary
The facility failed to ensure the kitchen was clean and sanitary. During lunch meal service, surveyors observed the cart holding clean plates covered with crumbs and old food debris, open shelves under preparation tables dusty with food crumbs and dried drink spills, the top of the convection oven dirty with food debris and grease buildup, stationary cabinets underneath littered with dropped dishes, paper trash, and dirt, gnats throughout the kitchen, dried juice spilled under the juice machine, and a floor that appeared sticky and not mopped under carts and stationary tables. In the dry storage area, corn meal was left open to air from 9:00 AM until 2:00 PM, and boxes were found both empty and full, stacked or sitting on the ground at 9:00 AM and still present at 2:00 PM after the first shift had gone home. When the Administrator walked through the kitchen with the surveyor, she acknowledged that areas needed to be cleaned more thoroughly and stated she would call in an extra employee that evening to address the cleaning issues. The facility application documented 83 residents residing in the facility.
Failure to Preserve Resident Dignity During Meals
Penalty
Summary
The facility failed to treat one resident with dignity during mealtimes. The resident had been admitted with diagnoses including nontraumatic chronic subdural hemorrhage, Alzheimer's disease, major depressive disorder, cognitive communication deficit, and dysphagia, and the MDS documented a BIMS score of 01 indicating severe cognitive impairment. The care plan noted the resident sometimes felt lonely or isolated from others, with interventions to observe for changes in appetite, withdrawal, crying, tearfulness, and decreased social interaction, and to encourage involvement of choice. Social service notes documented that the resident was confused, unable to answer most questions, and continued to state she sometimes felt lonely or isolated from others. Family members and other witnesses stated the resident was routinely placed at a table by the nurses station, often facing a wall or corner, because staff said she was too loud or disruptive in the dining room. Observations confirmed the resident sitting in her wheelchair by the nurses station facing the wall during lunch, with no staff sitting with her while she ate. The family stated they had raised concerns during a care plan meeting that they did not like her eating outside the dining room, and the personal sitter reported that for several weeks the resident had been eating at the nurses station table facing the wall without staff companionship. The administrator stated it was her expectation that staff treat all residents with dignity and respect and acknowledged the resident sitting facing the wall may not have been the best option.
Failure to Maintain Resident Mobility and Restorative Walking Program
Penalty
Summary
The facility failed to maintain the functional mobility status of one resident, R34, who had diagnoses including muscle wasting and atrophy, generalized muscle weakness, gait and mobility abnormalities, chronic subdural hemorrhage, and Alzheimer's disease. R34's MDS documented severe cognitive impairment, lower extremity ROM impairment, and no restorative walking days completed. The care plan identified the resident as needing verbal cues and substantial to dependent staff assistance for ADLs and mobility, with a goal to maintain the current level of functioning. PT discharge documentation stated that R34 had made progress in sitting and standing balance, activity tolerance, endurance, AROM, and bilateral lower extremity strength and flexibility, and specifically recommended a restorative nursing program and walking program to prevent functional decline and maintain gains from therapy. The discharge recommendations also noted that a restorative program had been established and trained. Family members stated that staff were supposed to walk R34 to the dining room with a walker for restorative care, but they did not believe this was happening. Multiple staff interviews showed conflicting information about whether R34 was being walked. The restorative aide stated that restorative care was documented in the EHR but also said R34 did not get assistance in walking because she was unable to complete the task safely and had behaviors. A CNA stated R34 could not walk and was not walked by staff, while the administrator stated R34 had never had a walking program in the facility. PT stated R34 had been discharged with recommendations for restorative nursing and that nursing could have used a second person behind the resident for safety; the director of rehab and the MDS coordinator stated there had been no notification to therapy that R34 was not ambulating or maintaining function. Facility records showed some walking documentation in the point-of-care history during one look-back period, but later records showed no walking or only limited walking, and the MDS documented 0 days of restorative walking.
Failure to Provide Ordered ROM Services
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in ROM. The resident had a recent readmission and diagnoses including a displaced intertrochanteric fracture of the left femur, dementia, conversion disorder with seizures, hypertensive chronic kidney disease, mixed hyperlipidemia, hypothyroidism, COPD, and Parkinson's disease. The resident's MDS documented severe cognitive impairment and functional limitation in ROM in both lower extremities. The care plan called for verbal cues and substantial staff assistance with ADLs and mobility, mechanical lift transfers with two assists, and active/passive ROM as tolerated. Therapy notes and the restorative referral recommended restorative nursing programs for passive ROM, active ROM, and bed mobility, and the resident's point of care history showed active ROM was being provided. During interviews, the restorative CNA stated the resident was active assist ROM and was unsure why the chart order was for active ROM, adding there was no place to chart it. The CNA also stated the resident did not need passive ROM because he could participate with the program. The Administrator stated the RN was responsible for writing and assigning the restorative program after therapy discharge, and the RN/ADON stated all residents on admission are placed on active ROM and bed mobility programs, assuming each program is for all extremities unless a contracture is observed. On observation, the restorative CNA attempted to have the resident raise and lower an arm, but the resident was unable to follow commands and did not participate, and the CNA stated she would try again later. The facility policy stated residents with limited ROM will receive treatment and services to increase and/or prevent further decrease in ROM.
Failure to Obtain Ordered Daily Weights
Penalty
Summary
The facility failed to obtain daily weights as ordered for a resident with a history of weight loss. R5 was admitted with diagnoses including dementia, epilepsy, and chronic kidney disease, and the MDS documented moderate cognitive deficits. The care plan identified that R5 had lost 14% of body weight in 6 months and 2.7% in 1 month. In March 2026, the physician ordered daily weights beginning 3/19/26, but the weight record showed only two documented weights for the month: 156 pounds on 3/2/26 and 169.4 pounds on 3/27/26. The RD stated that R5's oral intake had improved within the past month and that the resident's weight was picking up and had stabilized, but also stated the facility should have carried out the daily weight orders. The Administrator stated the issue with failing to obtain daily weights as ordered would be discussed in QA. The facility's policy required resident weight to be managed through prevention, assessment, implementation, and evaluation of interventions, and another policy stated physician orders would be obtained and followed.
Failure to Maintain Dialysis Weights and Communication
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for a resident who required hemodialysis. The resident had diagnoses including end stage renal failure, cirrhosis of the liver, and type 2 diabetes, and the care plan identified the resident as at risk for complications due to ESRD and hemodialysis therapy. Physician orders included daily weights beginning with the admission date and obtaining post-dialysis weights from the dialysis provider on dialysis days. Record review showed the resident was not weighed on multiple days in March 2026, including several consecutive dates, and the only documented weights were on 3/2/26 and 3/27/26. There was no documentation that the dialysis center had communicated the resident’s post-dialysis weights to the facility from 2/8/26 through 3/27/26. The DON stated the facility did not have a dialysis communication book and only talked by phone at times with dialysis, while the dialysis center RN stated the resident is weighed after every dialysis session at their facility and that she had told the facility numerous times that a dialysis communication book should be maintained and sent with the resident.
Infection Control Practices Not Followed
Penalty
Summary
The facility failed to follow infection control practices for 2 of 6 residents reviewed for infection control. For R96, whose diagnoses included metabolic encephalopathy, type 2 diabetes mellitus, acute kidney failure, chronic kidney disease stage 4, a non-pressure chronic ulcer of the left foot, atherosclerotic heart disease, depression, essential hypertension, and hyperlipidemia, the physician ordered blood glucose checks before sliding scale insulin before meals. On 03/25/2026 at 7:46 AM, an LPN removed the blood glucose monitor from the medication cart, put on gloves, performed a fingerstick on R96, obtained the blood sample, recorded the result, and prepared insulin, but did not clean the glucose monitor with any cleaning pad or wipe before placing it back on the cart and later inside the medication cart. The LPN later stated she cleaned the glucometer with an alcohol prep pad, and the Administrator stated staff were expected to follow the policy for cleaning glucometers and that an alcohol prep pad was not what should have been used. For R10, whose admission record listed type 2 diabetes mellitus without complications, moderate protein-calorie malnutrition, vascular dementia, mild, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, the MDS documented a BIMS score of 10 indicating moderate cognitive impairment and identified the resident as at risk for pressure ulcers/injuries. The physician order sheet directed application of Silvadene cream 1% to the wound bed in the intergluteal cleft, covered with calcium alginate and bordered gauze dressing daily and as needed. The facility’s Infection Prevention and Control Program policy stated it was committed to infection prevention measures and an established program to help prevent the development and transmission of disease and infection.
Failure to Properly Secure Wheelchair During Transport Resulting in Resident Injury
Penalty
Summary
A deficiency occurred when a facility failed to properly secure a resident's wheelchair during transport in the facility van. The resident, who had diagnoses including COPD, atrial fibrillation, rheumatoid arthritis, and hypertension, and who required a wheelchair for mobility, was being transported by a staff member. During the trip, the staff member made a right turn, after which the resident's wheelchair tipped to the left side of the van. The wheelchair did not completely overturn, but the resident sustained a skin tear to the left forearm and reported possibly hitting the back of her head. The resident was subsequently sent to the emergency room for evaluation and treatment. Upon assessment, the resident was found to have significant bruising on various parts of the body and a skin avulsion on the left forearm. The resident was on anticoagulant therapy, which may have contributed to the extent of bruising. The resident was alert and oriented, and denied loss of consciousness or other major symptoms, but did report some back pain from sitting on the floor of the van after the incident. The staff member involved stated that she believed she had secured the wheelchair properly, but later realized she had not followed the correct procedure for attaching the restraint straps, having woven them through the wheels instead of attaching them to the wheelchair frame as required. Interviews and record reviews revealed that the staff member had not been properly trained on the correct method for securing wheelchairs in the van. The facility's policy required that all residents and wheelchairs be safely secured during transport, but this was not adhered to in this instance. The incident resulted in injury to the resident and demonstrated a failure to ensure the area was free from accident hazards and that adequate supervision and training were provided to prevent such accidents.
Failure to Use Appropriate PPE for COVID-19 Positive Residents
Penalty
Summary
The facility failed to adhere to CDC guidelines for the use of Personal Protective Equipment (PPE) when interacting with residents who tested positive for COVID-19. Observations revealed that staff members, including a Certified Nursing Assistant, a housekeeper, and a patient aid, entered rooms of COVID-positive residents wearing inappropriate PPE. Specifically, they wore surgical masks instead of the required N95 respirators, and in some instances, did not wear gowns as mandated by the facility's transmission-based droplet contact isolation precautions. This non-compliance was observed despite clear signage on the residents' doors indicating the need for N95 respirators and gowns. The deficiency involved residents with various medical conditions, including Parkinson's Disease, Dementia, and Alzheimer's Dementia, who were placed under droplet/contact isolation due to positive COVID-19 test results. Interviews with the Director of Nurses, who also serves as the Infection Control Preventionist, confirmed that the facility had five COVID-positive residents and that staff were expected to wear gowns, gloves, and N95 masks when entering COVID rooms. However, both staff and family members reported and were observed not following these guidelines, indicating a systemic issue in the facility's infection prevention and control program.
Failure to Implement Dietary Supplements Leads to Resident Weight Loss
Penalty
Summary
The facility failed to implement dietary supplements as ordered for four residents, leading to significant weight loss in one resident. Resident 63, who had severe cognitive impairment and was at risk for impaired nutrition, experienced a 7.88% weight loss within one month. Despite recommendations from the dietitian to provide health shakes twice daily and vitamin C for wound healing, these orders were not implemented in a timely manner. The dietary manager was unaware of the dietitian's recommendations, and the administrator failed to ensure that these recommendations were communicated and executed. Resident 45, diagnosed with severe protein-calorie malnutrition, was also affected by the facility's failure to implement dietary recommendations. Although the dietitian recommended health shakes twice daily, the dietary manager did not receive the list of residents requiring supplements, resulting in the resident not being included in the dietary plan. Similarly, Resident 39, with a diagnosis of severe protein-calorie malnutrition, had orders for sugar-free health shakes that were not consistently provided, as the dietary manager was not informed of the necessary dietary changes. Resident 44, who was severely cognitively impaired and on a mechanically altered diet, did not receive the recommended health shakes despite significant weight loss and a decline in condition. The resident's care plan included health shakes three times daily, but there was no documentation of these being provided. The facility's weight management program and supplementation policy were not followed, leading to a lack of communication and implementation of necessary dietary interventions for these residents.
Failure to Implement Physician-Ordered Therapeutic Diets
Penalty
Summary
The facility failed to provide the correct physician-ordered diet and dietary recommendations for three residents. One resident, who is severely cognitively impaired and requires a mechanically altered diet, was served a whole boneless chicken breast instead of ground meat, as per the mechanical soft diet order. This resident's care plan indicated a risk for impaired nutrition and hydration, and the dietary manager confirmed that the meat should have been ground. Another resident with diabetes mellitus and end-stage renal disease had a physician's order for ProStat for wound healing, but the dietary recommendations were not implemented. The resident's care plan highlighted a risk for impaired nutrition and hydration. A third resident, diagnosed with moderate protein-calorie malnutrition, had dietary recommendations for ProStat, vitamin C, and zinc sulfate for multiple wounds, but these were not included in the current physician order sheet. The facility administrator acknowledged that the dietary manager, a new employee, had not been provided with the list of residents requiring dietary recommendations, resulting in the failure to implement the nutritional recommendations from December 2024.
Failure to Maintain Range of Motion for Resident
Penalty
Summary
The facility failed to maintain the range of motion for a resident, identified as R25, who was reviewed for decreased range of motion. R25, a cognitively intact resident with a BIMS score of 15, has multiple diagnoses including chronic respiratory failure, type 2 diabetes mellitus with diabetic neuropathy, and morbid obesity. The resident's care plan included orders for active range of motion (AROM) and bed mobility exercises 6-7 times per week, which were later changed to passive range of motion (PROM) for the right lower extremity. However, the facility did not consistently provide these exercises, as documented in the resident's MDS and behavior analysis report, which showed minimal to no range of motion activities being performed over several months. Interviews with the resident and staff revealed that R25 did not receive the prescribed range of motion exercises. R25 stated that staff members did not offer to perform range of motion exercises, and a restorative certified nurse aide mentioned that R25 refused care. The Director of Nursing (DON) confirmed the change from active to passive range of motion due to the resident's needs. Despite the facility's policy to provide restorative nursing to maintain residents' physical function, the lack of consistent range of motion exercises for R25 indicates a deficiency in care provision.
Failure to Monitor and Justify Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident, identified as R25, was free from unnecessary psychotropic medications. R25, a cognitively intact individual with multiple chronic conditions including major depressive disorder, was prescribed bupropion and duloxetine for depression. Despite the facility's policy requiring behavior tracking to ensure the least amount of medication is given, there was no documented evidence of behaviors that would justify the increase in bupropion dosage. The behavior analysis report showed no behaviors from August 2024 to January 2025, and staff interviews confirmed the absence of crying, irritability, or sadness, which were the reasons cited for the medication increase. The facility's failure to document and track behaviors accurately led to the unnecessary continuation and increase of psychotropic medication for R25. The care plan included monitoring for adverse side effects and behavior tracking, but these interventions were not effectively implemented. Staff interviews revealed that while R25 exhibited behaviors such as refusing care and inappropriate urination, these were not related to the symptoms of depression that the medication was intended to address. This lack of proper documentation and monitoring resulted in a deficiency in the facility's compliance with its own policy on psychotropic medication use.
Inappropriate Shower Chair Size Leads to Resident Injury
Penalty
Summary
The facility failed to use the appropriate size shower chair for a resident, resulting in the resident sliding down in the chair and sustaining an acute impacted fracture of the left femoral neck. The resident, who had severe cognitive impairment and was dependent on staff for activities of daily living and mobility, was given a shower in a bariatric chair that was too large for her small stature. During the shower, the resident slid through the opening of the chair, which led to the injury. The resident's medical history included unspecified dementia, anorexia, hypokalemia, chronic obstructive pulmonary disease, anxiety, major depressive disorder, arthritis, restlessness, agitation, and pseudobulbar affect. The resident was noted to have severe cognitive impairment, was dependent on staff for care, and used a wheelchair for mobility. The resident's care plan highlighted her cognitive impairments and the need for substantial staff assistance for activities of daily living and mobility. Staff interviews revealed that the resident was difficult to shower due to her tendency to move and slide around in the chair. The resident was described as impulsive and had cognitive issues, which contributed to the difficulty in maintaining her position in the shower chair. The facility's investigation found that the bruise on the resident's leg aligned with the open area of the shower chair, indicating that the inappropriate size of the chair was a contributing factor to the injury.
Failure to Report Alleged Abuse to IDPH
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the Illinois Department of Public Health (IDPH). The incident involved a resident with severe cognitive impairment, as indicated by a BIMS score of 04, who was alleged to have been shoved out of her room in a wheelchair and yelled at by a housekeeper. The resident's family member reported the incident to the MDS coordinator, who then informed the facility administrator. Despite the report, the administrator did not conduct an investigation or report the incident to IDPH, believing the situation was resolved and did not constitute abuse. The facility's Abuse Prevention Program requires that any allegations of potential mistreatment be reported to the Regional Public Health Office, including details such as the resident's name, age, diagnosis, mental status, type of abuse, and steps taken to protect the resident. However, the administrator decided not to follow these procedures, as she felt the incident was minor and handled promptly. This inaction led to a deficiency in the facility's compliance with mandatory reporting requirements for suspected abuse.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to initiate and conduct a thorough investigation of an allegation of abuse involving a resident with severe cognitive impairment. The resident, who has diagnoses including unspecified dementia with agitation and other symptoms, was allegedly involved in an incident where a housekeeper reportedly shoved her out of her room in a wheelchair and yelled at her. This allegation was brought to the attention of the facility's administrator by the MDS coordinator, who relayed that a family member had reported the incident. However, the administrator did not conduct an investigation or report the incident, as it was considered secondhand information and not a reportable matter. The facility's Abuse Prevention Program requires that all incidents, allegations, or suspicions of abuse be immediately reported to the administrator and documented, regardless of whether abuse is confirmed. Despite this policy, the administrator treated the incident as a grievance rather than a reportable abuse allegation, and no documentation of a grievance was provided. This failure to follow internal reporting and investigation procedures constitutes a deficiency in the facility's handling of abuse allegations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 91 citations issued within 25 miles in the last 12 months — including the 2 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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) |
|---|---|---|---|---|
| Axiom Healthcare Of Mount Vernon | 0.2 mi | ★★★★★ | 5 | 0 |
| Nature Trail Health And Rehab | 1.5 mi | ★★★★★ | 8 | 0 |
| Axiom Gardens Of Mount Vernon | 1.5 mi | — | 8 | 0 |
| Centralia Manor | 19.3 mi | ★★★★★ | 5 | 0 |
| Fireside House Of Centralia | 19.3 mi | ★★★★★ | 14 | 0 |
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