Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mount Vernon Countryside Manor during CMS and state inspections, most recent first.
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.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mount Vernon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| 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 | — | 10 | 0 |
| Centralia Manor | 19.3 mi | ★★★★★ | 19 | 1 |
| Fireside House Of Centralia | 19.3 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.