Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Als Mount Vernon Inc during CMS and state inspections, most recent first.
A resident with multiple complex conditions and severe cognitive impairment was issued a NOMNC by phone, then transferred to the hospital for elevated heart rate. The transfer form contained only clinical information and lacked evidence of a written transfer/discharge notice. The resident was taken off the census the same day, and after the BFCC-QIO later upheld the end of Medicare coverage, there was no documentation that the resident or representative was offered the option to return or stay on a private-pay basis or informed of service costs. The Administrator confirmed that no bed-hold notice or option to hold the bed was provided, the bed was not held during hospitalization, and the bed was reassigned so no bed was available when the resident was ready to return.
A resident with severe cognitive impairment and multiple complex medical conditions was transferred twice to the hospital, but the facility failed to provide required bed-hold notices and written transfer/discharge notices to the resident or representative at the time of either transfer. Documentation showed only clinical information sent to the hospital and a telephone Notice of Medicare Non-Coverage, with no evidence that bed-hold rights or written discharge notices were issued, even after the facility decided the resident would not be allowed to return. The Administrator and Regional Business Office Manager stated that bed-hold notices were only given to Medicaid residents, and the DON was unable to explain the bed-hold process, despite facility policy requiring written bed-hold information and acknowledgment for all residents regardless of payor source.
Incomplete Legionella Assessment and Monitoring: The facility’s Legionella Environmental Assessment was inaccurate and incomplete, including an incorrect statement that no whirlpool tub was present, no documentation of Legionella testing, unclear municipal water disinfection details, and no location listed for thermostatic mixing valves. The monitoring records also did not match the stated process, as hot water temperatures and heater checks were not documented as required, and the lowest hot water temperature was not recorded.
Failure to provide dementia training on hire. The Facility Assessment stated that staff would receive training on caring for residents with dementia, Alzheimer’s disease, and cognitive impairments, but personnel records showed no documentation of dementia training for multiple newly hired staff, including CNAs, an SSD, and the MD. The HR Director said dementia training was only completed annually through internet modules, and the DON identified multiple residents with dementia in the facility.
Failure to provide behavioral health training on hire. The facility assessment required training on caring for residents with mental and psychosocial disorders, trauma history, PTSD, and non-pharmacological interventions, but personnel records showed no documentation of behavioral training for multiple newly hired staff, including CNAs, an SSD, and the MD. The HR Director stated the training was done annually through internet modules, and the DON identified several residents with behaviors currently in the facility.
PRN psychotropic medication order lacked required 14-day limitation or physician rationale. A resident with diabetes mellitus, anxiety, major depressive disorder, and severe cognitive impairment had a PRN Lorazepam order for agitation and anxiety with no stop date, and the chart contained no physician documentation supporting continued use beyond 14 days. The MAR showed no PRN doses given, and the DON confirmed the lack of rationale before the medication was discontinued.
MDS assessments were coded incorrectly for two residents. One resident with diabetes, anxiety, and major depressive disorder was on hospice, but the quarterly MDS did not indicate hospice during the look-back period despite severe cognitive impairment. Another resident with Alzheimer's disease, mood disorder, HTN, osteoporosis, and depression was admitted with hospice services, had hospice on the care plan and in physician orders, but the admission MDS incorrectly marked J1400 as not showing a condition or chronic disease with a life expectancy of less than six months.
Activities Not Provided Consistently to Meet Resident Needs: Two residents had limited access to meaningful activities. One resident with intact cognition and a manual wheelchair could not attend multiple group events held in another building, and records showed only one group activity participation while most self-directed activity was TV or reading. Another resident with severe cognitive impairment and multiple neurologic diagnoses had only one documented group activity, with observations showing the resident sitting in the common area without structured activities and no staff present for a movie.
Pureed diets were not prepared to a smooth consistency for two residents with dysphagia and significant care needs. During lunch observation, pureed spaghetti and meat sauce served to both residents contained pieces of pasta, and the DM verified by sight and taste that the food was not smooth. The facility diet protocol stated that pasta should be blenderized to a smooth homogenous consistency.
The facility failed to maintain complete medical records for five residents, affecting their treatment and monitoring. Orders for weight monitoring, skin preparation, behavior and pain monitoring, and medication side effect checks were not documented as completed. The DON confirmed the absence of documentation for these treatments, indicating a systemic issue with record-keeping.
The facility failed to provide adequate supervision for residents at choking risk during meals. Two residents with dysphagia were left unsupervised in the dining room, with one resident observed coughing and having food dripping down her chin. Staff were not present in the dining room, and the facility lacked a completed assessment to determine sufficient staffing levels.
The facility did not have a documented facility-wide assessment to determine necessary resources for resident care during routine and emergency situations. This deficiency was confirmed by the absence of the assessment in the facility's records and an interview with the Administrator, potentially impacting all 19 residents.
The facility did not maintain the required RN coverage of eight hours a day, seven days a week. A review of the June 2024 staff schedule showed multiple days without an RN, including weekends. Staff interviews confirmed the absence of an RN on the schedule, with the DON covering on some days, but no explanation was given for weekend coverage.
The facility failed to involve residents and their representatives in care planning meetings, affecting four residents. A resident with COPD and impaired cognition was not included in care planning after a fall, and the family was not informed about an orthopedic consult. Another resident with Huntington's Disease had no documented care conferences for over a year. A resident with a traumatic brain injury had only one care conference, and another resident did not have an initial care conference upon admission. The facility did not uphold its policy of involving residents in care planning.
A resident's room in the facility was found to have significant damage, including missing paint and drywall on the outer doorframe and large gouges on the wall beside the bed, exposing drywall material. This was confirmed by maintenance staff, indicating a failure to adhere to the facility's policy on maintaining a safe and comfortable environment.
Two residents in a LTC facility had inaccuracies in their MDS 3.0 assessments. One resident's fall resulting in a fractured clavicle was not correctly documented as a major injury, while another resident's use of oxygen therapy was inaccurately recorded. These errors were identified through observations and staff interviews.
A facility failed to complete a physician-ordered orthopedic consult for a resident with a clavicle fracture and did not change dressings as ordered for another resident with a skin tear. The orthopedic consult was not documented, and the family was not informed, while the dressing change was not performed as scheduled, contrary to the facility's policies.
The facility failed to implement effective fall prevention measures for two residents at high risk for falls. One resident, with Huntington's Disease, was observed with a walker out of reach and improperly worn socks, leading to a near fall. Another resident, with dementia, was found without a prescribed fall mat in place, despite a recent fall. Staff interviews confirmed the deficiencies, and the DON acknowledged the ineffectiveness of current interventions.
A facility failed to obtain a physician's order for oxygen therapy for a resident with multiple health issues, including pneumonia and heart failure. The resident was observed receiving continuous oxygen therapy without a current physician's order, despite facility policy requiring such orders. An LPN confirmed the oversight, noting the resident had been using oxygen since admission.
The facility failed to follow physician-ordered medication parameters for two residents, leading to unnecessary drug administration. One resident received Carvedilol and Lisinopril outside prescribed limits, while another was given Midodrine without required blood pressure documentation. The ADON confirmed these discrepancies.
A facility failed to conduct routine AIMS assessments for a resident on Olanzapine, an antipsychotic medication, as required by their policy. The resident, with Huntington's Disease and other conditions, had a significant gap in assessments, with the last one completed months ago. The DON confirmed the oversight, which affected one resident out of five reviewed for unnecessary medications.
A resident with a history of diabetes, myocardial infarction, and dementia was missing bottom dentures for four months without the facility's recognition or timely referral to a dental provider. Despite having an order to see a dentist, there was no record of a dental visit since admission. Staff interviews revealed a lack of awareness about the resident's denture status, and the medical record did not document the missing dentures or actions to ensure proper nutrition. The resident was eventually scheduled for a dental visit, but the issue was not noted in the examination list.
Failure to Provide Bed-Hold Notice and Permit Resident Return After Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to permit a resident to return after hospitalization and to provide required transfer/discharge and bed-hold notices. The resident, who had multiple complex diagnoses including nontraumatic intracerebral hemorrhage, atherosclerotic heart disease, hypertension, dysphagia, cognitive communication deficit, muscle weakness, gait abnormalities, and severe cognitive impairment (BIMS score of two), was admitted to the facility in early January. A Notice of Medicare Non-Coverage (NOMNC) was issued by social services via telephone to the resident’s responsible party, advising that Medicare coverage would end and that financial liability would begin on a specified date, and informing them of appeal rights. The resident was then transferred to the hospital for elevated heart rate and admitted for observation and treatment. The transfer documentation reflected only clinical and communication information sent to the hospital and did not show that a written notice of transfer or discharge was provided to the resident or representative at the time of transfer. The resident’s record showed that the resident was discharged from the facility and removed from the census on the same day as the hospital transfer. A subsequent BFCC-QIO determination letter documented that the resident lost the appeal of the NOMNC and no longer met Medicare coverage requirements for SNF services, and that the resident or representative was notified by telephone of the decision and of financial responsibility for continued services after Medicare coverage ended. However, there was no documentation in the medical record that the resident or representative was offered the option to return or remain at the facility on a private-pay basis or informed of the cost of services once Medicare coverage ended. The Administrator confirmed that no bed-hold notice was provided, no option to hold the bed was offered when the resident went to the hospital, the bed was not held during the hospitalization, and that by the time the resident was ready to return, the bed had been given to another resident and no bed was available for readmission.
Failure to Provide Required Bed-Hold and Transfer/Discharge Notices
Penalty
Summary
The deficiency involves the facility’s failure to provide required bed-hold notices and transfer/discharge notices to a resident and/or the resident’s representative at the time of hospital transfers. The resident, admitted on 01/09/2026, had multiple significant diagnoses including nontraumatic intracerebral hemorrhage, atherosclerotic heart disease, hypertension, aortic valve stenosis, malignant neoplasm of the prostate, dysphagia, gait abnormalities, and cognitive communication deficit. An MDS assessment documented a BIMS score of two, indicating severe cognitive impairment. The resident was transferred to the hospital on 01/16/2026 and again on 02/10/2026, with both transfers resulting in hospital admissions for treatment or observation. Record review showed that the discharge/transfer record dated 01/16/2026 did not contain documentation that a bed-hold notice was provided to the resident or the resident representative at the time of transfer, and there was no progress note related to the 01/16/2026 discharge. A Notice of Medicare Non-Coverage was provided by social services to the responsible party by telephone on 02/09/2026, advising that Medicare coverage would end on 02/11/2026 and that financial liability would begin on 02/12/2026, and informing of appeal rights. However, the transfer documentation dated 02/10/2026 only reflected clinical and communication information sent to the hospital and did not show that a written notice of transfer or discharge was provided to the resident or representative at the time of that hospital transfer. Progress notes from 02/10/2026 to 02/12/2026 also lacked documentation that a written discharge notice was issued after the facility determined the resident would not be permitted to return. Further review of the medical record confirmed there was no documentation that bed-hold rights were explained, no bed-hold notice was provided at either the 01/16/2026 or 02/10/2026 transfers, and no signed bed-hold notice was present. The record also lacked any documentation that a transfer/discharge notice was provided to the resident or representative. Interviews with the Administrator and the Regional Business Office Manager established that the facility’s practice was to provide bed-hold notices only to Medicaid residents and not to residents with Medicare or private pay, and the Administrator confirmed that no bed-hold notice was offered or provided in this case and that the bed was not held during hospitalization, leaving no bed available when the resident was ready to return. The DON reported not being knowledgeable about when bed-hold notices should be issued and could not clarify the process followed for the resident’s hospital transfer. Review of the facility’s undated Bed Hold Notice/Policy showed that written information about bed-hold duration, reserve bed payment, and conditions for return was required to be provided to all residents regardless of payment source, with signed and dated acknowledgment, which did not occur for this resident.
Incomplete Legionella Assessment and Monitoring
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not accurately complete the Legionella Environmental Assessment and did not follow its Legionella monitoring process. The assessment form stated the facility did not have a whirlpool spa, hot spa, or hydrotherapy spa, but Maintenance Director #102 later verified the facility did have a whirlpool tub and that the assessment was incorrect and incomplete. The form also indicated the facility had a water safety plan, but it did not show whether the facility had ever tested water samples for Legionella, did not document how municipal water was disinfected or whether the treatment had changed within the last year, and did not identify where thermostatic mixing valves were located. The facility documented that hot water temperatures were measured at points of use, but the lowest hot water temperature was not documented. The monitoring process stated that hot water temperatures would be checked weekly on each hall and hot water heaters would be checked weekly, but the water temperature logs showed hall temperatures were checked in 2024, on 05/07/25, and again on 01/23/26. Water heater temperatures were documented as checked monthly, but the form did not include the day or year. Maintenance Director #102, who had started working at the facility two weeks earlier, stated the Legionella binder contained documentation from 2024 through 2026 and that he had provided all available documentation, and he verified there was no documentation showing weekly water temperature checks as stated in the monitoring process.
Failure to Provide Dementia Training on Hire
Penalty
Summary
The facility failed to provide dementia training to staff upon hire, despite its Facility Assessment stating that training would be provided on hire and annually for caring for residents with dementia, Alzheimer's disease, cognitive impairments, and for implementing non-pharmacological interventions. Review of personnel records showed no documentation of dementia training for CNA #125, CNA #120, SSD #141, and MD #102. During interviews, the HR Director stated that dementia training is completed annually when it appears in the internet training modules, and the DON identified ten residents in the facility with a diagnosis of dementia. The HR Director also identified 11 staff members who had been hired within the last year, including nursing, dietary, activities, social services, and maintenance staff.
Failure to Provide Behavioral Health Training on Hire
Penalty
Summary
Behavioral health training was not provided upon hire as required by the facility assessment. The facility assessment dated [DATE] stated that staff training, education, and competencies would include training on hire and annually for caring for residents with mental and psychosocial disorders, caring for residents with a history of trauma and/or post-traumatic stress disorder, and implementing non-pharmacological interventions. Review of personnel records showed no documentation of behavioral training for CNA #125, CNA #120, SSD #141, and Maintenance Director #102. Interviews with the HR Director and DON indicated that behavioral training was being done annually when it populated into the internet training modules, and the DON identified six residents currently in the facility with behaviors. The HR Director also identified 11 staff members who had been hired within the last year, including nursing, activities, dietary, social services, and maintenance staff.
PRN Psychotropic Medication Order Lacked Required 14-Day Limitation or Physician Rationale
Penalty
Summary
The facility failed to ensure that PRN psychotropic medication orders were limited to 14 days or that the attending physician documented a rationale for continued use beyond 14 days. This deficiency affected one resident, who had diagnoses including diabetes mellitus, anxiety, and major depressive disorder, and whose quarterly MDS assessment showed a BIMS score of 02, indicating severe cognitive impairment. The resident’s current orders included 0.5 mg of Lorazepam by mouth every four hours as needed for agitation and anxiety, written with no stop date. Review of the resident’s MAR for January 2026 to date showed no PRN doses of Lorazepam were administered. Review of the electronic and hard chart found no documentation from the attending physician supporting continued PRN use of Lorazepam beyond 14 days. The DON confirmed during interview that no rationale had been documented in the resident’s medical record for continued use of the PRN Lorazepam, and the physician discontinued the medication on 01/29/26. The facility’s Psychotropic Management Policy stated that PRN psychotropic use was limited to 14 days and required prescriber evaluation prior to renewal.
MDS Assessments Incorrectly Coded for Hospice Status
Penalty
Summary
The facility failed to code MDS assessments accurately for two residents. Resident #12 had diagnoses including diabetes mellitus, anxiety, and major depressive disorder, and the medical record showed the resident was admitted to hospice services and remained on hospice. However, the quarterly MDS assessment recorded the resident as not receiving hospice services during the look-back period, even though the resident had a BIMS score of 02 and was severely cognitively impaired. Corporate MDS Nurse #201 stated that Resident #12 should have been marked as being on hospice on that quarterly assessment. Resident #21 had diagnoses including Alzheimer's disease, mood disorder, hypertension, osteoporosis, and depression. The record showed the resident signed a hospice agreement while at an assisted living facility, was admitted with hospice services, received hospice services on the baseline care plan, and had a physician order noting hospice services. The admission MDS showed severe cognitive impairment, but section J, item J1400 indicated the resident did not have a condition or chronic disease that may result in a life expectancy of less than six months. Corporate MDS Nurse #201 verified that Resident #21 received hospice services and that section J1400 on the admission MDS was marked incorrectly.
Activities Not Provided Consistently to Meet Resident Needs
Penalty
Summary
The facility failed to ensure activities were held where Resident #2 could attend and failed to ensure meaningful activities were provided for Resident #4. Resident #2 was admitted with osteomyelitis of the vertebra, type 2 diabetes, and chronic kidney disease. The activities initial review noted preferences including gaming, gardening, reading, word searches, coloring, television, and previously attending church. Although the resident was cognitively intact and used a manual wheelchair on the MDS, the care plan identified a risk for alteration in activity participation and included interventions to identify interests, reassess as indicated, encourage new activities, and provide one-on-one as needed. Records showed Resident #2 participated in only one social activity during the review period, and the self-directed log mainly documented television and reading. The resident stated she enjoyed bingo but could not walk far enough to attend activities held at the assisted living facility on the same campus, and the calendar showed multiple bingo, craft, resident council, and ice cream social activities scheduled there. The Activities Director verified that some residents did not like going to another building for activities and that scheduled appointments sometimes caused activities to be canceled or held later. Resident #4 was admitted with hemiplegia, multiple sclerosis, dementia, aphasia, and depression, and the significant change MDS showed severe cognitive impairment. The activity log showed only one group activity participation during the review period, with self-directed activities limited to television and a visitor. Multiple observations showed Resident #4 sitting in the common area without structured activities, and on one observation the television was on low volume with no activity staff present. The Activities Director verified there was not a staff member present for the movie and that only one group activity had been documented for Resident #4 during the last 30 days. The facility policy stated activities are offered based on individual preferences and needs and that participation is documented in the medical record.
Pureed Diets Served With Pasta Pieces
Penalty
Summary
The facility failed to serve pureed foods at a smooth consistency for safe swallowing. Two residents, one with Huntington's Disease, depression, dysphagia, severe cognitive impairment, and dependence for ADLs and eating assistance, and another with multiple sclerosis, depression, dysphagia, and dependence for ADLs with supervision and partial assistance at meals, were both ordered pureed diets with thin liquids. During lunch observation, both residents received early trays, and the pureed spaghetti with meat sauce served to each resident contained pieces of pasta rather than a smooth puree. During the meal observation, the Dietary Manager observed the pureed spaghetti and meat sauce on the steam table and verified that it appeared to have pieces of pasta in it. A taste test confirmed that the spaghetti and meat sauce was not pureed to a smooth consistency. The Dietary Manager stated that the cook who prepared the puree was nervous and would need to be retrained. The facility's undated diet protocol for Dysphagia 1/Puree Diet stated that pasta should be blenderized to a smooth homogenous consistency.
Incomplete Medical Records and Treatment Documentation
Penalty
Summary
The facility failed to ensure that resident medical records were complete, affecting five residents. Resident #4, diagnosed with Huntington's disease, major depressive disorder, and dementia, had multiple physician orders for daily weight monitoring, skin preparation, and monitoring for depression and medication side effects. However, there was no documented evidence that these treatments and monitoring were conducted on the morning of 03/07/25. The Director of Nursing confirmed the absence of documentation for these treatments. Resident #7, with diagnoses including dementia, type two diabetes mellitus, and chronic kidney disease, had orders for behavior and pain monitoring with non-pharmacological interventions. Similarly, Resident #11, diagnosed with cerebral infarction and multiple sclerosis, had orders for pain monitoring, head elevation, and wound care, among others. For both residents, there was no documentation of these orders being followed on the morning of 03/07/25, as confirmed by the Director of Nursing. Resident #12, with Alzheimer's disease and congestive heart failure, and Resident #20, with Huntington's disease and muscle weakness, also had multiple orders for behavior, pain, and medication side effect monitoring. The treatment administration records for both residents lacked evidence of these orders being carried out on the morning of 03/07/25. The Director of Nursing confirmed the lack of documentation for these treatments, indicating a systemic issue with record-keeping and treatment administration in the facility.
Inadequate Supervision of Residents at Choking Risk During Meals
Penalty
Summary
The facility failed to provide adequate nursing supervision for residents identified as choking risks while they were eating in the dining room. Specifically, two residents with dysphagia, who required pureed diets, were left unsupervised during meal times. Observations revealed that there was no staff present in the dining room while these residents were eating, and one resident was noted to cough multiple times and have food dripping down her chin. Staff members, including a Certified Nursing Aide and an LPN, were observed passing meal trays in the hall, out of sight from the dining room. Interviews with the LPN and the Director of Nursing confirmed that there was insufficient staffing to meet the needs of the residents, and that at least one staff member should be present in the dining room at all times during meals. The facility also lacked a completed facility assessment to determine the appropriate level of staffing needed based on the residents' conditions. Additionally, the facility's policy required staff presence in the dining room during meal times, which was not adhered to, leading to the identified deficiency.
Facility Lacks Documented Assessment for Staffing Needs
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. This deficiency was identified during a review of the facility's assessment records, which revealed the absence of a documented facility assessment. The lack of this assessment meant that the facility could not determine the appropriate level of staffing needed based on the residents' conditions and limitations, as well as the services required. An interview with the Administrator confirmed that a completed facility assessment was not available for review, potentially affecting all 19 residents in the facility.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure compliance with the requirement of having a registered nurse (RN) on duty for at least eight consecutive hours a day, seven days a week. This deficiency was identified through a review of the staff schedule for June 2024, which revealed multiple days without an RN scheduled, including weekends and specific weekdays. Interviews with staff, including an LPN and an RN, confirmed the absence of an RN on the schedule for the required hours. The LPN mentioned that the Director of Nursing (DON) was present on days when an RN was not scheduled, but no explanation or evidence was provided for RN coverage on weekends.
Failure to Involve Residents in Care Planning
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were invited to participate in initial and quarterly care plan meetings, affecting four residents. Resident #10, who had chronic obstructive pulmonary disease and severely impaired cognition, was not properly included in care planning. Despite having a significant change in condition due to a fall resulting in a clavicle fracture, there was no documentation of a care plan meeting being held or scheduled, and the family was not informed or involved in the decision-making process regarding an orthopedic consult. Resident #9, diagnosed with Huntington's Disease and severely impaired cognition, also experienced a lack of proper care planning. The only documented care conference was attended by the resident's power of attorney and the SSD, with no other staff members present. There was no documentation of any care conferences from March 2023 to June 2024, indicating a failure to conduct regular care planning meetings. Resident #13, with a traumatic brain injury and moderately impaired cognition, had only one documented care conference, and the family requested annual rather than quarterly meetings. However, there was no documentation of any care conferences from May 2023 to June 2024. Similarly, Resident #15, who required minimal assistance and had intact cognition, did not have an initial care conference upon admission, and there was no documentation of care conferences in the progress notes. The facility's policy states that residents have the right to participate in planning their care, which was not upheld in these cases.
Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment in the room of Resident #17, as observed during a survey. The outer doorframe of the resident's room had missing paint and drywall covering, with evidence of plastic covering previously taped around the doorframe. Inside the room, the wall to the left side of the bed had multiple large, vertical gouges approximately 12 inches long and half an inch deep, exposing the drywall material. The torn drywall covering was hanging loosely on the wall. Maintenance Staff #416 confirmed the extent of the damage during an interview. The facility's policy on Resident Environmental Quality, dated August 2022, mandates maintaining a safe, functional, sanitary, and comfortable environment, which was not adhered to in this instance.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) 3.0 assessments for two residents, leading to deficiencies in the accuracy of resident assessments. Resident #10, who had medical diagnoses including chronic obstructive pulmonary disease and muscle weakness, experienced a fall on 04/29/24, resulting in a major injury—a fractured clavicle. The MDS 3.0 discharge return anticipated assessment did not reflect this major injury, as it was initially recorded as a fall with a minor injury. The MDS Nurse was unaware of the fracture and did not modify the assessment to reflect the major injury, which was a requirement according to the Resident Assessment Instrument (RAI) Manual. Resident #11, who had diagnoses including pneumonia and heart failure, was observed receiving continuous oxygen therapy. However, the significant change MDS 3.0 assessment inaccurately indicated that the resident was not using oxygen therapy, despite the care plan specifying its use. This discrepancy was confirmed by the MDS Registered Nurse, who acknowledged the incorrect coding in the assessment. These inaccuracies in the MDS assessments for both residents highlight a failure in the facility's processes to ensure accurate and up-to-date resident assessments. The deficiencies were identified through observations, staff interviews, and record reviews, affecting the accuracy of the assessments for two out of eleven residents reviewed in a facility with a census of nineteen.
Failure to Complete Physician-Ordered Consult and Dressing Changes
Penalty
Summary
The facility failed to complete a physician-ordered orthopedic consult for a resident who had a fracture in the right clavicle. The resident, who had chronic obstructive pulmonary disease, unsteadiness on feet, and muscle weakness, was hospitalized and upon return, an x-ray revealed an acute fracture. Despite orders for an orthopedic consultation and a sling, there was no evidence that the consultation was completed or that the family was informed. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) indicated a lack of documentation regarding the consultation and possible family refusal, which was not recorded. Another deficiency involved a resident with diabetes mellitus, a history of myocardial infarction, and dementia, who sustained a skin tear after a fall. The physician's orders required dressing changes every three days, but the dressing was not changed as documented. An observation revealed the dressing was still dated from the initial application, and the DON confirmed the dressing had not been changed as required. The facility's policies on physician-ordered services and wound care were not followed, as evidenced by the lack of documentation and failure to perform ordered treatments. These deficiencies affected the quality of care for the residents involved, as the necessary medical consultations and wound care were not provided as per the physician's orders.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to implement appropriate safety interventions for residents at high risk for falls, affecting two residents. Resident #9, diagnosed with Huntington's Disease and a history of falls, was observed in the dining room with a four-wheeled walker out of reach and wearing non-skid socks, one of which was improperly worn and dragging on the floor. Despite previous fall incidents and interventions, such as encouraging the resident to ask for help and using a walker, the staff did not assist Resident #9 in regaining balance or adjusting the sock, leading to a near fall incident. Resident #6, with diagnoses including dementia and a high fall risk score, was found in bed without the prescribed padded fall mat in place. The resident had previously fallen out of bed and was hospitalized for evaluation. The care plan included interventions like a perimeter mattress and a floor mat, but during observation, the mat was found folded and not in use, contrary to the care plan requirements. Interviews with staff confirmed the deficiencies in implementing the fall prevention measures. The Director of Nursing acknowledged the repetitive and ineffective nature of the interventions for Resident #9 due to cognitive impairments. The facility's policy on managing falls emphasized the need for resident-centered fall prevention plans, which were not adequately followed in these cases.
Failure to Obtain Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician's order for the administration of oxygen therapy for a resident. The deficiency was identified during an observation where a resident was seen receiving continuous two liters of oxygen therapy via nasal cannula tubing from an oxygen concentrator. The resident had been admitted with diagnoses including pneumonia, high blood pressure, heart failure, and rib fractures, and required assistance with activities of daily living due to moderately impaired cognition. The resident's care plan indicated the use of oxygen as ordered, and hospice progress notes showed a physician order for oxygen therapy. However, the physician orders dated later did not include the necessary order for oxygen therapy. An LPN confirmed the absence of a physician's order for the oxygen therapy, despite the resident having used oxygen since admission. The facility's policy requires oxygen to be administered under a physician's order.
Failure to Follow Medication Parameters for Two Residents
Penalty
Summary
The facility failed to adhere to physician-ordered medication parameters for two residents, leading to the administration of unnecessary medications. Resident #4, who had a history of cerebrovascular accident, atrial fibrillation, coronary artery disease, and hypertension, was given Carvedilol despite having a heart rate below the prescribed threshold on multiple occasions in May and June 2024. Additionally, Resident #4 received Lisinopril when their systolic blood pressure was below the specified limit. These actions were contrary to the physician's orders, which required holding the medications under these conditions. Resident #5, diagnosed with diabetes mellitus, a history of myocardial infarction, and dementia, was prescribed Midodrine with instructions to hold the medication if the systolic blood pressure exceeded a certain level. However, the facility failed to document the necessary blood pressure readings before administering the medication in May and June 2024. An interview with the Assistant Director of Nursing confirmed these discrepancies, acknowledging that the medications were administered outside of the prescribed parameters and without the required documentation.
Failure to Conduct Routine AIMS Assessments for Psychotropic Medication
Penalty
Summary
The facility failed to complete routine assessments for monitoring the side effects of psychotropic medication for a resident diagnosed with Huntington's Disease, COPD, depression, anxiety, and a history of falls. The resident, who required assistance with activities of daily living and had severely impaired cognition, was prescribed Olanzapine, an antipsychotic medication. The facility's policy required that Abnormal Involuntary Movement Scale (AIMS) assessments be conducted when an antipsychotic medication is initiated and at least quarterly thereafter. However, the resident's medical records showed a significant gap in these assessments, with the first AIMS completed on 10/04/21 and the next not until 01/24/24, despite the resident's ongoing use of Olanzapine. The Director of Nursing confirmed that the AIMS assessments were not conducted as required, acknowledging that the last assessment was completed on 01/24/24 and none had been done since. This oversight in routine monitoring of the resident's medication side effects represents a failure to adhere to the facility's Medication Monitoring and Management policy, which aims to optimize therapeutic benefits and minimize adverse consequences. The deficiency affected one resident out of five reviewed for unnecessary medications, within a facility census of 19.
Failure to Address Missing Dentures for Resident
Penalty
Summary
The facility failed to recognize and address the missing bottom dentures of a resident, who had been without them for approximately four months. The resident, who had a history of diabetes mellitus, myocardial infarction, and dementia, was admitted to the facility on 02/03/23. Despite having an order to see a dentist as needed, there was no evidence in the medical record that the resident had seen a dental provider since admission. The resident's Minimum Data Set (MDS) assessment indicated moderately impaired cognition and required set-up assistance for eating, but did not report any issues with chewing or dental appliances. Interviews with staff, including State tested Nurse Aides (STNAs) and a Registered Nurse (RN), revealed a lack of awareness regarding the resident's denture status. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were also unaware of the missing dentures. Despite the resident having reported the issue to staff, the medical record did not reflect the missing dentures or any actions taken to ensure the resident's ability to eat or drink properly. The resident was eventually scheduled to see a dentist, but the list did not mention the missing dentures or the reason for the examination.
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Illustrative
What surveyors actually found near you
We read the 160 citations issued within 25 miles in the last 12 months — including the 1 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) |
|---|---|---|---|---|
| Ohio Eastern Star Hlth Care Ctr The | 1 mi | ★★★★★ | 16 | 0 |
| Country Club Retirement Center | 1 mi | ★★★★★ | 2 | 0 |
| Country Court | 1.2 mi | ★★★★★ | 9 | 1 |
| Whispering Hills Rehabilitation And Nursing Center | 1.4 mi | ★★★★★ | 13 | 0 |
| Laurels Of Mt Vernon The | 1.8 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.