Axiom Gardens of Mount Vernon

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Staffing

CMS has not published payroll-based (PBJ) staffing hours for this facility yet — this can happen for newer, hospital-based, or recently-certified homes. It can also mean the home simply did not file, which CMS does not distinguish in this data, so treat the gap as unexplained rather than benign. Staffing is one of the three parts of the CMS star rating; where it’s missing, weigh the independent health-inspection score most, and ask the facility directly about its nurse-to-resident ratios and weekend RN coverage.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

18 citations, most serious first. The 12 most serious are shown; the remaining 6 are one tap away and print in full.

• Actual harm · G2026-03-04 · tag F0697 — failed to manage pain — isolated
  Provide safe, appropriate pain management for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure effective pain management and treatment was provided in a timely manner for 1 (R1) of 3 residents reviewed for pain management in the sample of 5. This failure resulted in R1, who was admitted to the facility with a right femur fracture, and displaced trimalleolar and bimalleolar fractures of the right lower leg, experiencing prolonged, significant pain due to necessary pain medication not being available.The findings include:R1's admission Record documented an admission date of 02/14/26 and included diagnoses of fracture of unspecified part of neck of right femur, cellulitis of right lower limb, displaced Tri malleolar fracture of right lower leg, displaced bimalleolar fracture of right lower leg and end stage renal disease. R1's Discharge Minimum Data Set (MDS) dated [DATE] documented R1's short term memory was ok and cognitive skills for daily decision making regarding tasks of daily life was marked as independent. In the Functional Abilities…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Actual harm · Gcited before2025-08-12 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to ensure residents were free from resident to resident physical abuse for 2 of 4 residents (R1 and R2) reviewed for abuse in the sample of 6. This failure resulted in R1 sustaining a nasal fracture during and altercation with R2. R1's admission Record documents an admission date of 7/2/2025 and includes diagnoses of Encephalopathy, Unspecified Dementia with other behavioral disturbances, unspecified dementia with agitation, and convulsions.R1's MDS (Minimum Data Set) dated 7/11/2025 includes a BIMS (Brief Interview for Mental Status) score of 2 suggesting R1 has severe cognition impairment. Section E-Behaviors documents R1 does not hallucinations or delusions. R1 has no behaviors of wandering. Section GG -Functional Abilities documents R1 has no impairment with upper or lower extremities. R1's care plan documents a focus area of: R1 is at risk for abuse with date initiated 7/3/25. Goal: R1 will remain free of abuse, mistreatment or otherwise…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · F2026-03-19 · tag F0725 — failed to have enough nursing staff — widespread
  Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to provide enough staff to supervise and attend to the needs of the residents in a timely manner. This failure has the potential to affect all 70 residents that reside in the facility.Findings include: 1. R53's admission record documents an admission date of 9/15/2025 with the following diagnoses in part; Cerebral infarction due to thrombosis of right middle cerebral artery, hemiplegia and hemiparesis following a cerebral infarction affecting left non-dominant side, age-related physical debility. R53's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) of 15, indicating that R53 is cognitively intact. Section GG documents R53 has an impairment of lower extremities on both sides, requires substantial to maximum assistance with transfers. R53's MDS documents R53 requires supervision or touching assistance with eating. R53's care plan documents that he requires supervision with meal consumption and has an…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-19 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for 1 residents of 9 residents (R68) reviewed for call light response in a sample of 51. The findings include: R68's admission Record documents an admission date of 3/13/26 and a discharge date of 3/18/26, with the following diagnoses in part; cerebral atherosclerosis, blindness in right eye category 5, blindness in left eye category 5.R68's Minimum Data Set (MDS) was incomplete due to being a new admission.R68's care plan documents that she is at high risk for falls intervention to include anticipate and meet her needs, be sure her call light in within reach and encourage the resident to use it for assistance as needed, be aware of blindness.03/16/2026 at 10:01AM R68's call light was observed on. V9 (Certified Nursing Assistant/CNA) responded promptly. V12 (Family Member) stated to V9 that R68 needed to use the restroom. V9 stated that she was the only one on the hall, R68 was a two assist and it would be a minute. V9 shut the call…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-04 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain and provide necessary controlled prescription pain medication in a timely manner for 1 (R1) of 3 residents reviewed for pharmacy services in the sample of 5.The findings include:R1's admission Record documented an admission date of 02/14/26 and included diagnoses of fracture of unspecified part of neck of right femur, displaced Tri malleolar and bimalleolar fractures of right lower leg, cellulitis of right lower limb, and end stage renal disease. R1's Discharge Minimum Data Set (MDS) dated [DATE] documented R1's short term memory was ok and cognitive skills for daily decision making regarding tasks of daily life was marked as independent. In the Functional Abilities and Goals section, this MDS documented R1 was dependent for toileting, rolling left to right, sitting to lying, lying to sitting on side of bed, sit to stand, chair/bed-to chair transfer, toilet transfers, and tub/shower transfers. In the section titled Health Conditions, R1 was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-05-27 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from resident to resident physical abuse for 2 (R3 and R4) of 3 residents reviewed for abuse in the sample of 4. Findings Include: R3's admission Record documented R3 was admitted to the facility on [DATE] and included diagnoses of unspecified dementia, essential hypertension, unspecified protein-calorie malnutrition, atrial fibrillation, osteoarthritis of knee, adult failure to thrive, and unspecified macular degeneration. R3's Minimum Data Set (MDS) assessment dated [DATE], documented that R1 has a Brief Interview for Mental Status (BIMS) score of 11, indicating R3 is moderately impaired. R3's Care Plan with a date of 05/01/2025 included a focus area of I have a behavior problem (Physical altercation with roommate.) The interventions listed are administer meds as ordered, anticipate and meet residents needs, arrange placement with compatible roommate, and monitor for evidence of agitation. R4's admission Record documented…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2025-03-28 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, observation and record review, the facility failed to follow current CDC (Center for Disease Control) guidelines for proper PPE (Personal Protective Equipment) use and failed to effectively sanitize floors during COVID outbreak. This has the potential to affect all 53 residents living in the facility. The Findings Include: 1. On 3/27/25 at 11:00 am, V14 (Housekeeping Supervisor) said they use (Brand Cleaner) Lavender all purpose neutral cleaner when they mopped the floor currently and during the COVID outbreak. V14 said she is unsure if it kills COVID or not. On 3/26/25 at 2:30pm, V12 (Housekeeping) said there was cleaner in her mop water as she was moping. V12 said it is (Brand Cleaner) Lavender All Purpose Neutral Cleaner. V12 said she doesn't know if it kills COVID or not. On 3/27/25 at 10:37 am, V16 (floor cleaner manufacturer representative) said that (Brand Cleaner) Lavender All Purpose Neutral Floor Cleaner has zero kill time for COVID. V16 said it is just a multi purpose floor cleaner and does not kill COVID. On 3/27/25 at 1:00pm, V1 (Administrator) said…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-03-17 · tag F0550 — failed to protect resident dignity and rights — pattern
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed provide respectful dining service by serving residents at the same table at the same time, keeping residents from taking food from other residents for 8 (R4, R9, R10, R24, R29, R39, R42, R44) of 21 residents reviewed for dining in a sample of 39. Findings include: 1. R24's admission record dated 03/13/25, documents an admission date of 09/30/24 with diagnoses in part of diabetes mellitus and vitamin d deficiency. R24's MDS (Minimum Data Set) dated 01/06/25 documents in Section C a BIMS (Brief Interview for Mental Status) score of 99 which indicates severely impaired cognition. Section GG documents eating as setup and clean-up assistance. Section K documents no weight loss or weight gain. R24's Care Plan with date revised date of 10/20/24 documents a focus area of R24 (resident) has potential nutritional problem r/t (related to) edentulous, receives therapeutic diet. Interventions include in part: provide and serve diet as ordered. On 03/10/25…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-17 · tag F0692 — failed to prevent malnutrition and dehydration — pattern
  Provide enough food/fluids to maintain a resident's health.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure residents with a history of weight loss or at risk for nutritional problems received ordered supplements with meals for 6 of 6 residents (R7, R12, R17, R19, R23, R35) reviewed for nutrition in a sample of 39. Findings Include: On 03/11/24 between 11:40 AM and 12:25 PM, R7, R12, R17, and R23 did not receive a health shake or a nutritional ice cream with the lunch meal. On 03/12/25 between 11:43 AM and 12:27 PM, R7, R17, R19 and R23 did not receive a nutritional ice cream with the lunch meal. 1. R23's admission record documents an admission date of 11/09/21 with diagnoses including: dementia, cerebral infarction, delusional disorders, hallucinations, vitamin D deficiency, hereditary and idiopathic neuropathy, muscle wasting and atrophy and fatigue. R23's care plan documents a focus area noting: the resident has a potential nutritional problem of weight loss r/t (relating to) CVA (cerebrovascular accident), dementia with behaviors, and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-17 · tag F0712 — pattern
  Ensure that the resident and his/her doctor meet face-to-face at all required visits.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review the facility failed to have a physician perform a comprehensive evaluation within 30 days post admission for 5 of 5 residents (R2, R13, R48, R49, and R102) reviewed for physicians' visits in a sample of 39. Findings include: 1.) R2's admission Record documents an admission date of 01/20/25 with diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, heart failure, liver cell carcinoma, anxiety disorder, major depressive disorder, anemia, and hereditary and idiopathic neuropathy. 2.) R102's admission record documents an admission date of 02/12/25 with diagnoses including neurocognitive disorder with Lewy bodies, dementia, metabolic encephalopathy, acute systolic heart failure, chronic kidney disease stage 1, chronic atrial fibrillation, and depression. 3.) R49's admission record documents an admission date of 02/07/25 neurocognitive disorder with Lewy Bodies, hyperlipidemia, and gastro-esophageal reflux disease with esophagitis. 4.) R13's admission record documents an admission date of 01/30/25 with chronic obstructive…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2025-03-17 · tag F0744 — failed to care for residents with dementia — pattern
  Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to ensure residents with dementia received the necessary person-centered care and services consistent with the resident goals and symptomology for 5 of 8 residents (R23, R29, R32, R42, R44) reviewed for dementia care in the sample of 39. Findings include: 1. R32's admission record dated 3/13/25, documents an admission date of 05/17/23 with a diagnosis in part of unspecified dementia, unspecified severity with agitation. R32's MDS (Minimum Data Set), dated 3/01/25, documents a BIMS (Brief Interview for Mental Status) score of 99 which indicates severely impaired cognition. Section GG document set-up and clean up assistance with eating. Section I documents non-Alzheimer's dementia. R32's Care Plan with a revised date of 09/24/24 documents a focus area of risk for malnutrition r/t (related) dementia. 09/23/24 Remeron daily as ordered. Interventions include in part: Provide supervision during meals, R32 has another focus area of resident has…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-03-17 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, observation, and record review the facility failed to process the returning and/or destroying of unused medication for 4 of 4 (R12, R16, R32, R156) residents reviewed for medications storage in the sample of 39. Findings include: 1. R32's admission record dated 3/13/25, documents an admission date of 05/17/23 with a diagnosis in part of unspecified dementia, unspecified severity with agitation. R32's Physician orders documents order for Ipratr-albuter 0.5mg (milligrams)-3mg/ml (milliliters) ordered on 01/10/24. On 03/12/25 at 9:45AM, R32 had an open box of ipratropium Bromide and Albuterol Sulfate inhalation solution 0.5mg/3mg/3ml in the medication room refrigerator that expired on 02/2025. 2. R156's admission record dated 03/13/25, documents an admission date of 01/14/2019 and a discharge date of 02/25/25 with diagnoses in part of Alzheimer's, Dementia severe with other behavior disturbances, anemia, and hyponatremia. R156's Immunization record documents no Shingrix vaccine was given to R156. On 03/12/25 at 10:30AM there was a Shingrix vial kit 50mcg…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$63,330 in federal fines across 4 penalties.

• $25,830 — penalty dated 2026-03-04
• $7,000 — penalty dated 2024-10-03
• $10,000 — penalty dated 2024-06-27
• $20,500 — penalty dated 2024-03-11

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

CMS files one row per role, so the 32 rows in the source record cover these 21 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

3 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

What families pay in IL