Mount Vernon Nursing And Rehabilitation

Based on interview and record review, the facility failed to send a copy of the notice of transfer or discharge to a representative of the State LTC (Long Term Care) Ombudsman in a timely manner for 4 of 4 residents reviewed for admission/transfer/discharge. (Resident B, Resident C, Resident D, Resident E) Finding includes: On 2/13/26 at 9:57 a.m., the Social Services Director provided copies of the email communications she sent to the Ombudsman related to the facility discharging residents from the secured memory care unit. An email dated 10/6/25 at 9:58 a.m., from the Social Services Director, indicated the facility was in the process of transitioning the secured memory care unit to an unsecured, long-term care unit. The residents residing on the unit were being reviewed to determine appropriate placement. The Ombudsman would be copied on any involuntary discharge notices. An email dated 10/8/25 at 3:27 p.m., from the Ombudsman indicated to mail a resident list, their discharge plans, and she would be watching for the transfer/discharge notices to come by email.An email dated…

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.

Based on observation, record review, and interview, the facility failed to ensure a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Resident use equipment was not cleaned for 2 of 2 random observations of vitals during medication administration, staff did not change gloves during resident care for 3 of 5 residents observed for care, and failed to track all infections for 10 of 10 residents reviewed for infections. (Resident 49, Resident 33, Resident 22, Resident 18, Resident 53, Resident 42, Resident 25, Resident 161, Resident 15, Resident 36, Resident 12, Resident 53, Resident 5, Resident 51, Resident 2, Resident 7)) Findings include: 1. On 7/30/24 at 10:30 A.M. during a medication pass, QMA (Qualified Medication Aide) 23 was observed to take Resident 49's blood pressure, then take Resident 33's blood pressure with the same cuff. The blood pressure cuff was not sanitized prior to or after either resident. 2. On 8/2/24 at 10:04 A.M., CNA (Certified Nurse Aide) 6 and CNA 14 were observed performing incontinence…

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.

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored and labeled for 4 of 4 medication carts observed and 2 of 2 treatment carts.(Plaza Cart 101-113, Plaza cart 114-140, Cottage Short Hall, Cottage Long Hall, Plaza Treatment Cart, Cottage Treatment Cart) Findings include: On 7/30/24 at 10:03 A.M., the following was observed in the Plaza medication cart (for rooms 101-113): 3 jars of CBD (Cannabidiol) with Resident 26's name handwritten on it with no other label 1 package of donuts and a drink with no labels. At that time, QMA (Qualified Medicine Aide) 23 indicated they belonged to him. On 7/30/24 at 10:15 A.M., the following loose pill was observed in the Plaza medication cart (for rooms 114-140): 1 white oblong pill with marking ML8 On 7/30/24 at 10:30 A.M., the following loose pills were observed in the Cottage Short Hall medication cart: 1/2 round orange pill 1 white oblong pill with marking ATV 20 On 7/30/24 at 10:40 A.M., the following was observed in the Cottage Long Hall medication cart: 2 daily medication…

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.

Based on interview and record review, the facility failed to ensure residents who required an antibiotic were prescribed the appropriate antibiotic for 2 of 3 residents reviewed for UTI (urinary tract infection). (Resident 43, Resident 30) Findings include: 1. On 7/30/24 at 12:21 P.M., Resident 43's clinical record was reviewed. Diagnosis included, but were not limited to, anxiety and depression. The most recent Quarterly MDS (Minimum Data Set) Assessment, dated 6/23/24, indicated no cognitive impairment, occasional incontinence of the bladder, and no UTIs in the last 30 days. Physician orders included, but were not limited to: ceftriaxone (an antibiotic) injection, 1 gram, ordered on 7/17/24. Resident 43's MAR (Medication Administration Record) for July 2024 indicated ceftriaxone 1 gram was given on 7/17/24 at 8:00 P.M. A progress note, dated 7/17/24 at 3:01 P.M., indicated Resident report burning upon urination. New orders from MD, UA [urinalysis], CBC [complete blood count], BMP [basic metabolic panel], Rocephin [ceftriaxone] 1 gm [gram] x1 dose IM [intramuscular] . The clinical…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to provide supervision to prevent multiple falls. Supervision and effective interventions were not in place to prevent continued falls for 1 of 5 residents (Resident 52) reviewed for accidents. Findings include: During an interview on 5/8/23 at 9:30 A.M. with RN 1, she indicated that Resident 52 hollers out and becomes combative with staff. Resident was not aware of safety and tries to get out of bed on her own. During observation on 5/8/23 at 11:45 A.M., Resident 52 was observed in a high-back wheelchair at the table in the dining room on the locked unit. Resident called out sporadically help me! help me! On 5/9/23 at 1:52 P.M. Resident 52's clinical records were reviewed. Diagnoses included, but were not limited to: metabolic encephalopathy, type 2 diabetes, COPD (chronic obstructive pulmonary disease), dementia. Significant Change Minimum Data Set (MDS) assessment dated [DATE] indicated resident had severe cognitive impairment. Resident…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review, the facility failed to ensure that 1 resident who needed respiratory care, did not receive the prescribed amount of oxygen and 2 residents' equipment was not labeled or maintained for 2 of 2 residents (Resident 1 and Resident 43) reviewed for respiratory care. Findings include: 1. During an interview with Resident 1 on 5/8/23 at 9:40 A.M., she said she wears her oxygen when she sleeps. Oxygen was on at 2 liters per minute (lpm) per nasal cannula (nc). Filter on the oxygen concentrator was covered with white lint. On 5/9/23 at 10:00 A.M., observed resident asleep in bed with oxygen on at 2 lpm per nc. Filter on concentrator is covered with white lint. During an interview on 5/11/23 at 9:12 A.M. with RN 1, she indicated a respiratory care company manages their oxygen concentrators. The company is supposed to change the filters and maintain the machines. On 5/11/23 at 9:19 A.M., observed resident's oxygen concentrator while resident was out of the room; the…

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.

Based on observation, interview, and record review, the facility failed to ensure medications were labeled with open dates for 1 of 3 medication carts observed. ( Plaza Unit Cart) Finding includes: During an observation on 5/10/23 at 8:37 a.m., of the Plaza Unit medication cart, the following medications were observed to be open and undated: sulfacetamide sodium drops 10% ; amt : 1 drop; ophthalmic (eye) insulin lispro insulin pen; 100 unit/ml (milliliter); amt; per sliding scale; subcutaneous hyoscyamine sulfate ( anticholinergics/antispasmodics) drops; 0.125 mg/ml (milligram, milliliter); oral refresh P.M. ( white petrolatum-mineral oil) ointment; 57.3- 42.5% ophthalmic (eye) On 5/10/23 at 8:46 a.m., RN 1 indicated if the seal is not broken on a medication it is not dated, when the seal is broken it should be dated, insulin is good for 28 days after it is open, if it is in the medication cart, even if not open, a date it should be applied. On 5/15/23 at 11:30 a.m., the Administrator provided the current LTC facility pharmacy services and procedures policy with a revision date of…

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.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were implemented for 2 of 4 observations of personal care. Hand hygiene was not done and gloves not changed. (Resident 12, Resident 53). Findings include: 1. On 5/11/23 at 9:39 a.m., CNA 1 and CNA 2 were observed giving Resident 12 a shower. CNA 1 and CNA 2 entered the shower room pushing Resident 12 on a shower bed and donned gloves. No hand hygiene was observed before donning gloves. CNA 1 was observed to take off gloves, leave the shower room to obtain supplies, enter the shower room and don gloves. No hand hygiene was observed before donning gloves. After the shower, CNA 1 was observed to obtain a denture cup, hand to Resident 12 to put his dentures in, clean the dentures at the sink, hand the dentures back to Resident 12 with gloved hands, pull the shower bed to the doorway, doff gloves and push Resident 12 down the hallway to his room. No hand hygiene was observed after doffing gloves. On 5/12/23 at 10:02 a.m., CNA 1 indicated hands should be washed before gloves are…

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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 5 residents reviewed for environment. Findings include: During an observation on 5/8/23 at 8:45 A.M., the mirror in bathroom of room [ROOM NUMBER] was hanging forward from the wall, with a broken bracket on the right side and the left side of the mirror leaning on the paper towel dispenser. The air conditioning unit had a black mold-like substance underneath it and on the left side of it. Two residents were assigned to room [ROOM NUMBER] and shared the bathroom. During an interview on 5/10/23 at 10:15 A.M. with housekeeper 5, she indicated that if the housekeepers saw anything in resident rooms that required maintenance, they would fill out a work order for the maintenance staff to fix it. During an interview on 5/11/23 at 1:05 P.M. with housekeeper 7, she indicated that if the housekeepers saw anything in resident rooms that required…

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.