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Deficiency Records for Mount Vernon Healthcare Center
A list of the most recent deficiencies for Mount Vernon Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Mount Vernon Healthcare Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-15 | 2023-12-28 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-09-22 | 2023-07-19 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-09-22 | 2023-07-19 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2022-09-22 | 2023-07-19 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-29 | 2023-02-22 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-09-29 | 2023-02-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-09-29 | 2023-02-22 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-11 | 2023-02-22 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-01-11 | 2023-02-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-11 | 2023-02-22 | Y |
| Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. | Health | 2022-09-29 | 2023-02-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-09-29 | 2023-02-10 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-09-29 | 2023-02-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-29 | 2023-02-10 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-29 | 2023-02-10 | N |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2022-09-29 | 2023-02-10 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-09-29 | 2023-02-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-29 | 2023-02-10 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-09-29 | 2023-02-10 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-09-29 | 2023-02-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-29 | 2023-02-10 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-09-29 | 2023-02-10 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-01-11 | 2023-02-10 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-01-11 | 2023-02-10 | Y |
| Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. | Health | 2023-01-11 | 2023-02-10 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-01-11 | 2023-02-10 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-01-11 | 2023-02-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-11 | 2023-02-10 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-01-11 | 2023-02-10 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-01-11 | 2023-02-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-11 | 2023-02-10 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-01-11 | 2023-02-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-11 | 2023-02-10 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-01-11 | 2023-02-10 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-11 | 2023-02-10 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2022-09-29 | 2023-02-10 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-09-29 | 2022-11-13 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2022-09-29 | 2022-11-13 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2022-09-29 | 2022-11-13 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2022-09-29 | 2022-11-13 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-09-29 | 2022-11-13 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-09-29 | 2022-11-13 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-09-29 | 2022-11-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-09-29 | 2022-11-13 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-09-29 | 2022-11-13 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-09-29 | 2022-11-13 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-09-29 | 2022-11-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-29 | 2022-11-13 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-09-29 | 2022-11-13 | N |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2022-09-29 | 2022-11-13 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-09-29 | 2022-11-13 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-09-29 | 2022-11-13 | N |
| Post nurse staffing information every day. | Health | 2022-09-29 | 2022-11-13 | N |
| Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | Health | 2022-09-29 | 2022-11-13 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2022-09-29 | 2022-11-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-29 | 2022-11-13 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-09-29 | 2022-11-13 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-09-29 | 2022-11-13 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-29 | 2022-11-13 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-09-29 | 2022-11-13 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-09-29 | 2022-11-13 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-29 | 2022-11-13 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-09-29 | 2022-11-13 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-09-29 | 2022-11-13 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-29 | 2022-11-13 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-09-29 | 2022-11-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-29 | 2022-11-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-29 | 2022-11-13 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-09-29 | 2022-11-13 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-29 | 2022-11-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-29 | 2022-11-13 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-29 | 2022-11-13 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-09-29 | 2022-11-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-29 | 2022-11-13 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-09-29 | 2022-11-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-29 | 2022-11-13 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-29 | 2022-11-13 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-08-17 | 2022-09-20 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-03-11 | 2020-06-08 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2020-03-11 | 2020-06-08 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2020-03-11 | 2020-06-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-03-11 | 2020-06-08 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-11-08 | 2020-01-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-08 | 2020-01-15 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-11-08 | 2019-12-10 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-11-08 | 2019-12-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-11-08 | 2019-12-10 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-11-08 | 2019-12-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-11-08 | 2019-12-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-08 | 2019-12-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-08 | 2019-12-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-08 | 2019-12-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-11-08 | 2019-12-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-08 | 2019-12-10 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-05-24 | 2018-07-06 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-05-24 | 2018-07-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-24 | 2018-07-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-05-24 | 2018-07-06 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-24 | 2018-07-06 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-05-24 | 2018-07-06 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-05-24 | 2018-07-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-24 | 2018-07-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-05-24 | 2018-07-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-24 | 2018-07-06 | N |
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