Axiom Gardens of Mount Vernon

In the surveyor’s words

From the most serious findings on record at Axiom Gardens of Mount Vernon, in the surveyor’s own words.

• Actual harm, isolatedF697Mar 4, 2026

  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… […]

• Actual harm, isolatedF600Aug 12, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF725Mar 19, 2026

  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. […]

• No harm, potential for more than minimal, widespreadF880Mar 28, 2025

  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. […]

• No harm, potential for more than minimal, patternF550Mar 17, 2025

  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. […]