Life Care Center of Mount Vernon

In the surveyor’s words

From the most serious findings on record at Life Care Center of Mount Vernon, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684May 20, 2025

  Based on interview and record review, the facility failed to provide a thorough assessment to timely recognize a significant change in condition, take action to notify the medical provider as ordered, and to ensure required staff were certified in Cardiopulmonary Resuscitation (CPR) for 1 of 1 resident (Resident 1) reviewed for an unexpected death in the facility. Resident 1 experienced harm when they had a significant weight gain over a 24-hour period, swelling in their left arm, slurring of their speech, difficulty breathing and change in their mentation throughout the day of [DATE], until they were found unresponsive without a pulse when assessment and treatment were delayed for several hours that constituted an immediate jeopardy. […]

• Actual harm, isolatedF684Nov 18, 2025

  Based on interview and record review, the facility failed to establish an appropriate plan of care, consistently provide the required assessments monitoring, and care interventions following a total knee replacement surgery for 3 of 4 residents (Residents 1, 2, and 3) reviewed for post-surgical care and hospitalization. Resident 1 experienced harm when they verbalized increased pain to the right foot that was unassessed for six days, developed a blood clot to their right foot that caused lack of blood flow to the foot that required transfer to the hospital where a surgical intervention was performed to remove the clot and the potential for right foot amputation (removal of limb). […]

• Actual harm, isolatedF686Nov 18, 2025

  Based on interviews and record review, the facility failed to ensure assessments were completed to evaluate the need for pressure offloading preventative measures post-surgery, assess and monitor skin integrity, and to consistently implement interventions to prevent development of an avoidable pressure ulcer/pressure injury (PU/PI - injury to skin and underlying tissue resulting from prolonged pressure) for 1 of 1 sampled resident (Resident 1), reviewed for pressure ulcers. Resident 1 experienced harm when they developed an unstageable PI [a full thickness wound where the depth of damage cannot be determined because the base is covered by slough (yellow, tan, or grayish tissue) or eschar (brown or black leathery tissue)] to their right heel, an unstageable PI to their right bottom foot,… […]

• Actual harm, isolatedF686Jul 31, 2025

  Based on interviews, observation, and record reviews, the facility failed to assess/monitor the position of a catheter tubing (a flexible tube inserted into the bladder to remove urine and attached to a drainage bag) during catheter care and bed mobility/positioning to prevent the occurrence of an avoidable pressure ulcer (PU) and provide ordered treatment for the PU for 1 of 3 residents (Resident 3) reviewed for PU's. Resident 3 experienced harm when they developed an avoidable Stage III PU (full-thickness skin loss of skin, which is when fat is visible in the ulcer and granulation tissue which is new connective tissues and microscopic blood vessels, and rolled wound edges are often present. Slough, nonviable tissue, and/or eschar, dead or devitalized tissue, may be visible. […]

• Actual harm, isolatedF600May 20, 2025

  Based on interview and record review the facility failed to protect the resident's right to be free from neglect when they failed to conduct a thorough assessment, communicate a change in condition timely to the physician and notify other nursing staff to respond correctly to a medical emergency for 1 of 1 resident (Resident 1) reviewed for abuse and neglect. Resident 1 experienced harm when they had a change in condition, several caregivers were aware of the change from the resident's baseline, which worsened when nursing staff failed to take timely action; the resident became unresponsive, required cardiopulmonary resuscitation (CPR), and an unexpected death occurred. These failures placed all residents at risk of unmet care needs and potential neglect. […]