Mount Vernon Countryside Manor

In the surveyor’s words

From the most serious findings on record at Mount Vernon Countryside Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF803Aug 23, 2022

  Based on interview and record review, the facility failed to provide the correct textured diet to a resident (R2) with an order for a mechanical soft diet. This failure resulted in R2's choking and death. This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when the facility failed to provide a mechanical soft texture diet as ordered for R2. This was identified as past non-compliance that occurred from [DATE] to [DATE]. V1 (Regional Director) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 9:10 AM. The surveyor confirmed by observations, record review and interview that the Immediate Jeopardy was removed on [DATE]. […]

• Immediate jeopardy, isolatedF580Jun 7, 2022

  Based on interview and record review the facility failed to notify the primary care physician of a change in condition for 1 (R166) of 8 residents reviewed for physician notification in the sample of 34. This failure resulted in R166 experiencing prolonged restlessness, increased confusion, anxiety, shortness of breath, diaphoresis, an abnormal oxygen saturation level, and death on [DATE]. This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] at 11:00 PM, when the facility failed to notify the primary care physician R3 was experiencing a change in baseline status which included restlessness, increased confusion, anxiety, shortness of breath, pulling at foley catheter, and diaphoresis resulting in R166's expiration at the facility at 1:37 AM on… […]

• Immediate jeopardy, isolatedF684Jun 7, 2022

  Based on interview and record review, the facility failed to thoroughly assess a resident reported to be in distress and recognize the need to call the physician for additional guidance after a change in condition to seek medical treatment for 1 (R166) of 8 residents reviewed for a change in condition in the sample of 34. This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] at 11:00 PM, when the facility failed to notify the primary care physician R166 was experiencing a change in his baseline status which included: restlessness, increased confusion, anxiety, shortness of breath, pulling at foley catheter, abnormal oxygen saturation level, and diaphoresis which resulted in R166's expiration at the facility at 1:37 AM on [DATE]. […]

• Immediate jeopardy, isolatedF689Nov 9, 2021

  Based on interview and record review the facility failed to provide required supervision, support and assistance, during an episode of agitation, that resulted in a fall for 1 (R3) of 3 residents reviewed for falls in a sample of 3. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 10/13/21 at 6:30 am, when the facility failed to implement supervision, physical support/assist for R3 as required, to provide stabilization, while seated on the side of the bed. This failure resulted in R3 attempting to transfer independently and resulted in a fall. R3 sustained a fracture to the right femur, requiring hospitalization , a subsequent surgical repair, and then R3's demise on 10/15/21. This past noncompliance occurred from 10/13/21 to 10/25/21. […]

• Actual harm, isolatedF692Jan 24, 2025

  Based on interview and record review the facility failed to implement dietary supplements as ordered for 4 (R39, R44, R45 and R63) of 8 residents reviewed for nutrition in a sample of 36. This failure resulted in R63 experiencing a 7.88 percent weight loss within one month. Findings include: 1. R63's Resident Face Sheet documented an admitted [DATE] with diagnoses including: dementia, underweight, mild protein-calorie malnutrition, muscle wasting and atrophy. R63's 12/13/24 Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of 1, indicating R63 had severe cognitive impairment. R63's Progress Note dated 12/19/24 from V3 (Dietician) documents, Note r/t (related to) wound. Resident has skin tear to R (right) hip/buttock. […]