Mount Vernon Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Mount Vernon Nursing and Rehabilitation, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF628Feb 13, 2026

  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. […]

• No harm, potential for more than minimal, patternF880Aug 6, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF656Aug 6, 2024

  Based on interview, record review, and observation, the facility failed to ensure a person-centered comprehensive care plan was developed for 1 of 3 residents reviewed for unnecessary medications receiving diuretics. (Resident 34) Finding includes: On 8/1/24 at 1:03 P.M., Resident 34's clinical record was reviewed. Resident 34 was admitted on [DATE]. Diagnoses included, but were not limited to congestive heart failure (CHF) and chronic respiratory failure. An Admission MDS (Minimum Data Set) Assessment, dated 6/26/24, indicated Resident 34 was cognitively intact and was received a diuretic medication in the last seven days. Resident had used oxygen while a resident. […]

• No harm, potential for more than minimal, isolatedF761Aug 6, 2024

  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. […]

• No harm, potential for more than minimal, isolatedF881Aug 6, 2024

  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. […]