Axiom Gardens of Mount Vernon

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to answer call lights for residents needing assistance in a timely manner to promote dignity for 1 residents of 9 residents (R68) reviewed for call light response in a sample of 51.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to obtain and provide necessary controlled prescription pain medication in a timely manner for 1 (R1) of 3 residents reviewed for pharmacy services in the sample of 5.

Inspectors wroteBased 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. Section GG -Functional Abilities documents R1 has no impairment with upper or lower extremities. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from resident to resident physical abuse for 2 (R3 and R4) of 3 residents reviewed for abuse in the sample of 4. Findings Include: R3's admission Record documented R3 was admitted to the facility on [DATE] and included diagnoses of unspecified dementia, essential hypertension, unspecified protein-calorie malnutrition, atrial fibrillation, osteoarthritis of knee, adult failure to thrive, and unspecified macular degeneration. R3's Minimum Data Set (MDS) assessment dated [DATE], documented that R1 has a Brief Interview for Mental Status (BIMS) score of 11, indicating R3 is moderately impaired. [...]

Inspectors wroteBased 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. V12 said she doesn't know if it kills COVID or not. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with a history of weight loss or at risk for nutritional problems received ordered supplements with meals for 6 of 6 residents (R7, R12, R17, R19, R23, R35) reviewed for nutrition in a sample of 39. Findings Include: On 03/11/24 between 11:40 AM and 12:25 PM, R7, R12, R17, and R23 did not receive a health shake or a nutritional ice cream with the lunch meal. On 03/12/25 between 11:43 AM and 12:27 PM, R7, R17, R19 and R23 did not receive a nutritional ice cream with the lunch meal. 1. R23's admission record documents an admission date of 11/09/21 with diagnoses including: dementia, cerebral infarction, delusional disorders, hallucinations, vitamin D deficiency, hereditary and idiopathic neuropathy, muscle wasting and atrophy and fatigue. R23's care plan documents a focus area noting: [...]

Inspectors wroteBased on interview and record review the facility failed to have a physician perform a comprehensive evaluation within 30 days post admission for 5 of 5 residents (R2, R13, R48, R49, and R102) reviewed for physicians' visits in a sample of 39.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure residents with dementia received the necessary person-centered care and services consistent with the resident goals and symptomology for 5 of 8 residents (R23, R29, R32, R42, R44) reviewed for dementia care in the sample of 39.

Inspectors wroteBased on interview, observation, and record review the facility failed to process the returning and/or destroying of unused medication for 4 of 4 (R12, R16, R32, R156) residents reviewed for medications storage in the sample of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the approved menu for portion sizes and items to be served for 8 of 21 residents (R2, R5, R7, R10, R11, R12, R14, R44) reviewed for dining in the sample of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to have assessments and/or physician's orders for lap restraints for 2 (R12 and R19) of 2 residents reviewed for restraints in a sample of 39.

Inspectors wroteBased on interview and record review the facility failed to perform fall risk assessments timely and implement effective interventions to prevent falls for 1 of 6 residents (R17) reviewed for falls in a sample of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that tables were properly cleaned and sanitized, prior to residents eating on them for 3 of 16 (R32, R41, and R44) reviewed for dining in the sample of 39.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide Enhanced Barrier Precautions according to professional standards of practice for 3 out of 3 residents (R13, R22, R38) reviewed for infection control in a sample of 39.

Inspectors wroteBased on interview and record review the facility failed to maintain/offer influenza vaccinations for one (R34) resident of 5 residents reviewed for immunizations in a sample of 39.