Home / Illinois / Mount Vernon
1700 White Street, Mount Vernon, IL 62864 · Jefferson County · (618) 242-4075
65 certified beds, about 47 residents a day · For profit - Corporation · Medicare and Medicaid since 1985
CMS Care Compare ratings, data as of September 1, 2026 · CCN 145517 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on December 19, 2024, inspectors cited 14 health deficiencies (the Illinois average is 12.6, the national average 9.2).
Of 64 health citations since October 2022, 11 were rated as actual harm or immediate jeopardy to residents (4 immediate jeopardy).
CMS lists 7 fines totaling $355,763 in the last three years; the largest was $226,026, and the latest is dated April 7, 2026.
Nurses and nurse aides worked 3.60 hours per resident per day, against 3.45 across Illinois and 3.86 nationally. Registered nurses accounted for 0.60 of those hours.
60.4% of nursing staff left within the year CMS measured (Illinois average 44.5%).
CMS links it to Axiom Healthcare, an affiliated group of 8 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 64 health citations on file.
Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from abuse from staff for 1 of 3 residents (R1) reviewed for abuse and neglect in the sample of 11. This failure resulted in a staff member physically forcing a resident in to the residents room and shutting the door causing bruising to R1's chest with vocal complaints of pain.
Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from involuntary seclusion for 1 of 3 residents (R1) reviewed for abuse and neglect in the sample of 11. This failure resulted in R1 being forced in to R1's room and staff closing the door to keep R1 in R1's room multiple times causing R1 to knock on R1's door in attempts to have door opened.
Inspectors wroteBased on interview and record review, facility staff failed to notify law enforcement in a timely manner of an alleged staff to resident abuse incident for 1 of 3 residents (R1) reviewed for abuse and neglect in the sample of 11.
Inspectors wroteBased on interview, observation and record review, the facility failed to thoroughly investigate bruising from potential staff to resident abuse for 1 of 3 residents (R1) reviewed for abuse and neglect in a sample of 11.
Inspectors wroteBased on interviews and record review the facility failed to ensure they maintained sufficient staff to meet the needs of the residents timely for 3 of 3 residents (R1, R2, and R3) reviewed for staffing in the sample of 7. This failure has the potential to affect all 47 resident who currently reside at the facility.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff donned the required Personal Protective Equipment. The facility also failed to ensure contaminated Personal Protective Equipment was discarded as required after use, failed to separate covid positive residents from covid negative residents, and failed to monitor vital signs of covid positive residents. These failures affected 6 of 6 residents (R1-R6) who were reviewed for infection control practices. These failures also have the potential to affect all 44 residents living in the facility.
Inspectors wroteBased on interview and record review, the facility failed to designate an individual as the Infection Preventionist. This failure has the potential to affect all 44 residents living in the facility.
Inspectors wroteBased on observation, interview and record review, the facility failed to use appropriate alternatives prior to installation of bed rails, adequately assess and monitor residents for risk of injury/entrapment prior to installation, ensure adherence to appropriate dimensions and manufacturer's recommendations, and failed to obtain a physician order for use of bed rails for 6 (R2, R3, R4, R7, R8, R9) of 9 residents reviewed for bed rails in the sample of 29. This failure resulted in R2's death by positional asphyxiation, when R2 was found in the sitting position on the floor beside the bed with legs straight out and head and neck between mattress and bed rail. This failure also has the potential for risk of serious harm/injury and possible death for R3, R4, R7, R8 and R9. [...]
Inspectors wroteBased on interview and record review, the facility failed to seek emergency care for a resident with Type 2 Diabetes Mellitus who was experiencing elevated blood sugars too high for accurate readings to be obtained with facility glucose monitoring device for 1 of 3 residents (R16) reviewed for change in condition in a sample of 29. This failure resulted in R16's death with cause of death listed as possible diabetic ketoacidosis. This failure resulted in an Immediate Jeopardy, which was identified to have begun on [DATE] when the facility failed to seek emergency care for R16 who was experiencing high blood sugar readings which lead to R16's death as possible diabetic ketoacidosis. V1 (Administrator), V33 (Regional Reimbursement), and V34 (Regional Clinical Nurse) were notified of the Immediate Jeopardy on [DATE] at 11:35 AM. [...]
Inspectors wroteBased on interview and record review, the facility failed to provide safe administration of peritoneal dialysis by qualified trained staff as ordered by a physician for 1 (R22) of 3 residents reviewed for dialysis in the sample of 29. This failure resulted in R22 experiencing severe shortness of breath requiring transfer to local hospital, R22 receiving intubation and mechanical ventilation for respiratory failure to prevent imminent deterioration and further organ dysfunction from hypoxia and hypercarbia. [...]
Inspectors wroteBased on observation, interview and record review, the facility failed to implement new fall interventions for a resident who was a high risk for falls for 1 of 3 residents (R25) reviewed for falls in the sample of 29. This failure resulted in R25 being sent to the hospital for a fall that that resulted in a new hyper density in the posterior right globe and swelling/hematoma to the right scalp.
Inspectors wroteBased on interview and record review, the facility failed to ensure the physician reviews the resident's plan of care and sign and date orders. This failure has the potential to affect all 50 residents residing in the facility.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. This failure has the potential to affect all 50 residents residing in the facility.
Inspectors wroteBased on interview and record review, the facility failed to ensure the medical director was available 24 hours a day for emergencies. This failure has the potential to affect all 50 residents residing in the facility.
Inspectors wroteBased on interview, and record review the facility failed to provide a sufficient level of nursing staff to provide timely assistance with activities of daily living. This failure has the potential to affect all 50 residents residing in the facility.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide food in accordance with the planned menus. This failure has the potential to affect all 50 residents residing in the facility.
Inspectors wroteBased on observation, interview, and record review the facility failed to provide food at palatable temperatures. This failure has the potential to affect all 50 residents residing in the facility.
Inspectors wroteBased on interview and record review, the facility failed to investigate and report a resident death to the Department, failed to seek emergency services for a resident experiencing a change of condition, failed to implement new fall interventions, failed to obtain orders for a resident receiving peritoneal dialysis (PD) along with training staff on emergency PD procedures, failed to maintain communications with facility medical director during off hours, failed to provide routine training to staff, and failed to provide an Administrator the training needed to direct the day to day functions at the facility. The failure has the potential to affect all 50 residents living in the facility.
Inspectors wroteBased on interview and record review the facility failed to conduct ongoing training in effective resident care communications for all staff. This failure has the potential to affect all 50 residents residing in the facility.
Inspectors wroteBased on interview and record review the facility failed to conduct ongoing training in Quality Assurance and Performance Improvement (QAPI) for all staff. This failure has the potential to affect all 50 residents residing in the facility.
Inspectors wroteBased on interview and record review the facility failed to conduct ongoing training in Compliance and Ethics for all staff. This failure has the potential to affect all 50 residents residing in the facility.
Inspectors wroteBased on interview and record review the facility failed to conduct required in-service training and competencies for Certified Nursing Assistants (CNA). This failure has the potential to affect all 50 residents residing in the facility.
Inspectors wroteBased on interview and record review the facility failed to conduct ongoing training for all staff, to meet the resident's behavioral health care needs. This failure has the potential to affect all 50 residents residing in the facility.
Inspectors wroteBased on interview, and record review the facility failed to provide assistance with activities of daily living for 4 of 5 residents (R8, R18, R21, R28) reviewed for activities of daily living care in a sample of 29.
Inspectors wroteBased on interview, observation, and record review the facility failed to notify the physician of intravenous medications being unavailable for administration. The facility also failed to notify the physician for residents change in condition for 2 of 3 residents (R1, R16) reviewed for physician notification in a sample of 29.
Inspectors wroteBased on interview, observation, and record review the facility failed to obtain and administer Intravenous medications as ordered by the physician to 1 of 3 residents (R1) in a sample of 29.
Inspectors wroteBased on interview, observation, and record review the facility failed to ensure physician's orders were followed for administering Intravenous medications and insulin to 2 of 3 residents (R1 and R21) reviewed for medications in a sample of 29.
Inspectors wroteBased on observation, interview, and record review the facility failed to assess, treat, and implement interventions to prevent pressure ulcers for 2 of 3 (R33 and R18) residents reviewed for pressure ulcers in the sample of 24. This failure resulted in R33 developing a Stage 3 pressure ulcer to his right Ischium and R18's left heel pressure wound worsening/declining. The Findings Include: 1. R33's admission record documents an admission date of 7/17/22. This same document includes the following diagnosis: Parkinsonism, Diabetes Mellitus Type 2, Dementia, and other specified nutritional deficiencies. R33's Quarterly Minimum Data Set (MDS) dated [DATE] Section C0700 documents R33 has a short term and long term memory problem conducted by staff. This same MDS Section GG documents that R33 is dependent on staff for toileting, hygiene and bed mobility. [...]
Inspectors wroteBased on interview and record review, the facility failed to provide the services of a Registered Nurse (RN) for 8 consecutive hours per day seven days a week. This failure has the potential to affect all 48 residents living in the facility. Findings Include: The Long-Term Care Facility Application for Medicare and Medicaid document dated 12/10/2024, documents 48 residents residing in the facility. Review of the nursing schedules document that no RN was on shift 4/6/2024, 5/4/2024, 5/12/2024, 6/1/2024, 6/29/2024, 6/30/24, 8/3/2024, 8/4/2024, 8/10/2024, 8/11/2024, 8/17/2024, 8/18/2024, 8/24/2024, 8/25/2024, 8/31/2024, 9/7/204, 9/8/2024, 9/21/2024, 9/22/2024, 9/23/2024, 9/25/2024, 9/26/2024, 9/27/2024, 9/29/2024, 10/1/2024, 11/3/2024, 11/17/2024. On 12/10/24 at 2:17 PM, V2 (Director of Nursing/DON) stated the facility had been having issues with having daily Registered Nurse (RN) coverage. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to prepare food according to planned menu/recipe. This has the potential to affect all 48 residents living in the facility Findings Include: The Week at a Glance menu documents Chicken Cordon Bleu Casserole for lunch on 12/12/24 and Sweet and Sour Pork for lunch on 12/13/24 On 12/12/24 at 12:30PM, V19 (Family Member) questioned what the standards for the food is in a long term care setting because it is poor quality here. V19 went on to state that that her concern is the food quality is low and that makes it hard for the residents to eat. On 12/12/24 at 12:42PM, V12 (Cook) stated that they did not have the chicken or the ham the recipe called for. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to ensure the kitchen was clean and sanitary to prevent cross contamination. This has the potential to affect all 48 residents living in the facility. Findings Include: On 12/10/24 at 7:50AM, during the initial tour of the kitchen the following concerns were noted: The back door was propped open with no screen in place. The kitchen window was open. The window had a screen but the screen had holes in it allowing anything from the outside in. The refrigerator in the store room had a dried spilled puddle that was brown under a bottle of worcestershire sauce that only had loose plastic wrap as a lid and was laying on its side. Milk with a date of 11/10/24 was in the refrigerator crisper drawer in the store room refrigerator. Cups with a clear milky liquid were on the bottom shelf in the door not dated or labeled. [...]
Inspectors wroteBased on record review and interview, the facility failed to hold quarterly Quality Assurance and Performance Improvement (QAPI) meetings. This has the potential to affect all 48 residents residing in the facility. Findings Include: On 12/12/24 at 9:00 AM, V1 (Administrator) stated she is not able to provide any documentation of minutes or attendance sheets for the facility's quarterly QAPI meetings for January 2024 and April 2024. V1 further stated her employment in the administration role at this facility began in July 2024 and she is not aware if a meeting had been held. During the survey, a review of facility records revealed no documentation quarterly QAPI meetings were held in January 2024 and July 2024. No meeting minutes or attendance sheets were found. The facility was unable to provide reproducible evidence QAPI meetings had been scheduled or occurred. [...]
Inspectors wroteBased on interview and record review, the facility failed to notify resident representatives in writing of hospital transfers for 1 (R27) of 2 resident reviewed for hospitalizations in a sample of 24. Findings Include: R27's admission Record documented R27 is [AGE] years old with an Initial admission Date to the facility of 08/27/2021. R27's Nurse's Notes documented on 09/11/2024, that R27 was sent out to the local emergency department for an episode of choking. R27's Nurse's Notes documented on 11/11/2024, that R27 was admitted to the local hospital with a diagnosis of preseptal cellulitis. On 12/13/2024 at 10:09 A.M. V1 (Administrator) stated they do not have the bed hold / notice of discharge on R27 for dates 9/11/2024 and 11/11/2024. V1 stated typically the facility sends the notifications when a resident is sent to the hospital. [...]
Inspectors wroteBased on interview and record review, the facility failed to notify resident representatives in writing of the bed hold policy during resident transfers for 1 (R27) of 2 resident reviewed for hospitalization in the sample of 24. Findings Include: R27's admission Record documented R27 is [AGE] years old with an Initial admission Date to the facility of 08/27/2021. R27's Nurse's Notes documented on 09/11/2024, that R27 was sent out to the local emergency department for an episode of choking. R27's Nurse's Notes documented on 11/11/2024, that R27 was admitted to the local hospital with a diagnosis of preseptal cellulitis. On 12/13/2024 at 10:09 A.M. V1 (Administrator) stated they do not have the bed hold / notice of discharge on R27 for dates 9/11/2024 and 11/11/2024. V1 stated that she is not sure why R27's representative was not notified of the bed hold. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for 1 (R21) of 2 residents reviewed for accuracy of assessments in the sample of 24. Findings Include: R21's admission Record documented R21 is [AGE] years old with an Initial admission Date to the facility of 11/08/2024. Diagnoses listed on this document included Schizophrenia, depression, unspecified dementia, essential hypertension, anxiety disorder and hyperlipidemia. R21's (name of company) Notice of PASRR (Preadmission Screening and Resident Review) Level I Outcome dated 06/04/2024, documented PASRR Level I Determination: Refer for Level II onsite. R21's (name of company) Notice of PASRR Level II Outcome dated 06/06/2024, documented PASRR Determination: [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to provide toileting assistance to dependent residents for 1 (R33) of 12 residents reviewed for activities of daily living in the sample of 24. Findings Include: R33's admission record documents an admission date of 7/17/22. This same document includes the following diagnoses: Parkinsonism, Diabetes Mellitus Type 2, Dementia, and other specified nutritional deficiencies. R33's Quarterly Minimum Data Set (MDS) dated [DATE] Section C0700 documents R33 has a short term and long term memory problem conducted by staff. This same MDS Section GG documents that R33 is dependent on staff for toileting, hygiene, and bed mobility. Section H, Bladder and Bowel, documents that R33 always has urinary and bowel incontinence. On 12/10/24, intermittent observations were made of R33 at: [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to implement treatment and services to a resident with limited range of motion to maintain or improve range of motion for 1 of 1 (R33) residents reviewed for positioning and mobility in the sample of 24. Findings Include: R33's admission record documents an admission date of 7/17/22. This same document includes the following diagnoses: Parkinsonism, Diabetes Mellitus Type 2, Dementia, and other specified nutritional deficiencies. R33's Quarterly Minimum Data Set (MDS) dated [DATE] Section C0700 documents R33 has a short term and long term memory problem conducted by staff. This same MDS documents in Section GG that R33 is dependent on staff for toileting, hygiene, showering, lower body dressing, oral hygiene, toilet transfer, chair/bed transfer, roll left and right and bed mobility. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to maintain communication and collaboration with an offsite dialysis center and failed to provide meals as ordered for a resident receiving dialysis for 1 (R8) of 1 residents reviewed for dialysis in the sample of 24. Findings Include: R8's admission record documents an admission date of 4/19/22. This same document includes the following diagnosis: muscle weakness, end stage renal disease, dependence on renal dialysis. R8's care plan documents a focus area revised on 10/22/24 that R8 needs dialysis related to ESRD (end stage renal disease). The goal for this focus area with the same revision date of 10/22/24 is for R8 to have no signs or symptoms of complications from dialysis through the review date. The interventions for this focus area are as follows: [...]
Inspectors wroteBased on interview and record review, the facility failed to implement a gradual dose reductions (GDR) for 1 (R20) of 5 residents reviewed for unnecessary medications in the sample of 24. Findings Include: R20's admission Record documented R20 was [AGE] years old with an Initial admission Date to the facility of 04/28/2023. Diagnoses listed are chronic obstructive pulmonary disease, major depressive disorder, unspecified dementia, unspecified atrial fibrillation, essential hypertension, hyperlipidemia, chronic diastolic heart failure and generalized anxiety disorder. R20's Physician's Order with a date of December 2024 documented an order for lorazepam 0.5 mg (milligram) by mouth twice a day. Company Consultant Report dated 05/10/2024 documented under section titled comment, R20 has received Lorazepam 0.5 mg po BID from 10/2023. [...]
Inspectors wroteBased on interview and record review the facility failed to ensure that residents are free from significant medication errors for 1 (R20) of 4 residents reviewed for medication administration in the sample of 24. Findings Include: R20's admission Record documented R20 was [AGE] years old with an Initial admission Date to the facility of 04/28/2023. Diagnoses listed are: chronic obstructive pulmonary disease, major depressive disorder, unspecified dementia, unspecified atrial fibrillation, essential hypertension, hyperlipidemia, and chronic diastolic heart failure. R20's Nurse's Note dated 10/06/2024 authored by V2 (Director of Nursing) documented R20 returned to the facility from being in the hospital. R20 returned with orders to discontinue Eliquis due to R20 having a positive occult blood and anemia. [...]
Inspectors wroteBased on interview, observation and record review the facility failed to follow infection control protocol per current standards of practice for 2 of 2 residents (R33 and R197) reviewed for infection control practices in the sample of 24. Findings Include: 1. R197's admission Record documented R197 is [AGE] years old with an Initial admission Date to the facility of 11/25/2024. Diagnoses listed on this document included presence of urogenital implants, colostomy status, neurogenic bowel, bladder - neck obstruction, paraplegia, pressure ulcer of sacral region, right hip, right buttock, left buttock, and personal history of transient ischemic attack. R197's Physician Orders with a date of December 2024 document an order for #16 Fr urinary catheter with 5 cc (cubic centimeters) bulb. [...]
Inspectors wroteBased on observation, interview and record review the facility failed to provide a sufficient number of dietay staff to ensure meals are served at the facility designated meal times. This failure has the potential to affect all 29 residents living in the facility.
Inspectors wroteBased on observation, interview and record review the facility failed to serve meals at the facility's designated meal times. This failure has the potential to affect all 29 residents living in the facility.
Inspectors wroteBased on observation, interview, and record review, the facility failed to serve meals as per there designated schedule. This has the potential to affect all 27 residents living at the facility.
Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and/or initiate investigations on allegations of resident to resident abuse and allegations of staff to resident abuse for three residents (R4, R6, R9) reviewed for abuse in a sample of 9. Findings Include: 1. R4's admission Record dated 03/24/2024 documents R4 was admitted to the facility on [DATE] with diagnoses that include Unspecified systolic (congestive) heart failure, chronic obstructive pulmonary disease, essential primary hypertension, type 2 diabetes mellitus, Urinary tract infections, anemia, acquired absence of left leg above the knee. R4's MDS (Minimum Data Set) dated 03/29/24 documents R4 has a BIMS (Brief Interview for Mental Status) score of 12, which indicates a moderate cognitive impairment. On 05/28/2024 at 01:53PM, R4 stated she had an incident on 05/26/2024 with R9. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pressure ulcer treatment according to physicians orders for 1 of 1 resident (R5) reviewed for pressure ulcers in the sample of 9.
Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the food intake for a resident with a history weight loss for 1 of 9 residents (R5) reviewed for weight loss in a sample of 9.
Inspectors wroteBased on interview and record review the facility failed to provide 8 hours of daily Registered Nurse (RN) coverage. This has the potential to affect all 27 residents residing in the facility. Findings Include: On 5/15/24 at 11:00am, V1 (Administrataor) said that they are short on Registered Nurses but it is getting better. V1 said she knows there is times when they did not have the 8 hours a day of coverage. On 5/14/24 at 11:30am, V2 (DON/Director of Nurses) said she is always trying to get more Registered Nurses, but it is better than it was. Review of the nursing staff schedules for March, April and May 2024 documents the facility did not have RN coverage on 3/2/24, 3/30/24, 4/6/24, 5/4/24, and 5/12/24. The facility Midnight Census Report Form dated 5/14/24 documents that 27 residents reside at the facility, with 1 resident in the hospital.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Physician visited and examined residents at least once every 30 days for the first 90 days after admission or at least once every 60 days thereafter for 3 of 3 residents (R1, R2 and R3) reviewed for physician services in a sample of 7.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the shower room was kept clean clean and sanitary condition for 13 of 17 (R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17) residents reviewed for environment in the sample of 17. Findings Include: On 3/3/24 at 9:44 AM, what is described as being the main shower room was inspected with V1 (Administrator). A black/brown/reddish substance was observed to the back wall of the shower stall extending from the floor to approximately 1 foot in height and 1 1/2 feet in width. The substance was wiped with a piece of toilet paper, with the substance wiping off on the toilet paper. V1 acknowledged the presence of the substance, and stated staff should be cleaning out the stall in between resident uses. R5 was observed in the shower room, waiting for his shower prior to this inspection. [...]
Inspectors wroteBased on interview and record review, the facility failed to obtain timely wound care orders and implement pressure wound treatment for 1 (R3) of 5 residents reviewed for wounds in the sample of 5. This failure resulted in R3 receiving no treatment to pressure wounds on his bilateral buttocks from 12/27/2023 to 1/02/2024 with wounds deteriorating as evidence by an increase in size, staging, and onset of odor.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions and dietary recommendations for residents at risk for altered nutritional status for 2 of 3 residents (R3 and R1) reviewed for nutrition in a sample of 3. These failure resulted in R3 experiencing a significant weight loss of 8.09% in 1 month, and R1 experiencing a significant weight loss of 11% in 6 months.
Inspectors wroteBased on interview and record review, the facility failed to administer bolus enteral feedings as ordered by the physician for 1 of 1 residents (R1) reviewed for enteral feedings in a sample of 3.
Inspectors wroteBased on interview and record review, the facility failed to provide a mechanically altered diet as ordered for 1 of 4 (R17) residents reviewed for mechanically altered diets in a sample of 35. This resulted in R17 choking on 9/6/23, requiring the Heimlich maneuver, chest compressions, and evaluation in the emergency room, and a subsequent choking episode on 10/28/23, in which the Heimlich maneuver was again required. These failures resulted in an Immediate Jeopardy, which was identified to have begun on 9/6/23, when the facility failed to provide the proper mechanically altered diet as ordered. V1 (Administrator) was notified of the Immediate Jeopardy on 11/20/23 at 2:58 pm. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to anticipate a residents pain and administer as needed pain medication prior to wound care for one resident of one resident (R12) reviewed for pain in the sample of 35. This failure resulted in R12, while being repositioned and treated during wound care, crying out in pain and distress. The Findings Include: R12's Face Sheet documented an admission Date of 1/27/22. R12's Cumulative Diagnosis Log documented diagnoses including Diabetes Type 2, Lung Cancer, CVA (Cerebral Vascular Accident) by history, and Dementia. R12's 8/28/23 Minimum Data Set (MDS) documented a Brief Inventory for Mental Status Score of zero, indicating R12 experiences severe deficits in cognition. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to properly date, label, and cover food/drink items once opened; failed to throw out expired supplements; failed to maintain equipment and food contact surfaces in a safe and sanitary manner; and failed keep door closed to prevent potential pest contamination. This has the potential to affect all 32 residents residing in the facility. The Findings Include: On 11/14/23 at 9:45AM during the initial tour of the kitchen, the following items were found: 1. freezer base was dirty with food debris and papers 2. cheese in plastic bag was not sealed 3. a pitcher of a purple colored liquid was not labeled or dated 4. shredded cheese and ham and a bottle of thousand island dressing was not labeled and dated after being opened 5. mighty shakes best by used day 11/9/23 6. [...]
Inspectors wroteBased on interview, observation, and record review, the facility failed to implement interventions to prevent falls for one resident (R25) of three residents reviewed for falls in the sample of 35.
Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications for 1 of 5 (R16) residents reviewed for unnecessary medications in a sample of 35. The Findings Include: R16's new admission information sheet document an admission date of 4/28/23. A cumulative diagnosis log includes the following diagnosis: anxiety and depression with non date identified, and dementia with behaviors, with a date identified as 4/25/23 and updated 11/16/23. R16's current physician order sheet as of 11/17/23 has an order for Seroquel 25milligram (mg) twice daily. On 11/17/23 at 1:30 am, V1 (Administrator) confirmed the dementia diagnosis for R16 was not on the cumulative diagnosis sheet on 11/16/23, but she sent a request to the physician to add the diagnosis to R16's chart. V1 said she went ahead and added it before the physician responded. [...]
Inspectors wroteBased on interview, observation, and record review, the facility failed to provide nutritional supplements according to Physicians Orders for one residents (R20) of seven residents reviewed for therapeutic diets in the sample of 35.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain time/temperature controlled foods at proper holding temperatures. This has the potential to affect all 38 residents residing in the facility. The Findings Include: On 10/11/22 at 9:30 AM during the initial walk through of the kitchen, an external refrigerator temperature gauge was showing a temperature of 52 degrees Fahrenheit. No internal thermometer was found inside the unit by V3 (Dietary Supervisor). V3 stated she would place a thermometer inside now to be checked at a later time to determine internal temperature accurately. V3 went on to state there has not been any known issues to refrigerator, and the current month log all showed temperatures up to date within acceptable range. [...]
Inspectors wroteBased on record review and interview, the facility failed to ensure quarterly assessments were completed timely for 5 of 27 residents (R10, R4, R7, R3) reviewed for timely quarterly assessments in a sample of 27. The Findings Include: 1. R10's facility undated New admission Information documents R10 was admitted to the facility on [DATE]. R10's most recent quarterly MDS (Minimum Data Set) found in R10's clinical record was dated 5/14/22. On 10/12/22 at 2:30 PM, V4 (RN/Clinical Reimbursement Specialist) confirmed the most recent quarterly MDS completed for R10 was on 5/14/22. The computer system is showing an MDS was started, but not completed on 8/10/22, when it was due. 2. R4's facility undated New admission Information documents R4 was admitted to the facility on [DATE]. R4's most recent quarterly MDS (Minimum Data Set) found in R4's clinical record was dated 4/21/22. On 10/12/22 at 2: [...]
Inspectors wroteBased on record review and interview, the facility failed to ensure annual assessments were completed timely for 1 of 27 residents (R1) reviewed for timely annual assessments in a sample of 27. The Findings Include: 1. R1's facility undated New admission Information documents R1 was admitted to the facility on [DATE]. The most recent MDS (Minimum Data Set) found in R1's Clinical Record was a quarterly assessment, dated 4/18/22. On 10/12/22 at 2:30 PM, V4 (RN/Clinical Reimbursement Specialist) confirmed the most recent quarterly MDS completed for R1 was on 4/18/22, and was due for an annual on 7/14/22, and was not completed.
Inspectors wroteBased on interview and record review, the facility failed to complete a significant change Minimum Data Set (MDS) for 1 of 8 (R22) residents reviewed for significant change in condition in a sample of 27 .
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement proper hand hygiene during wound care procedures for 1 of 8 (R22) residents reviewed for infection control in a sample of 27.
16 fire safety citations on file: 8 on December 19, 2024, 6 on November 21, 2023, 2 on October 14, 2022.
| Date | Penalty | Amount or length |
|---|---|---|
| April 7, 2026 | Fine | $15,520 |
| December 18, 2025 | Fine | $81,680 |
| December 18, 2025 | Payment Denial | 21 days from February 26, 2026 |
| December 19, 2024 | Fine | $226,026 |
| December 19, 2024 | Payment Denial | 126 days from January 21, 2025 |
| May 15, 2024 | Payment Denial | 13 days from August 15, 2024 |
| January 5, 2024 | Fine | $8,824 |
| January 5, 2024 | Fine | $8,824 |
| November 21, 2023 | Fine | $7,443 |
| November 21, 2023 | Fine | $7,446 |
| November 21, 2023 | Payment Denial | 10 days from December 19, 2023 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Illinois | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.60 | 3.45 | 3.86 |
| Registered nurses | 0.60 | 0.72 | 0.69 |
| All nursing staff on weekends | 2.97 | 3.07 | 3.42 |
| Nurse aides | 2.22 | ||
| Licensed practical nurses | 0.78 | ||
| Nursing staff turnover (share who left in a year) | 60.4% | 44.5% | 45.8% |
| Registered nurse turnover | 40.0% | 41.8% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.81 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.85 on weekdays and 2.97 on weekends, 23% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 8.9% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.62 in April to June 2025 to 3.60 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.60 | 0.60 | 3.85 | 2.97 | 8.9% | 1 of 90 | 47 |
| Oct to Dec 2025 | 3.23 | 0.46 | 3.50 | 2.56 | 2.2% | 1 of 92 | 44 |
| Jul to Sep 2025 | 3.47 | 0.39 | 3.75 | 2.75 | 5.4% | 0 of 92 | 41 |
| Apr to Jun 2025 | 3.62 | 0.55 | 3.82 | 3.11 | 9.6% | 1 of 91 | 41 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Illinois, Jan to Mar 2026 | 3.26 | 0.65 | 3.40 | 2.92 | 5.4% | 0.6% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Illinois, all employers | |||
| CNAs (nursing assistants) | $22.10 | $18.95 to $23.26 | 68,640 |
| LPNs and LVNs | $36.06 | $30.57 to $38.25 | 17,440 |
| Registered nurses | $46.15 | $38.47 to $50.94 | 138,910 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Illinois | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 28.1 | 13.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.4 | 0.9 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 6.8 | 3.1 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.0 | 2.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 26.8 | 14.3 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 14.2 | 4.8 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 20.0 | 21.7 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 21.1 | 26.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 17.3 | 13.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.3 | 2.0 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 4.2 | 2.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Axiom Healthcare of Mount Vernon's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (38.7% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
38.7% this home
No different from the national rate
US median of homes 51.5% · Illinois: 106 better, 85 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 42 eligible stays.
12.0% this home
No different from the national rate
US median of homes 10.7% · Illinois: 2 better, 14 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 61 eligible stays.
8.5% this home
No different from the national rate
US median of homes 7.1% · Illinois: 3 better, 10 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 33 eligible stays.
56.4% this home
Median of homes: Illinois50.0% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 39 residents counted.
1.6% this home
Median of homes: Illinois0.3% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 61 residents counted.
1.4% this home
Median of homes: Illinois1.5% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 61 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: Illinois100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 10 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: AXIOM HEALTHCARE OF MOUNT VERNON LLC. CMS links this home to Axiom Healthcare, a group of 8 nursing homes averaging 1.4 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Hoffman, Joshua | Indirect ownership interest | Individual | 10/20/2025 | |
| Moore, Maranda | Managing control - governing body | Individual | 12/01/2024 | |
| Webb, Jessica | Managing control - governing body | Individual | 12/01/2024 | |
| Axiom Care, LLC | Operational/managerial control | Organization | 12/01/2024 | |
| Cochrane, Tobbie | Operational/managerial control | Individual | 12/01/2024 | |
| Dauber, Jonathan | Operational/managerial control | Individual | 12/01/2024 | |
| Moore, Maranda | Operational/managerial control | Individual | 12/01/2024 | |
| Spector, Jennifer | Operational/managerial control | Individual | 12/01/2024 | |
| Turofsky, Steven | Operational/managerial control | Individual | 12/01/2024 | |
| Wilhelm, Naftali | Operational/managerial control | Individual | 12/01/2024 | |
| Zaman, Asad | Operational/managerial control | Individual | 12/01/2024 | |
| Dauber, Eliana | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 07/16/2025 | |
| Axiom Care, LLC | Adp of the SNF | Organization | 07/16/2025 | |
| Curis Services LLC | Adp of the SNF | Organization | 12/01/2024 | |
| David a Berkowitz Delta Trust | Adp of the SNF | Organization | 11/07/2025 | |
| Joshua Hoffman Trust | Adp of the SNF | Organization | 03/02/2026 | |
| Petersen SNF Holdings LLC | Adp of the SNF | Organization | 07/16/2025 | |
| Yosef Meystel Delta Trust | Adp of the SNF | Organization | 11/07/2025 | |
| Cochrane, Tobbie | Adp of the SNF | Individual | 12/01/2024 | |
| Dauber, Jonathan | Adp of the SNF | Individual | 12/01/2024 | |
| Moore, Maranda | Adp of the SNF | Individual | 12/01/2024 | |
| Spector, Jennifer | Adp of the SNF | Individual | 12/01/2024 | |
| Turofsky, Steven | Adp of the SNF | Individual | 12/01/2024 | |
| Webb, Jessica | Adp of the SNF | Individual | 12/01/2024 | |
| Wilhelm, Naftali | Adp of the SNF | Individual | 12/01/2024 | |
| Zaman, Asad | Adp of the SNF | Individual | 12/01/2024 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in Illinois. NursingHomeClear cannot take or act on complaints.