Cycle 1
Health 2024-12-19 · Fire 2024-12-19
37 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Mount Vernon, IL
Axiom Healthcare Of Mount Vernon
1-star overall rating with 1-star inspections with Special Focus status with $254,604 in total fines with 37 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1700 White Street, Mount Vernon, IL
(618) 242-4075
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
65
Certified beds
Average residents
41
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Axiom Healthcare
Operator or chain grouping
Approved since
1985-02-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
7 facilities
Chain averages 1 overall / 2 health / 1 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
2.18
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.47
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.75
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.37
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.38
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,895
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9850
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.66% · Performance 22.54% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.27
Baseline 10.60% · Performance 8.48% · Measure score 3.27 · Achievement 0 · Improvement 3.27
Total nurse turnover
4.57
Baseline 37.21% · Performance 45.00% · Measure score 4.57 · Achievement 4.57 · Improvement 0
Adjusted total nurse staffing
3.55
Baseline 3.76 hours · Performance 4.09 hours · Measure score 3.55 · Achievement 3.55 · Improvement 1.13
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.02% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 61 · Observed rate 18.03% · Lower 95% interval 8.13% |
| Discharge to community | 38.68% |
50.57%
11.9 pts worse
|
No Different than the National Rate · Eligible stays 42 · Observed rate 28.57% · Lower 95% interval 25.99% |
| Medicare spending per beneficiary | 1.1 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 54 · Denominator 54 |
| Falls with major injury | 1.85% |
0.77%
1.1 pts worse
|
Numerator 1 · Denominator 54 |
| Discharge self-care score | 37.04% |
53.69%
16.6 pts worse
|
Numerator 10 · Denominator 27 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 12 · Denominator 27 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 54 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.48% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 33 · Observed rate 18.18% · Lower 95% interval 4.86% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 43 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 51.85% |
56.45%
4.6 pts worse
|
Numerator 14 · Denominator 27 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 14.29% |
25.2%
10.9 pts worse
|
Numerator 5 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
2.0
1.4 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 4.4 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
2.3
0.8 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 3.8 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 49.3% |
89.6%
40.3 pts worse
|
93.4%
44.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 80.0% · Q2 48.7% · Q3 38.9% · Q4 33.3% · 4Q avg 49.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 64.3% |
91.6%
27.3 pts worse
|
95.5%
31.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 64.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.3%
1.8 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 2.6% · Q3 8.3% · Q4 6.1% · 4Q avg 5.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 19.2% |
50.3%
31.1 pts better
|
11.4%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 15.2% · Q3 8.8% · Q4 25.8% · 4Q avg 19.2% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
6.5%
1.5 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 5.7% · Q3 10.0% · Q4 0.0% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.3% |
18.5%
4.2 pts better
|
19.6%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 13.9% · Q3 15.6% · Q4 10.0% · 4Q avg 14.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.5% |
22.8%
6.3 pts better
|
16.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 23.8% · Q3 16.7% · Q4 15.0% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.1% |
17.2%
3.9 pts worse
|
16.3%
4.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.9% |
15.0%
10.9 pts worse
|
14.9%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.0% · Q2 25.0% · Q3 20.0% · Q4 24.1% · 4Q avg 25.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
1.1%
0.1 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 1.8% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
1.7%
0.2 pts better
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.9% |
21.3%
5.6 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.9% · Q2 33.3% · Q3 29.4% · Q4 34.3% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 12.3% |
5.2%
7.1 pts worse
|
5.1%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 13.8% · Q3 14.2% · Q4 13.5% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 17.3% |
68.8%
51.5 pts worse
|
81.7%
64.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 34.1% · Q2 14.5% · Q3 11.9% · Q4 11.4% · 4Q avg 17.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.6% |
14.0%
8.6 pts worse
|
12.0%
10.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 25.8% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.3%
2.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 3.6% |
63.0%
59.4 pts worse
|
79.7%
76.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 3.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.4% |
26.2%
0.8 pts better
|
23.9%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 28.8% · Expected 27.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-21 · Fire 2023-11-21
15 health deficiencies
Top issue: Nutrition and Dietary (6 deficiencies)
6 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Cycle 3
Health 2022-10-14 · Fire 2022-10-14
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-19
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-19
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Not marked corrected
F · Potential for more than minimal harm
2024-12-19
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-16
F · Potential for more than minimal harm
2024-12-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-16
E · Potential for more than minimal harm
2024-12-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Not marked corrected
F · Potential for more than minimal harm
2023-11-21
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-12-11
F · Potential for more than minimal harm
2023-11-21
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2023-12-11
F · Potential for more than minimal harm
2023-11-21
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-12-29
F · Potential for more than minimal harm
2023-11-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-11
E · Potential for more than minimal harm
2023-11-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-11
E · Potential for more than minimal harm
2023-11-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-12-11
F · Potential for more than minimal harm
2022-10-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-10-25
F · Potential for more than minimal harm
2022-10-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-18
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Not marked corrected
F · Potential for more than minimal harm
2025-04-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-04-02
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-04-30
K · Immediate jeopardy
2025-03-25
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-04-23
J · Immediate jeopardy
2025-03-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-24
J · Immediate jeopardy
2025-03-25
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-10-31
G · Actual harm
2025-03-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-23
F · Potential for more than minimal harm
2025-03-25
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2025-05-08
F · Potential for more than minimal harm
2025-03-25
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2025-05-21
F · Potential for more than minimal harm
2025-03-25
F713 · Nursing and Physician Services Deficiencies
Health
Provide or arrange emergency care by a doctor 24 hours a day.
Corrected 2025-04-19
F · Potential for more than minimal harm
2025-03-25
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-03-25
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-05-14
F · Potential for more than minimal harm
2025-03-25
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-03-25
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-03-25
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-03-25
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-03-25
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2025-04-18
F · Potential for more than minimal harm
2025-03-25
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-04-28
F · Potential for more than minimal harm
2025-03-25
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-25
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-05-13
D · Potential for more than minimal harm
2025-03-25
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-03-25
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-18
G · Actual harm
2024-12-19
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-12-19
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-01-15
F · Potential for more than minimal harm
2024-12-19
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-05-14
F · Potential for more than minimal harm
2024-12-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-14
F · Potential for more than minimal harm
2024-12-19
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-19
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-19
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-23
D · Potential for more than minimal harm
2024-12-19
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2025-05-27
D · Potential for more than minimal harm
2024-12-19
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-19
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-01-15
D · Potential for more than minimal harm
2024-12-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-18
D · Potential for more than minimal harm
2024-12-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-30
F · Potential for more than minimal harm
2024-08-05
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-08-28
F · Potential for more than minimal harm
2024-08-05
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-08-28
F · Potential for more than minimal harm
2024-05-31
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-05-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-24
D · Potential for more than minimal harm
2024-05-31
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-06-24
F · Potential for more than minimal harm
2024-05-15
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-05-28
D · Potential for more than minimal harm
2024-05-15
F712 · Nursing and Physician Services Deficiencies
Health
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected 2024-06-01
E · Potential for more than minimal harm
2024-03-12
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-03-19
G · Actual harm
2024-01-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-23
G · Actual harm
2024-01-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-01-16
D · Potential for more than minimal harm
2024-01-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-16
J · Immediate jeopardy
2023-11-21
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-12-11
G · Actual harm
2023-11-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-12-11
F · Potential for more than minimal harm
2023-11-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-11-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-11-21
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-11-21
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-12-11
F · Potential for more than minimal harm
2022-10-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-11-04
E · Potential for more than minimal harm
2022-10-14
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-10-14
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-10-14
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-10-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-11-04
Penalties and ownership
What sits behind the stars
$222,067
2024-12-19
Fine
Fine · fine $222,067
Fine
$0
2024-12-19
Payment Denial
Payment Denial · denial start 2025-01-21 · 126 days
126 day denial
$0
2024-05-15
Payment Denial
Payment Denial · denial start 2024-08-15 · 13 days
13 day denial
$8,824
2024-01-05
Fine
Fine · fine $8,824
Fine
$8,824
2024-01-05
Fine
Fine · fine $8,824
Fine
$7,443
2023-11-21
Fine
Fine · fine $7,443
Fine
$7,446
2023-11-21
Fine
Fine · fine $7,446
Fine
$0
2023-11-21
Payment Denial
Payment Denial · denial start 2023-12-19 · 10 days
10 day denial
Ownership
Dauber, Jonathan
5% Or Greater Direct Ownership Interest · Individual
David A Berkowitz Delta Trust
5% Or Greater Direct Ownership Interest · Organization
Yosef Meystel Delta Trust
5% Or Greater Direct Ownership Interest · Organization
Axiom Care, LLC
Operational/Managerial Control · Organization
Cochrane, Tobbie
Operational/Managerial Control · Individual
Dauber, Jonathan
Operational/Managerial Control · Individual
Moore, Maranda
Operational/Managerial Control · Individual
Spector, Jennifer
Operational/Managerial Control · Individual
Spector, Jennifer
Corporate Officer · Individual
Turofsky, Steven
Operational/Managerial Control · Individual
Webb, Jessica
Corporate Officer · Individual
Wilhelm, Naftali
Operational/Managerial Control · Individual
Wilhelm, Naftali
Corporate Officer · Individual
Zaman, Asad
Operational/Managerial Control · Individual
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