Cycle 1
Health 2025-01-24 · Fire 2025-01-24
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Mount Vernon, IL
Mount Vernon Countryside Manor
3-star overall rating with 3-star inspections with $126,387 in total fines with 5 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
606 East Il Hwy 15, Mount Vernon, IL
(618) 242-1800
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
91
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Palladian Healthcare
Operator or chain grouping
Approved since
1990-06-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 2 overall / 2 health / 1 staffing / 2 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.69
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.13 · national 2.35
Total nurse hours
3.00
All reported nurse hours · state 3.49 · national 3.89
Licensed hours
1.13
RN + LPN hours · state 1.36 · national 1.54
Weekend hours
2.70
Weekend nurse staffing · state 3.09 · national 3.43
Weekend RN hours
0.38
Weekend registered nurse coverage · state 0.56 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.05 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
2.79
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 44% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 46% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,845
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
15.02
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 26.14% · Performance 26.19% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.52% · Performance 9.21% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
6.01
Baseline 46.58% · Performance 39.13% · Measure score 6.01 · Achievement 6.01 · Improvement 2.93
Adjusted total nurse staffing
0
Baseline 3.26 hours · Performance 2.80 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.57% |
10.72%
2.8 pts worse
|
Worse than the National Rate · Eligible stays 281 · Observed rate 17.08% · Lower 95% interval 10.74% |
| Discharge to community | 52.27% |
50.57%
1.7 pts better
|
No Different than the National Rate · Eligible stays 286 · Observed rate 44.41% · Lower 95% interval 44.9% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 200 · Denominator 200 |
| Falls with major injury | 2.5% |
0.77%
1.7 pts worse
|
Numerator 5 · Denominator 200 |
| Discharge self-care score | 35.82% |
53.69%
17.9 pts worse
|
Numerator 48 · Denominator 134 |
| Discharge mobility score | 46.27% |
50.94%
4.7 pts worse
|
Numerator 62 · Denominator 134 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 200 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 9.21% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 161 · Observed rate 11.18% · Lower 95% interval 6.43% |
| Staff COVID-19 vaccination coverage | 1.92% |
8.2%
6.3 pts worse
|
Numerator 2 · Denominator 104 |
| Staff flu vaccination coverage | 50.43% |
42%
8.4 pts better
|
Numerator 58 · Denominator 115 |
| Discharge function score | 37.31% |
56.45%
19.1 pts worse
|
Numerator 50 · Denominator 134 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 63 · Denominator 63 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 90 · Denominator 90 |
| Resident COVID-19 vaccinations up to date | 64.58% |
25.2%
39.4 pts better
|
Numerator 62 · Denominator 96 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
2.0
0.1 pts better
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.8 · Expected 2.8 · 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 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
89.6%
9.1 pts better
|
93.4%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 94.7% · 4Q avg 98.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
91.6%
8.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.2% |
3.3%
3.9 pts worse
|
3.3%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 8.5% · Q3 6.9% · Q4 8.8% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
50.3%
50.3 pts better
|
11.4%
11.4 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 who lose too much weight | 11.4% |
6.5%
4.9 pts worse
|
5.4%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 30.2% · Q3 3.9% · Q4 0.0% · 4Q avg 11.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.0% |
18.5%
4.5 pts worse
|
19.6%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 26.3% · Q3 21.6% · Q4 21.2% · 4Q avg 23.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.0% |
22.8%
11.8 pts better
|
16.7%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 8.6% · Q3 13.9% · Q4 10.5% · 4Q avg 11.0% · 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 | 36.2% |
17.2%
19 pts worse
|
16.3%
19.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 37.7% · Q4 49.2% · 4Q avg 36.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.3% |
15.0%
11.3 pts worse
|
14.9%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 23.6% · Q3 14.0% · Q4 36.5% · 4Q avg 26.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
1.1%
0.2 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.6% · Q4 2.2% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.7%
1.3 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.2% |
21.3%
1.9 pts worse
|
19.8%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 15.0% · Q3 34.0% · Q4 25.4% · 4Q avg 23.2% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
5.2%
0.4 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.0% · Q3 5.7% · Q4 10.6% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
68.8%
29.9 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.2% · Q4 96.9% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.8% |
14.0%
5.8 pts worse
|
12.0%
7.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 19.5% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
2.3%
1.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 1.4% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
63.0%
37 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.3% |
26.2%
5.1 pts worse
|
23.9%
7.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.3% · Observed 31.0% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-01 · Fire 2024-03-01
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-03-09 · Fire 2023-03-09
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-01-24
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-02-10
F · Potential for more than minimal harm
2025-01-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-20
F · Potential for more than minimal harm
2025-01-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Not marked corrected
F · Potential for more than minimal harm
2025-01-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-10
E · Potential for more than minimal harm
2025-01-24
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-02-10
E · Potential for more than minimal harm
2025-01-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-10
E · Potential for more than minimal harm
2025-01-24
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-02-10
E · Potential for more than minimal harm
2025-01-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-10
F · Potential for more than minimal harm
2024-03-01
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-03-22
F · Potential for more than minimal harm
2024-03-01
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-03-11
F · Potential for more than minimal harm
2024-03-01
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-03-22
F · Potential for more than minimal harm
2024-03-01
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-03-22
F · Potential for more than minimal harm
2024-03-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-22
E · Potential for more than minimal harm
2024-03-01
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-03-11
E · Potential for more than minimal harm
2024-03-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-03-01
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-03-16
E · Potential for more than minimal harm
2024-03-01
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-11
F · Potential for more than minimal harm
2023-03-09
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-04-08
F · Potential for more than minimal harm
2023-03-09
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-03-13
F · Potential for more than minimal harm
2023-03-09
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-04-13
F · Potential for more than minimal harm
2023-03-09
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-07
F · Potential for more than minimal harm
2023-03-09
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-04-07
E · Potential for more than minimal harm
2023-03-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-07
E · Potential for more than minimal harm
2023-03-09
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-04-07
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-10-09
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 2025-09-20
F · Potential for more than minimal harm
2025-02-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-24
G · Actual harm
2025-01-24
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-01
E · Potential for more than minimal harm
2025-01-24
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 2025-02-10
D · Potential for more than minimal harm
2025-01-24
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 2025-02-10
D · Potential for more than minimal harm
2025-01-24
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 2025-02-10
G · Actual harm
2024-08-27
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 2024-07-16
D · Potential for more than minimal harm
2024-06-13
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-03
D · Potential for more than minimal harm
2024-06-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-03
G · Actual harm
2024-03-01
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-03-18
F · Potential for more than minimal harm
2024-03-01
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2024-03-19
F · Potential for more than minimal harm
2024-03-01
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 2024-03-18
E · Potential for more than minimal harm
2024-03-01
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-03-01
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-18
E · Potential for more than minimal harm
2024-03-01
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-03-18
D · Potential for more than minimal harm
2024-03-01
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 2024-03-20
G · Actual harm
2024-02-06
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 2023-12-18
D · Potential for more than minimal harm
2024-02-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-02-20
F · Potential for more than minimal harm
2024-01-18
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.
Corrected 2024-02-06
D · Potential for more than minimal harm
2024-01-18
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 2024-02-06
F · Potential for more than minimal harm
2023-03-09
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 2023-03-31
D · Potential for more than minimal harm
2023-03-09
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 2023-03-31
Penalties and ownership
What sits behind the stars
$56,024
2025-01-24
Fine
Fine · fine $56,024
Fine
$0
2025-01-24
Payment Denial
Payment Denial · denial start 2025-02-15 · 14 days
14 day denial
$14,050
2024-08-27
Fine
Fine · fine $14,050
Fine
$39,767
2024-03-01
Fine
Fine · fine $39,767
Fine
$0
2024-03-01
Payment Denial
Payment Denial · denial start 2024-03-28 · 1 days
1 day denial
$16,546
2024-01-18
Fine
Fine · fine $16,546
Fine
Ownership
Miller, Stephen
5% Or Greater Direct Ownership Interest · Individual
Miller, Stephen
Corporate Officer · Individual
Miller, Stephen
Contracted Managing Employee · Individual
Mills, Michael
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Axiom Healthcare Of Mount Vernon
Mount Vernon, IL
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
#2
Nature Trail Health And Rehab
Mount Vernon, IL
3-star overall rating with 3-star inspections with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Axiom Gardens Of Mount Vernon
Mount Vernon, IL
1-star overall rating with 2-star inspections with abuse icon flag with $37,500 in total fines with 13 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
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