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Deficiency Records for Axiom Gardens of Mount Vernon
A list of the most recent deficiencies for Axiom Gardens of Mount Vernon. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Axiom Gardens of Mount Vernon. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2025-03-12 | 2025-03-28 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2025-03-12 | 2025-03-28 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2025-03-12 | 2025-03-28 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2025-03-12 | 2025-03-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2025-03-12 | 2025-03-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2025-03-12 | 2025-03-28 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2025-03-12 | 2025-03-28 | N |
| Have exits that are accessible at all times. | Fire Safety | 2025-03-12 | 2025-03-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2025-03-12 | 2025-03-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2025-03-12 | 2025-03-28 | N |
| Construct fire resistant interior walls. | Fire Safety | 2025-03-12 | 2025-03-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2025-03-12 | 2025-03-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2025-03-12 | 2025-03-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2025-03-12 | 2025-03-28 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2025-03-12 | 2025-03-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2025-03-12 | 2025-03-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2025-03-17 | 2025-03-26 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2025-03-17 | 2025-03-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2025-03-17 | 2025-03-26 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2025-03-17 | 2025-03-26 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2025-03-17 | 2025-03-26 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2025-03-17 | 2025-03-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2025-03-17 | 2025-03-26 | N |
| 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. | Health | 2025-03-17 | 2025-03-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2025-03-17 | 2025-03-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2025-03-17 | 2025-03-26 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2025-03-17 | 2025-03-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-10-03 | 2024-10-17 | Y |
| 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. | Health | 2024-10-03 | 2024-10-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-06-27 | 2024-07-17 | Y |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2024-03-13 | 2024-06-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-03-11 | 2024-05-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-04-17 | 2024-05-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-04-17 | 2024-05-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-11 | 2024-05-14 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-03-13 | 2024-04-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-13 | 2024-04-05 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-11 | 2024-04-04 | N |
| Assess the resident when there is a significant change in condition | Health | 2024-03-11 | 2024-04-04 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2024-03-11 | 2024-04-04 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-11 | 2024-04-04 | N |
| Provide activities to meet all resident's needs. | Health | 2024-03-11 | 2024-04-04 | N |
| 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. | Health | 2024-03-11 | 2024-04-04 | N |
| 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. | Health | 2024-03-11 | 2024-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-11 | 2024-04-04 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-03-11 | 2024-04-04 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-26 | 2023-10-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-26 | 2023-10-09 | Y |
| 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. | Health | 2023-06-02 | 2023-09-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-26 | 2023-07-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-06-02 | 2023-06-28 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-06-02 | 2023-06-15 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-06-02 | 2023-06-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-02 | 2023-06-15 | N |
| 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. | Health | 2023-06-02 | 2023-06-15 | N |
| 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. | Health | 2023-06-02 | 2023-06-15 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-07-01 | 2022-07-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-07-01 | 2022-07-01 | Y |
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