Inspection Reports for Mount Vernon Nursing and Rehabilitation
1415 COUNTRY CLUB RD, IN, 47620
Back to Facility ProfileInspection Report Summary
The most recent inspection on July 2, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a pattern of deficiencies primarily involving infection control, medication management, and maintaining a safe environment, including issues such as improper medication storage, inaccurate nurse staffing postings, and environmental concerns like mold and broken fixtures. Complaint investigations were mostly unsubstantiated or found no related deficiencies, with one substantiated complaint that did not result in citations. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows improvement over time, with recent inspections consistently finding the facility in compliance.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
2.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
40% better than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a July 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 0
Jul 2, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00462056.
Findings
No deficiencies related to the allegations in Complaint IN00462056 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00462056 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 51
Medicare Census: 5
Medicaid Census: 27
Other Payor Census: 19
Inspection Report
Complaint Investigation
Census: 45
Capacity: 45
Deficiencies: 0
Apr 24, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454475.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00454475 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 45
Total Capacity: 45
Medicare Census: 4
Medicaid Census: 23
Other Payor Census: 18
Inspection Report
Complaint Investigation
Census: 53
Capacity: 53
Deficiencies: 0
Jan 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00447240.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00447240 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicare residents: 4
Medicaid residents: 26
Other residents: 23
Inspection Report
Renewal
Deficiencies: 0
Oct 2, 2024
Visit Reason
The inspection was conducted as a paper compliance review for Recertification and State Licensure survey.
Findings
Mount Vernon Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 during the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 59
Capacity: 66
Deficiencies: 0
Aug 22, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a).
Findings
The facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, as well as with Life Safety Code requirements including fire safety and sprinkler systems.
Inspection Report
Annual Inspection
Census: 61
Capacity: 61
Deficiencies: 4
Aug 6, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted over multiple days from July 30 to August 6, 2024.
Findings
The facility was found deficient in multiple areas including inaccurate posting of nurse staffing hours, improper labeling and storage of medications, failure to maintain infection prevention and control practices, and inappropriate antibiotic prescribing for urinary tract infections.
Severity Breakdown
SS=C: 1
SS=D: 2
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to post accurate actual hours worked for licensed and unlicensed nursing staff for 2 of 6 days during the annual survey period. | SS=C |
| Failed to ensure medications were properly stored and labeled for 4 medication carts and 2 treatment carts. | SS=D |
| Failed to ensure a safe, sanitary, and comfortable environment to prevent infection transmission; equipment not cleaned between residents, improper glove use, and failure to track all infections. | SS=E |
| Failed to ensure residents requiring antibiotics were prescribed appropriate antibiotics for 2 of 3 residents reviewed for UTI. | SS=D |
Report Facts
Census: 61
Total Capacity: 61
Deficiency count: 4
Medicare residents: 4
Medicaid residents: 31
Other payor residents: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| QMA 23 | Qualified Medication Aide | Named in medication storage and infection control findings |
| QMA 7 | Qualified Medication Aide | Named in medication storage findings |
| LPN 15 | Licensed Practical Nurse | Named in medication storage findings |
| DON | Director of Nursing | Named in infection control and antibiotic stewardship findings |
| IP | Infection Preventionist | Named in infection control and antibiotic stewardship findings |
| CNA 6 | Certified Nurse Aide | Named in infection control findings |
| CNA 9 | Certified Nurse Aide | Named in infection control findings |
| CNA 14 | Certified Nurse Aide | Named in infection control findings |
| CNA 16 | Certified Nurse Aide | Named in infection control findings |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 6, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00408247 completed on May 15, 2023.
Findings
Mount Vernon Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the complaint investigation.
Complaint Details
Investigation of Complaint IN00408247 completed on May 15, 2023; facility found in compliance.
Inspection Report
Renewal
Deficiencies: 0
Jul 6, 2023
Visit Reason
The visit was conducted as a paper compliance review for Recertification and State Licensure survey.
Findings
Mount Vernon Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for Recertification and State Licensure.
Inspection Report
Life Safety
Census: 60
Capacity: 66
Deficiencies: 0
May 31, 2023
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, and with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC). The facility is fully sprinklered except for a detached house used for activities storage.
Report Facts
Facility capacity: 66
Census: 60
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 1
May 15, 2023
Visit Reason
This visit was for the investigation of Complaint IN00408247 and was conducted in conjunction with a Recertification and State Licensure Survey and Investigation of Complaint IN00405306.
Findings
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public due to a broken mirror bracket and black mold-like substance on an air conditioning unit in one resident bathroom. The mirror was repaired and the PTAC unit replaced, with corrective actions implemented to prevent recurrence.
Complaint Details
Complaint IN00408247 Federal/state deficiencies related to the allegations are cited at F921. Complaint IN00405306 - No deficiencies related to allegations are cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Mirror in bathroom of room 120 was hanging forward with a broken bracket and the air conditioning unit had a black mold-like substance underneath it. | SS=D |
Report Facts
Census: 59
Total Capacity: 59
Medicare Census: 6
Medicaid Census: 28
Other Payor Census: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Bailey | Executive Director | Signed the report |
| Housekeeper 5 | Interviewed regarding maintenance work orders | |
| Housekeeper 7 | Interviewed regarding maintenance work orders | |
| Maintenance Supervisor | Interviewed regarding maintenance work orders and mirror repair |
Inspection Report
Annual Inspection
Census: 59
Capacity: 59
Deficiencies: 5
May 15, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaints IN00405306 and IN00408247.
Findings
The facility was found deficient in multiple areas including failure to provide adequate supervision to prevent falls, failure to ensure respiratory care equipment was properly maintained and labeled, failure to label medications with open dates, failure to implement proper infection control practices including hand hygiene, and failure to maintain a safe environment due to a broken mirror and mold on an air conditioning unit.
Complaint Details
Complaint IN00405306 - No deficiencies related to allegations are cited. Complaint IN00408247 - Federal/State deficiencies related to the allegations are cited at F921.
Severity Breakdown
SS=D: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to provide supervision to prevent multiple falls for 1 of 5 residents reviewed for accidents. | SS=D |
| Failure to ensure respiratory care equipment was properly maintained and labeled for 2 of 2 residents reviewed. | SS=D |
| Medications were observed to be open and undated on the Plaza Unit medication cart. | SS=D |
| Failure to ensure infection control practices were implemented; hand hygiene was not done and gloves not changed for 2 of 4 observations of personal care. | SS=D |
| Failure to provide a safe, functional, sanitary, and comfortable environment due to a broken bathroom mirror and mold on an air conditioning unit. | SS=D |
Report Facts
Census: 59
Total Capacity: 59
Resident Falls: 11
Oxygen flow rate: 2
Oxygen flow rate: 1
Medication cart undated meds: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Brian Bailey | Executive Director | Signed the report |
| RN 1 | Interviewed regarding Resident 52 falls and respiratory care | |
| Director of Nursing (DON) | Director of Nursing | Notified of falls and respiratory care issues |
| CNA 1 | Certified Nursing Assistant | Observed failing to perform hand hygiene and glove changes |
| QMA 3 | Qualified Medication Aide | Observed failing to perform hand hygiene and glove changes |
| Housekeeper 5 | Interviewed about maintenance reporting | |
| Housekeeper 7 | Interviewed about maintenance reporting | |
| Maintenance Supervisor | Interviewed about maintenance work orders and mirror repair |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 0
Feb 7, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399780 and included a COVID-19 Focused Infection Control Survey.
Findings
The complaint IN00399780 was substantiated, but no deficiencies related to the allegations were cited. The facility was found to be in compliance with relevant regulations regarding the complaint investigation and the COVID-19 survey.
Complaint Details
Complaint IN00399780 was substantiated; however, no deficiencies related to the allegations were cited.
Report Facts
Census SNF/NF: 54
Total Capacity: 54
Census Payor Type Medicare: 4
Census Payor Type Medicaid: 24
Census Payor Type Other: 26
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 0
Jan 3, 2023
Visit Reason
This visit was for the investigation of Complaint IN00396337.
Findings
The complaint IN00396337 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00396337 was investigated and found unsubstantiated due to lack of evidence.
Report Facts
Census: 54
Total Capacity: 54
Medicare Census: 6
Medicaid Census: 24
Other Payor Census: 24
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 0
Sep 21, 2022
Visit Reason
This visit was for the investigation of Complaint IN00373522.
Findings
Complaint IN00373522 was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00373522 - Substantiated. No deficiencies related to the allegations are cited.
Report Facts
Census: 48
Total Capacity: 48
Medicare Census: 4
Medicaid Census: 22
Other Payor Census: 22
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