Inspection Reports for
Mount Vernon Nursing and Rehabilitation
1415 COUNTRY CLUB RD, MOUNT VERNON, IN, 47620
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
19% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
100% occupied
Based on a July 2025 inspection.
Occupancy rate over time
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 18, 2025
Visit Reason
Annual inspection survey of Mount Vernon Nursing and Rehabilitation facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00462056.
Complaint Details
Complaint IN00462056 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00462056 were cited. The facility was found to be in compliance with applicable regulations.
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
Date: Apr 24, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00454475.
Complaint Details
Complaint IN00454475 was investigated and found to have no deficiencies related to the allegations.
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.
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
Date: Jan 16, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00447240.
Complaint Details
Complaint IN00447240 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 4
Medicaid residents: 26
Other residents: 23
Inspection Report
Renewal
Deficiencies: 0
Date: 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
Date: 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
Deficiencies: 4
Date: Aug 6, 2024
Visit Reason
The inspection was conducted as part of the facility's annual survey to assess compliance with federal regulations regarding staffing, medication management, infection control, and antibiotic stewardship.
Findings
The facility was found deficient in posting accurate nurse staffing hours, proper labeling and storage of medications, infection prevention and control practices including inadequate infection tracking and hand hygiene, and antibiotic stewardship with inappropriate antibiotic use for some residents.
Deficiencies (4)
F 0732: The facility failed to post accurate actual hours worked for licensed and unlicensed nursing staff per shift daily for 2 of 6 days during the annual survey period.
F 0761: The facility failed to ensure medications and biologicals were properly labeled and stored in locked compartments for 4 medication carts and 2 treatment carts.
F 0880: The facility failed to provide and implement an infection prevention and control program, including failure to clean equipment between residents, failure to change gloves appropriately, and failure to track all infections for 10 residents reviewed.
F 0881: The facility failed to implement a program that monitors antibiotic use, resulting in inappropriate antibiotic prescribing for 2 of 3 residents reviewed for urinary tract infections.
Report Facts
Days with inaccurate staffing hours posted: 2
Medication carts observed with labeling/storage issues: 4
Treatment carts observed with labeling/storage issues: 2
Residents with untracked infections: 10
Residents reviewed for UTI antibiotic appropriateness: 3
Inspection Report
Annual Inspection
Census: 61
Capacity: 61
Deficiencies: 4
Date: 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.
Deficiencies (4)
Failed to post accurate actual hours worked for licensed and unlicensed nursing staff for 2 of 6 days during the annual survey period.
Failed to ensure medications were properly stored and labeled for 4 medication carts and 2 treatment carts.
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.
Failed to ensure residents requiring antibiotics were prescribed appropriate antibiotics for 2 of 3 residents reviewed for UTI.
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
Date: 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.
Complaint Details
Investigation of Complaint IN00408247 completed on May 15, 2023; facility found in compliance.
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.
Inspection Report
Renewal
Deficiencies: 0
Date: 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
Date: 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
Deficiencies: 1
Date: May 15, 2023
Visit Reason
The inspection was conducted in response to a complaint (IN00408247) regarding the safety and condition of the nursing home environment.
Complaint Details
This Federal tag relates to complaint IN00408247.
Findings
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, specifically noting a broken mirror bracket and mold-like substance in a resident bathroom.
Deficiencies (1)
F 0921: The nursing home failed to maintain a safe, clean, and comfortable environment. The mirror in a resident bathroom was hanging forward with a broken bracket and the air conditioning unit had a black mold-like substance underneath it.
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: May 15, 2023
Visit Reason
The inspection was conducted due to complaints regarding inadequate supervision to prevent falls, respiratory care deficiencies, medication labeling issues, infection control lapses, and environmental safety concerns at Mount Vernon Nursing and Rehabilitation.
Complaint Details
The investigation was complaint-related, focusing on falls, respiratory care, medication labeling, infection control, and environmental safety. The complaint number referenced is IN00408247.
Findings
The facility failed to provide adequate supervision to prevent multiple falls for one resident, failed to ensure proper respiratory care and equipment maintenance for two residents, failed to label medications properly on one medication cart, failed to implement proper infection control practices during personal care, and failed to maintain a safe and comfortable environment in one resident's bathroom.
Deficiencies (5)
F 0689: The facility failed to provide supervision and effective interventions to prevent multiple falls for Resident 52, who fell 11 times since admission with some injuries noted.
F 0695: The facility failed to provide safe and appropriate respiratory care, including maintenance and labeling of oxygen equipment, for Residents 1 and 43.
F 0761: The facility failed to ensure medications were labeled with open dates for 1 of 3 medication carts observed (Plaza Unit Cart).
F 0880: The facility failed to implement infection control practices during 2 of 4 personal care observations; hand hygiene was not performed and gloves were not changed appropriately.
F 0921: The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public; a bathroom mirror was broken and the air conditioning unit had mold-like substance.
Report Facts
Number of falls: 11
Medication carts observed: 3
Personal care observations: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Interviewed regarding Resident 52's falls and respiratory care practices. |
| Director of Nursing | Director of Nursing | Notified of Resident 52's falls and involved in care plan reviews. |
| Administrator | Facility Administrator | Provided facility policies and interviewed regarding infection control and respiratory care policies. |
| Housekeeper 5 | Housekeeper | Interviewed about maintenance reporting for resident rooms. |
| Housekeeper 7 | Housekeeper | Interviewed about maintenance reporting for resident rooms. |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed about maintenance work orders and bathroom mirror repair. |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 59
Deficiencies: 1
Date: 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.
Complaint Details
Complaint IN00408247 Federal/state deficiencies related to the allegations are cited at F921. Complaint IN00405306 - No deficiencies related to allegations are cited.
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.
Deficiencies (1)
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.
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
Date: May 15, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Complaints IN00405306 and IN00408247.
Complaint Details
Complaint IN00405306 - No deficiencies related to allegations are cited. Complaint IN00408247 - Federal/State deficiencies related to the allegations are cited at F921.
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.
Deficiencies (5)
Failure to provide supervision to prevent multiple falls for 1 of 5 residents reviewed for accidents.
Failure to ensure respiratory care equipment was properly maintained and labeled for 2 of 2 residents reviewed.
Medications were observed to be open and undated on the Plaza Unit medication cart.
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.
Failure to provide a safe, functional, sanitary, and comfortable environment due to a broken bathroom mirror and mold on an air conditioning unit.
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
Date: Feb 7, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00399780 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00399780 was substantiated; however, no deficiencies related to the allegations were cited.
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.
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
Date: Jan 3, 2023
Visit Reason
This visit was for the investigation of Complaint IN00396337.
Complaint Details
Complaint IN00396337 was investigated and found unsubstantiated due to lack of evidence.
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.
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
Date: Sep 21, 2022
Visit Reason
This visit was for the investigation of Complaint IN00373522.
Complaint Details
Complaint IN00373522 - Substantiated. No deficiencies related to the allegations are cited.
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.
Report Facts
Census: 48
Total Capacity: 48
Medicare Census: 4
Medicaid Census: 22
Other Payor Census: 22
Viewing
Loading inspection reports...
