Mount Vernon Countryside Manor - Mount Vernon Nursing Home
General Information
UPDATEFederal Provider Number
145685
Provider Name
MOUNT VERNON COUNTRYSIDE MANOR
Provider Address
606 EAST IL HWY 15
MOUNT VERNON, IL 62864
MOUNT VERNON, IL 62864
Provider Phone Number
(618) 242-1800
Provider SSA County
490
Provider County Name
Jefferson
Provider Website
Provider Description
Ownership Type
For profit - Corporation
Number of Certified Beds
91
Number of Residents in Certified Beds
74
Provider Type
Medicare and Medicaid
Provider Resides in Hospital
N
Legal Business Name
MT. VERNON COUNTRYSIDE MANOR, INC.
Date First Approved to Provide Medicare and Medicaid services
1990-06-05
Continuing Care Retirement Community
N
Special Focus Facility
N
Provider Changed Ownership in Last 12 Months
N
With a Resident and Family Council
Resident
Automatic Sprinkler Systems in All Required Areas
Yes
Rating Detail Information
Overall Rating
4
Overall Rating Footnote
Health Inspection Rating
4
Health Inspection Rating Footnote
QM Rating
4
QM Rating Footnote
Staffing Rating
3
Staffing Rating Footnote
RN Staffing Rating
4
RN Staffing Rating Footnote
Reported Staffing Footnote
Physical Therapist Staffing Footnote
Reported CNA Staffing Hours per Resident per Day
2.53041
Reported LPN Staffing Hours per Resident per Day
0.44122
Reported RN Staffing Hours per Resident per Day
0.77297
Reported Licensed Staffing Hours per Resident per Day
1.21419
Reported Total Nurse Staffing Hours per Resident per Day
3.74460
Reported Physical Therapist Staffing Hours per Resident Per Day
0.08716
Expected CNA Staffing Hours per Resident per Day
2.56498
Expected LPN Staffing Hours per Resident per Day
0.65473
Expected RN Staffing Hours per Resident per Day
1.01679
Expected Total Nurse Staffing Hours per Resident per Day
4.23650
Adjusted CNA Staffing Hours per Resident per Day
2.42063
Adjusted LPN Staffing Hours per Resident per Day
0.55933
Adjusted RN Staffing Hours per Resident per Day
0.56803
Adjusted Total Nurse Staffing Hours per Resident per Day
3.56287
Cycle 1 Total Number of Health Deficiencies
3
Cycle 1 Number of Standard Health Deficiencies
1
Cycle 1 Number of Complaint Health Deficiencies
2
Cycle 1 Health Deficiency Score
8
Cycle 1 Standard Survey Health Date
2014-12-11
Cycle 1 Number of Health Revisits
0
Cycle 1 Health Revisit Score
0
Cycle 1 Total Health Score
8
Cycle 2 Total Number of Health Deficiencies
6
Cycle 2 Number of Standard Health Deficiencies
6
Cycle 2 Number of Complaint Health Deficiencies
0
Cycle 2 Health Deficiency Score
44
Cycle 2 Standard Health Survey Date
2014-01-28
Cycle 2 Number of Health Revisits
1
Cycle 2 Health Revisit Score
0
Cycle 2 Total Health Score
44
Cycle 3 Total Number of Health Deficiencies
5
Cycle 3 Number of Standard Health Deficiencies
5
Cycle 3 Number of Complaint Health Deficiencies
0
Cycle 3 Health Deficiency Score
16
Cycle 3 Standard Health Survey Date
2012-11-26
Cycle 3 Number of Health Revisits
1
Cycle 3 Health Revisit Score
0
Cycle 3 Total Health Score
16
Total Weighted Health Survey Score
21.33300
Number of Facility Reported Incidents
0
Number of Substantiated Complaints
1
Number of Fines
0
Total Amount of Fines in Dollars
0
Number of Payment Denials
0
Total Number of Penalties
0
Location
Processing Date
2015-06-01
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