Axiom Gardens of Mount Vernon
#5 Doctors Park Rd · Mount Vernon, IL · 62864 · 6182421064
106 certified beds For profit - Corporation
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $32,830 in fines in the last 24 months.
- 6 citations involved actual harm to residents.
- Inspection results have improved across recent cycles.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
3 abuse-related citations at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
Total nurse staffing below 3.0 hours per resident-day
2.97 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 2 of 5 Staffing: 1 of 5 Quality measures: 1 of 5
| Total nurse hours / resident-day | 2.97 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.31 | 0.55–0.75 |
| Weekend hours / resident-day | 2.68 | ≈ weekday level |
| Nursing turnover / year | 42% | median 45% |
| Fines (3-yr window) | 4 · $63,330 |
Inspection citations (47 in the current record)
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Potential for harm · D March 19, 2026 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected March 27, 2026 · Resident Rights
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Potential for harm · F March 19, 2026 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected March 27, 2026 · Nursing and Physician Services
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Actual harm · G March 4, 2026 · found via complaint
Provide safe, appropriate pain management for a resident who requires such services.
Corrected March 16, 2026 · Quality of Life and Care
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Potential for harm · D March 4, 2026 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected March 16, 2026 · Pharmacy Service
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Actual harm · G August 12, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected September 2, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 27, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected June 10, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · F March 28, 2025 · found via complaint
Provide and implement an infection prevention and control program.
Corrected April 7, 2025 · Infection Control
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Potential for harm · E March 17, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected March 26, 2025 · Resident Rights
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Potential for harm · D March 17, 2025
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected March 26, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D March 17, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected March 26, 2025 · Quality of Life and Care
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Potential for harm · E March 17, 2025
Provide enough food/fluids to maintain a resident's health.
Corrected March 26, 2025 · Quality of Life and Care
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Potential for harm · E March 17, 2025
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Corrected April 22, 2025 · Nursing and Physician Services
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Potential for harm · E March 17, 2025
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected March 26, 2025 · Quality of Life and Care
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Potential for harm · E March 17, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected March 26, 2025 · Pharmacy Service
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Potential for harm · E March 17, 2025
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.
Corrected April 1, 2025 · Nutrition and Dietary
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Potential for harm · D March 17, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 26, 2025 · Nutrition and Dietary
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Potential for harm · D March 17, 2025
Provide and implement an infection prevention and control program.
Corrected March 26, 2025 · Infection Control
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Potential for harm · D March 17, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected April 1, 2025 · Infection Control
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Potential for harm · E February 21, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected February 28, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E February 21, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected February 28, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 21, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected March 31, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 5, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected February 28, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G October 3, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected October 17, 2024 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E October 3, 2024 · found via complaint
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 October 14, 2024 · Resident Rights
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Actual harm · G June 27, 2024 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected July 17, 2024 · Freedom from Abuse, Neglect, and Exploitation
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| March 4, 2026 | Fine | $25,830 |
| October 3, 2024 | Fine | $7,000 |
| June 27, 2024 | Fine | $10,000 |
| March 11, 2024 | Fine | $20,500 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 14E812 · certified since March 3, 1981. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.