Mount Vernon Countryside Manor: Van Crash Injures Resident - IL
The driver, identified in inspection records only as V4, a transport staff member at Mount Vernon Countryside Manor, had been behind the wheel when something went wrong during transport. The resident, referred to as R1, ended up in the emergency room. When R1 came back, the Director of Nurses documented a skin tear to the left forearm and significant bruising across several areas of the body.
The bruising, the Director of Nurses noted, was most likely due to anticoagulant therapy. R1 also came back with complaints of back pain, which staff said had been managed with pain medication. By the time inspectors arrived on September 30, the Director of Nurses said R1 had returned to baseline in functioning and cognition.
What inspectors found in the days after the incident was a training gap that nobody had caught before a resident got hurt.
The maintenance staff member who oversees vehicle safety, identified as V5, told inspectors on September 30 that after the September 19 incident, he pulled all transport staff together for reeducation on securing wheelchairs in the van. He required each of them to demonstrate the procedure and pass a road test he administered himself. All of them passed.
Except, at first, V4.
When V4 demonstrated how she had secured R1's wheelchair, she failed. She could not show the correct procedure. Only after additional instruction did she complete the return demonstration appropriately. V5 told inspectors he did not think V4 had been properly trained in the first place.
That detail sits at the center of what inspectors cited under F0689, the federal tag governing a facility's obligation to protect residents from accident hazards. The harm level was classified as minimal harm or potential for actual harm. The number of residents affected was listed as few.
But a resident went to the emergency room. And the person transporting that resident had apparently never been shown, in any complete way, how to do the job safely.
The facility moved quickly once the incident happened. By September 19, the same day as the crash, V4 had received disciplinary action and a safety inspection had been conducted on all vehicles. The following day, September 20, all drivers were educated on wheelchair securement and evaluated through road tests with V5. The administrator produced a document on September 30 titled Ad Hoc QAPI, an emergency quality assurance plan drawn up before inspectors ever walked through the door. The administrator said all corrective steps had been completed by September 20, ten days before the survey began.
The plan included twice-weekly audits of resident transportation for four weeks, with the administrator or a designee physically checking that wheelchairs are secured before vans leave. Findings from those audits are to be reported to the facility's Quality Assurance Committee at its quarterly meeting, scheduled for October 2025.
The administrator, V1, presented the QAPI document to inspectors and walked through each step. The Director of Nurses confirmed R1's condition had stabilized. V5 confirmed the training had been completed and competency verified.
What the documents do not answer is how long V4 had been transporting residents before September 19, or how many trips she had made with wheelchairs that may not have been fully secured. The inspection report does not say. V5 said only that he did not believe she had been properly trained initially, which raises the question of what the initial training looked like and who was responsible for confirming it had happened.
R1 came back from the emergency room with a torn forearm and bruising across the body, complaining of back pain. The facility says the pain is now controlled. The facility says R1 is back to baseline.
What baseline looked like before September 19, and whether it will hold, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mount Vernon Countryside Manor from 2025-10-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 25, 2026 · Our methodology
MOUNT VERNON COUNTRYSIDE MANOR in MOUNT VERNON, IL was cited for violations during a health inspection on October 9, 2025.
The resident, referred to as R1, ended up in the emergency room.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.