The most recent inspection on June 27, 2025, found no deficiencies related to the complaint investigated. Earlier inspections showed a mixed pattern, with several investigations substantiated and deficiencies cited primarily in medication management, resident care practices, and documentation of rights and notifications. Inspectors noted issues such as missed medication doses, failure to follow physician orders, inadequate supervision to prevent resident-to-resident abuse, and improper use of restraints. Complaint investigations were often unsubstantiated, though some substantiated complaints led to citations, including medication errors and failure to provide required dental services. The facility appears to have made improvements in recent months, with the latest inspections showing compliance after addressing prior concerns.
Deficiencies (last 4 years)
Deficiencies (over 4 years)6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
43% worse than Indiana average
Indiana average: 4.2 deficiencies/year
Deficiencies per year
86420
2022
2023
2024
2025
Census
Latest occupancy rate100% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
This visit was conducted for the investigation of Complaint IN00461337.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaint IN00461337 found no deficiencies related to the allegations.
Report Facts
Census SNF/NF: 47Total Capacity: 47Census Payor Type Medicaid: 47
Inspection Report Plan of CorrectionDeficiencies: 0Jun 18, 2025
Visit Reason
Paper compliance review to the Investigation of Complaints IN00459066 and IN00458788 completed on May 14, 2025.
Findings
Vernon Health 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 review of the investigations.
Complaint Details
The visit was related to complaint investigations IN00459066 and IN00458788; compliance was found upon paper review.
This visit was conducted for the investigation of multiple complaints (IN00459066, IN00458788, IN00459316, IN00459144, and IN00459081) regarding the facility's compliance with federal and state regulations.
Findings
The facility was found deficient in ensuring the resident's representative was notified in writing of transfer/discharge appeal rights for one hospitalization, and failed to follow physician orders regarding continuation of care for residents transported to day programs with medications for two residents. Several complaints had no deficiencies cited.
Complaint Details
Complaint IN00459066 and IN00458788 resulted in deficiencies cited at F684 and F628 respectively. Complaints IN00459316, IN00459144, and IN00459081 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
Description
Severity
Failed to ensure the resident's representative was notified in writing of the transfer/discharge appeal rights for 1 of 3 hospitalizations (Resident D).
SS=D
Failed to follow physician orders regarding continuation of care for residents transported to day programs with medications for 2 of 3 residents reviewed for day services (Residents B and C).
This visit was conducted for the investigation of complaints IN00454076, IN00453864, IN00452282, and IN00451409 at Vernon Health & Rehabilitation.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaints IN00454076, IN00453864, IN00452282, and IN00451409 were investigated and found to have no deficiencies related to the allegations.
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on October 22, 2024.
Findings
Vernon Health & Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census SNF/NF: 48Total Capacity: 48Census Payor Type Medicare: 1Census Payor Type Medicaid: 47
Inspection Report Life SafetyCensus: 53Capacity: 119Deficiencies: 0Oct 31, 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) respectively on 10/31/2024.
Findings
At the Emergency Preparedness survey, Vernon Health & Rehabilitation was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the Life Safety Code survey, the facility was found in compliance with requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility consists of three connected buildings, all sprinklered except for detached rooms housing generator #1 and a detached storage building.
This visit was for a Recertification and State Licensure Survey conducted from October 15 to 22, 2024.
Findings
The facility was found deficient in multiple areas including failure to ensure privacy during incontinence care, inadequate supervision to prevent resident-to-resident abuse, failure to implement ordered interventions for acute medical decline, unqualified staff performing GJ-tube care, incomplete narcotic counts, failure to monitor vital signs prior to medication administration, medication errors, and failure to provide proper arbitration agreements.
Severity Breakdown
SS=D: 6SS=E: 2
Deficiencies (8)
Description
Severity
Failed to ensure privacy was provided during incontinence care for 2 of 3 residents reviewed.
SS=D
Failed to provide adequate supervision and intervention to prevent physical resident-to-resident abuse for 4 of 4 residents reviewed.
SS=E
Failed to ensure interventions were implemented as ordered for a resident experiencing an acute medical decline.
SS=D
Failed to ensure staff were qualified to perform GJ-tube care for 1 resident.
SS=D
Failed to ensure shift to shift narcotic count and reconciliation was completed for 2 of 5 medication carts reviewed.
SS=D
Failed to ensure monitoring of vital signs parameters as ordered for 1 resident during medication administration.
SS=D
Failed to ensure medication error rate was less than 5%, with errors related to administration of atenolol and levothyroxine.
SS=D
Failed to provide arbitration agreement that granted residents or representatives the right to rescind within 30 days for 3 residents admitted after 2/1/24.
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00441262 completed on September 10, 2024.
Findings
Vernon Health 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 review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00441262 was completed with the facility found in compliance.
This visit was conducted for the investigation of Complaint IN00441262 regarding medication administration and medication availability issues at Vernon Health & Rehabilitation.
Findings
The facility failed to ensure that medications were administered per physician orders for 5 of 6 residents reviewed and failed to ensure medication availability for 1 of 6 residents reviewed. The agency nurse responsible for missed medication doses will not return to the facility. The facility implemented audits and in-services to address these issues.
Complaint Details
Complaint IN00441262 was substantiated with federal/state deficiencies cited at F726 and F755 related to medication administration and medication availability.
Severity Breakdown
SS=D: 2
Deficiencies (2)
Description
Severity
Failed to ensure residents received medications per physician orders for 5 of 6 residents reviewed for medication administration.
SS=D
Failed to ensure a resident's medication was available for administration for 1 of 6 residents reviewed for medication availability.
SS=D
Report Facts
Residents reviewed for medication administration: 6Residents reviewed for medication availability: 6Facility census: 46Facility total capacity: 46
Employees Mentioned
Name
Title
Context
Jessica Bates
HFA
Laboratory Director's or Provider/Supplier Representative's signature on the report.
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00437378, IN00437511, and IN00438619.
Findings
Vernon Health 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
The visit was related to complaint investigations IN00437378, IN00437511, and IN00438619, and the facility was found to be in compliance.
This visit was conducted for the investigation of four complaints (IN00437378, IN00437387, IN00437511, and IN00438619) concerning alleged deficiencies at Vernon Health & Rehabilitation.
Findings
The investigation found federal and state deficiencies related to medication management and dental services. Specifically, discrepancies in controlled substance counts were identified for Resident B, and the facility failed to ensure dental services were provided to Residents C, E, and F as required.
Complaint Details
Complaint IN00437378 and IN00437511 had federal/state deficiencies cited related to the allegations. Complaint IN00437387 had no deficiencies related to the allegations. Complaint IN00438619 had federal/state deficiencies cited related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
Description
Severity
Failure to ensure controlled substances were properly accounted for and reconciled during shift changes for Resident B.
SS=D
Failure to ensure residents received routine and emergency dental services for Residents C, E, and F.
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00433587 completed on May 1, 2024.
Findings
Vernon Health 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 of the complaint investigation.
Complaint Details
Investigation of Complaint IN00433587 completed on May 1, 2024; facility found in compliance.
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00432997 completed on April 24, 2024.
Findings
Vernon Health 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 IN00432997 completed on April 24, 2024; facility found in compliance.
This visit was conducted for the investigation of Complaint IN00433587 regarding allegations of failure to report changes in a resident's condition.
Findings
The facility failed to ensure that changes in Resident B's condition were reported immediately to the charge nurse, resulting in delayed recognition of a dislocated left hip and femur fracture. The investigation revealed a delay in notification by staff despite observable signs of injury.
Complaint Details
Complaint IN00433587 was substantiated with federal/state deficiencies cited at F580 related to failure to notify changes in Resident B's condition in a timely manner.
Severity Breakdown
SS=D: 1
Deficiencies (1)
Description
Severity
Failure to ensure changes in a resident's condition were reported immediately to the charge nurse for 1 of 3 residents reviewed for accidents (Resident B).
SS=D
Report Facts
Census Bed Type: 49Total Capacity: 49Medication administration times: 11.26Medication administration times: 13.14
Employees Mentioned
Name
Title
Context
Activity Assistant 5
Activity Assistant and CNA
Provided shower care to Resident B and observed abnormal leg positioning; reported concerns to nursing staff.
LPN 21
Licensed Practical Nurse
Nurse who was to be notified of Resident B's condition changes; assessed Resident B and administered medications.
LPN 45
Licensed Practical Nurse
Assessed Resident B after LPN 21 and noted resident's reaction.
LPN 33
Licensed Practical Nurse
Assessed Resident B and called nurse practitioner to send resident to emergency room.
DON
Director of Nursing
Interviewed regarding the incident and facility policy on notification of changes.
This visit was for the investigation of complaints IN00432997 and IN00433003. Complaint IN00432997 resulted in federal/state deficiencies related to the allegations, while Complaint IN00433003 had no deficiencies cited.
Findings
The facility failed to ensure a resident (Resident B) was free from a physical restraint for 1 of 3 residents reviewed for abuse. Resident B was found restrained in another resident's wheelchair with a chest harness and seat belt without proper authorization or physician order. Multiple observations and interviews revealed inconsistent use and monitoring of restraints and wheelchair use. Resident B was mobile but unable to buckle or unbuckle restraints himself. The facility investigation led to suspension of a nurse and implementation of corrective actions.
Complaint Details
Complaint IN00432997 was substantiated with federal/state deficiencies cited at F604 related to physical restraints. Complaint IN00433003 had no deficiencies cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
Description
Severity
Facility failed to ensure Resident B was free from physical restraint by being found restrained in another resident's wheelchair with chest harness and seat belt without proper authorization.
This visit was conducted for the investigation of complaints IN00431099 and IN00431178.
Findings
No deficiencies related to the allegations in complaints IN00431099 and IN00431178 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Investigation of Complaints IN00431099 and IN00431178 found no deficiencies related to the allegations.
This visit was conducted for the investigation of complaints IN00427136 and IN00428527.
Findings
No deficiencies related to the allegations in complaints IN00427136 and IN00428527 were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00427136 and Complaint IN00428527 were investigated; no deficiencies related to the allegations were cited.
Report Facts
Census: 51Total Capacity: 51Payor Type Census: 1Payor Type Census: 49Payor Type Census: 1
Paper compliance review to the Investigation of Complaint IN00425880 completed on January 12, 2024.
Findings
Vernon Health 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 to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00425880 completed with findings of compliance.
This visit was conducted for the investigation of complaints IN00423877 and IN00425880. Complaint IN00423877 had no deficiencies cited, while Complaint IN00425880 resulted in federal/state deficiencies related to medication errors.
Findings
The facility failed to ensure a resident with a brain injury was free from significant medication errors, specifically repeated missed doses of the muscle relaxer dantrolene for one of three residents reviewed. The resident experienced neuro storming and was hospitalized due to medication unavailability and delays in prior authorization.
Complaint Details
Complaint IN00423877 had no deficiencies related to allegations. Complaint IN00425880 was substantiated with federal/state deficiencies cited at F760 related to medication errors involving missed doses of dantrolene and resulting adverse resident outcomes.
Severity Breakdown
SS=D: 1
Deficiencies (1)
Description
Severity
Failed to ensure a resident with a brain injury was free from significant medication errors related to repeated missed doses of dantrolene.
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey and Investigation of Complaint IN00415964 completed on September 15, 2023.
Findings
Vernon Health & Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and Investigation of Complaint IN00415964.
Complaint Details
Complaint IN00415964 was investigated and found to be corrected.
Report Facts
Census SNF/NF beds: 50Census total residents: 50Census Medicare residents: 2Census Medicaid residents: 47Census other payor residents: 1
Inspection Report Life SafetyCensus: 48Capacity: 119Deficiencies: 0Sep 28, 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
At the Emergency Preparedness survey, Vernon Health and Rehabilitation was found in compliance with Emergency Preparedness Requirements. At the Life Safety Code survey, the facility was found in compliance with Life Safety from Fire requirements and the 2012 edition of NFPA 101 Life Safety Code. The facility consists of three connected buildings, all sprinklered except for detached rooms housing generator #1 and a detached storage building.
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00415964 and IN00416015.
Findings
The facility failed to develop and implement individualized activities programming to meet individual resident needs for 6 of 7 residents with developmental disabilities. Additionally, medications were found unsecured on a medication cart, and the facility failed to provide recommended dental services to a resident. The facility also did not ensure residents were not required to sign binding arbitration agreements as a condition of admission.
Complaint Details
Complaint IN00415964 resulted in federal/state deficiencies related to the allegations. Complaint IN00416015 had no deficiencies related to the allegations.
Severity Breakdown
SS=E: 2SS=D: 2
Deficiencies (4)
Description
Severity
Failed to develop and implement individualized activities programming to meet individual resident needs for 6 of 7 residents with developmental disabilities.
SS=E
Failed to securely store medications during a random observation of 1 of 2 medication carts utilized for the east end of the 300 Hall.
SS=D
Failed to provide recommended dental services to 1 of 2 residents reviewed for nutrition.
SS=D
Failed to ensure residents and/or their representatives were not required to sign an agreement for binding arbitration as a requirement for admission to the facility for 6 of 7 current residents admitted after 8/1/22.
SS=E
Report Facts
Census: 48Total Capacity: 48Deficiencies cited: 4
Employees Mentioned
Name
Title
Context
Jessica McKinley
Laboratory Director or Provider/Supplier Representative
Signed the report
LPN 3
Interviewed regarding residents' mobility and activities
CNA 4
Interviewed regarding residents' mobility and activities
LPN 5
Interviewed regarding medication cart security
LPN 6
Interviewed regarding medication cart security
DON
Director of Nursing
Interviewed regarding medication cart security and dental services
Corporate Clinical Support Nurse
Interviewed regarding medication storage policy and arbitration agreement policy
Social Services Designee
Interviewed regarding dental services and arbitration agreements
Administrator
Interviewed regarding arbitration agreements and dental services
This visit was conducted for the Investigation of Complaint IN00404319 and included a COVID-19 Focused Infection Control Survey.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant federal and state regulations regarding the complaint investigation and COVID-19 infection control.
Complaint Details
Complaint IN00404319 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 54Census total residents: 54Census Medicare residents: 3Census Medicaid residents: 51
This visit was conducted for the investigation of complaints IN00400368 and IN00399977.
Findings
Complaint IN00400368 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00399977 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations regarding these complaints.
Complaint Details
Complaint IN00400368 - Substantiated with no deficiencies cited. Complaint IN00399977 - Unsubstantiated due to lack of evidence.
Report Facts
Census SNF/NF beds: 52Census total residents: 52Medicare residents: 1Medicaid residents: 51
This visit was conducted for the investigation of complaints IN00393943 and IN00397093.
Findings
Complaint IN00393943 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00397093 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00393943 - Substantiated with no deficiencies cited. Complaint IN00397093 - Unsubstantiated due to lack of evidence.
This visit was conducted for the investigation of Complaint IN00388462.
Findings
The complaint IN00388462 was found to be unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00388462 was investigated and found to be unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type: 52Census Payor Type: 52
Inspection Report Life SafetyCensus: 52Capacity: 119Deficiencies: 0Sep 8, 2022
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
At the Emergency Preparedness survey, Vernon Health & Rehabilitation was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. At the Life Safety Code survey, the facility was found in compliance with requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility consists of three connected buildings, all sprinklered except for detached rooms housing generator #1 and a detached storage building.
This visit was for a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on August 1, 2022.
Findings
Vernon Health & Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census SNF/NF: 52Census Payor Type Medicaid: 51Census Payor Type Other: 1
This visit was for a Recertification and State Licensure Survey conducted from July 26 to August 1, 2022.
Findings
The facility was found deficient in accurately reflecting residents' wound status in assessments, consistently implementing pressure ulcer prevention and treatment interventions, and ensuring fall prevention interventions were in place. Deficiencies were identified related to wound assessment accuracy, pressure injury care, and fall prevention for specific residents.
Severity Breakdown
SS=D: 3
Deficiencies (3)
Description
Severity
Failed to ensure the MDS assessment accurately identified a resident's leg wounds for 1 of 4 residents reviewed for wounds (Resident 9).
SS=D
Failed to ensure interventions to aid in pressure relief were consistently in place during random observations for 2 of 4 residents reviewed for pressure injuries (Residents 7 and 32).
SS=D
Failed to ensure fall prevention interventions were consistently implemented for 1 of 2 residents reviewed for falls (Resident 51).
SS=D
Report Facts
Census: 56Total Capacity: 56Survey Dates: 5
Report
Aug 25, 2025
File
complaint-inspection_2025-08-25.pdf
Report
May 14, 2025
File
complaint-inspection_2025-05-14.pdf
Report
Oct 22, 2024
File
health-inspection_2024-10-22.pdf
Report
Sep 10, 2024
File
complaint-inspection_2024-09-10.pdf
Report
Jul 18, 2024
File
complaint-inspection_2024-07-18.pdf
Report
May 1, 2024
File
complaint-inspection_2024-05-01.pdf
Report
Apr 24, 2024
File
complaint-inspection_2024-04-24.pdf
Report
Jan 12, 2024
File
complaint-inspection_2024-01-12.pdf
Report
Sep 15, 2023
File
complaint-inspection_2023-09-15.pdf
Report
Sep 15, 2023
File
health-inspection_2023-09-15.pdf
Report
Mar 24, 2023
File
infection-control-inspection_2023-03-24.pdf
Report
Aug 1, 2022
File
health-inspection_2022-08-01.pdf
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