Inspection Reports for Vernon Health & Rehabilitation
1955 S VERNON ST, WABASH, IN, 46992
Back to Facility ProfileInspection Report Summary
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)
12.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
198% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
100% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 25, 2025
Visit Reason
The inspection was conducted due to a complaint intake (1753947.3) regarding medication administration practices at the facility.
Complaint Details
This citation relates to Intake 1753947.3.
Findings
The facility failed to administer medications according to physician orders for 1 of 3 residents reviewed. Specifically, Resident B was documented as receiving diazepam on the Medication Administration Record, but the medication was not signed out on the controlled substance log, indicating it was likely not administered.
Deficiencies (1)
Failed to administer medications according to physician order for Resident B; diazepam was documented as given but not signed out on the narcotic count sheet.
Report Facts
Residents reviewed for medication administration: 3
Doses of diazepam documented: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| ADON | Interviewed regarding medication administration and documentation discrepancies | |
| Administrator | Interviewed regarding medication administration and documentation discrepancies |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 47
Deficiencies: 0
Date: Jun 27, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00461337.
Complaint Details
Investigation of Complaint IN00461337 found 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 relevant regulations.
Report Facts
Census SNF/NF: 47
Total Capacity: 47
Census Payor Type Medicaid: 47
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jun 18, 2025
Visit Reason
Paper compliance review to the Investigation of Complaints IN00459066 and IN00458788 completed on May 14, 2025.
Complaint Details
The visit was related to complaint investigations IN00459066 and IN00458788; compliance was found upon paper review.
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.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: May 14, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to failure to notify resident representatives of transfer/discharge appeal rights and failure to follow physician orders regarding continuation of care for residents attending day programs.
Complaint Details
This citation relates to Complaint IN00458788 regarding notification of transfer/discharge appeal rights and Complaint IN00459066 regarding continuation of care for residents attending day programs.
Findings
The facility failed to ensure the resident's representative was notified in writing of transfer/discharge appeal rights for 1 of 3 hospitalizations (Resident D). Additionally, the facility failed to follow physician orders regarding continuation of care for residents transported to day programs with medications for 2 of 3 residents reviewed (Residents B and C).
Deficiencies (2)
Failed to ensure the resident's representative was notified in writing of transfer/discharge appeal rights for 1 of 3 hospitalizations (Resident D).
Failed to follow physician orders regarding continuation of care for residents transported to day programs with medications for 2 of 3 residents reviewed (Residents B and C).
Report Facts
Residents affected: 1
Residents affected: 2
Hospitalizations reviewed: 3
Residents reviewed for day services: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 6 | Licensed Practical Nurse | Indicated discussion of bed hold policy but not appeal rights with resident representatives |
| LPN 8 | Licensed Practical Nurse | Indicated discussion of bed hold policy but not appeal rights with resident representatives |
| Social Services Director | Indicated nurses responsible for transfer forms and discussed resident transfers | |
| DON | Director of Nursing | Indicated she did not inform residents or representatives of appeal rights during transfers or discharges |
| Regional Nurse Consultant | Unable to locate documentation of notification of appeal rights; provided facility policies | |
| Administrator | Indicated Resident B was sent to school without approval and school requested pickup | |
| CNA 4 | Certified Nursing Assistant | Transported Resident B from school back to facility after school requested pickup |
| RN 7 | Registered Nurse | Sent Resident B to school; noted miscommunication with DON about approval |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 2
Date: May 12, 2025
Visit Reason
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.
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.
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.
Deficiencies (2)
Failed to ensure the resident's representative was notified in writing of the transfer/discharge appeal rights for 1 of 3 hospitalizations (Resident 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).
Report Facts
Census: 49
Total Capacity: 49
Medicare Census: 2
Medicaid Census: 46
Other Payor Census: 1
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 0
Date: Mar 7, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00454076, IN00453864, IN00452282, and IN00451409 at Vernon Health & Rehabilitation.
Complaint Details
Complaints IN00454076, IN00453864, IN00452282, and IN00451409 were investigated and found to have no deficiencies related to the allegations.
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.
Report Facts
Census: 50
Total Capacity: 50
Medicare Census: 2
Medicaid Census: 48
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00449001.
Complaint Details
Complaint IN00449001 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
Medicaid residents: 47
Other payor residents: 1
Inspection Report
Re-Inspection
Census: 48
Capacity: 48
Deficiencies: 0
Date: Dec 23, 2024
Visit Reason
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: 48
Total Capacity: 48
Census Payor Type Medicare: 1
Census Payor Type Medicaid: 47
Inspection Report
Life Safety
Census: 53
Capacity: 119
Deficiencies: 0
Date: Oct 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.
Report Facts
Facility capacity: 119
Census: 53
Inspection Report
Renewal
Census: 48
Capacity: 48
Deficiencies: 8
Date: Oct 22, 2024
Visit Reason
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.
Deficiencies (8)
Failed to ensure privacy was provided during incontinence care for 2 of 3 residents reviewed.
Failed to provide adequate supervision and intervention to prevent physical resident-to-resident abuse for 4 of 4 residents reviewed.
Failed to ensure interventions were implemented as ordered for a resident experiencing an acute medical decline.
Failed to ensure staff were qualified to perform GJ-tube care for 1 resident.
Failed to ensure shift to shift narcotic count and reconciliation was completed for 2 of 5 medication carts reviewed.
Failed to ensure monitoring of vital signs parameters as ordered for 1 resident during medication administration.
Failed to ensure medication error rate was less than 5%, with errors related to administration of atenolol and levothyroxine.
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.
Report Facts
Survey dates: 8
Census: 48
Total capacity: 48
Medication error rate: 5.56
Blood glucose level: 456
Blood glucose level: 502
Oxygen saturation: 87
Oxygen liters: 5
Medication administration dates: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Bates | HFA | Signed the Statement of Deficiencies report. |
| LPN 4 | Observed administering medications without checking vital signs and involved in narcotic count. | |
| LPN 5 | Involved in Resident 18's care and medication administration issues. | |
| Certified Nurse Assistant 6 | CNA | Observed failing to provide privacy during incontinence care. |
| Certified Nurse Assistant 7 | CNA | Interviewed about privacy curtain use. |
| Certified Nurse Assistant 8 | CNA | Interviewed about privacy curtain use and care plan knowledge. |
| Director of Nursing | DON | Provided multiple interviews regarding privacy, resident abuse, medication administration, and facility policies. |
| Administrator | Provided interviews and resident-to-resident abuse investigations. | |
| Social Services Director | SSD | Explained arbitration agreement process during admissions. |
Inspection Report
Routine
Deficiencies: 8
Date: Oct 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, abuse prevention, medical care, medication administration, and arbitration agreements.
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 medical interventions timely for acute decline, unqualified staff performing feeding tube care, incomplete narcotic counts, failure to monitor medication parameters, and failure to provide proper arbitration agreement disclosures.
Deficiencies (8)
Failed to ensure privacy was provided during incontinence care for 2 of 3 residents reviewed for dignity.
Failed to provide adequate supervision and intervention to prevent physical resident-to-resident abuse for 4 of 4 residents reviewed.
Failed to ensure interventions were implemented as ordered for a resident experiencing an acute medical decline.
Failed to ensure staff were qualified to perform GJ-tube care for 1 resident.
Failed to ensure shift to shift narcotic count and reconciliation was completed for 2 of 5 medication carts reviewed.
Failed to ensure monitoring of vital signs parameters as ordered for 1 resident during medication administration.
Failed to ensure medication error rate less than 5%, including administering levothyroxine with other medications and not checking parameters before atenolol administration.
Failed to provide arbitration agreement that granted the resident or representative the right to rescind the agreement within 30 days of signing for 3 residents admitted after 2/1/24.
Report Facts
Medication administration opportunities: 36
Medication errors: 2
Medication error rate: 5.56
Blood glucose levels: 456
Blood glucose levels: 330
Blood glucose levels: 502
Blood glucose levels: 373
Oxygen saturation: 87
Oxygen flow: 4
Oxygen saturation: 86
Oxygen flow: 5
Medication administration dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 6 | Certified Nurse Assistant | Named in privacy deficiency related to incontinence care |
| CNA 7 | Certified Nurse Assistant | Interviewed regarding privacy curtain use |
| CNA 8 | Certified Nurse Assistant | Interviewed regarding privacy curtain use and Resident 43 interventions |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding privacy, resident care, and medication administration |
| CNA 10 | Certified Nurse Assistant | Observed and interviewed regarding resident-to-resident abuse incidents |
| Activity Aide 13 | Activity Aide | Interviewed regarding Resident 43 behavior |
| Administrator | Administrator | Provided resident-to-resident investigation reports and interviews |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding arbitration agreement and Resident 43 behavior |
| LPN 14 | Licensed Practical Nurse | Interviewed regarding Resident 43 behavior |
| LPN 5 | Licensed Practical Nurse | Interviewed regarding Resident 18 care and GJ-tube care |
| QMA 12 | Qualified Medication Aide | Observed providing GJ-tube care for Resident 42 |
| LPN 4 | Licensed Practical Nurse | Observed medication administration and narcotic count |
| MDS Coordinator | MDS Coordinator | Interviewed regarding medication administration parameters |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 21, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00441262 completed on September 10, 2024.
Complaint Details
Investigation of Complaint IN00441262 was completed with the facility found in compliance.
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.
Inspection Report
Complaint Investigation
Census: 47
Capacity: 47
Deficiencies: 0
Date: Oct 8, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00444078.
Complaint Details
Complaint IN00444078 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00444078 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 47
Total Capacity: 47
Inspection Report
Complaint Investigation
Census: 46
Capacity: 46
Deficiencies: 2
Date: Sep 10, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00441262 regarding medication administration and medication availability issues at Vernon Health & Rehabilitation.
Complaint Details
Complaint IN00441262 was substantiated with federal/state deficiencies cited at F726 and F755 related to medication administration and medication availability.
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.
Deficiencies (2)
Failed to ensure residents received medications per physician orders for 5 of 6 residents reviewed for medication administration.
Failed to ensure a resident's medication was available for administration for 1 of 6 residents reviewed for medication availability.
Report Facts
Residents reviewed for medication administration: 6
Residents reviewed for medication availability: 6
Facility census: 46
Facility total capacity: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica Bates | HFA | Laboratory Director's or Provider/Supplier Representative's signature on the report. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 10, 2024
Visit Reason
The inspection was conducted in response to Complaint IN00441262 regarding medication administration and availability issues at Vernon Health & Rehabilitation.
Complaint Details
Complaint IN00441262 related to medication administration and availability errors.
Findings
The facility failed to ensure that 5 of 6 residents reviewed received medications per physician orders, with medications found undistributed in the medication cart. Additionally, one resident did not receive a medication dose due to failure to secure a refill prescription. The facility's medication administration policy requires documentation of refusals or missed medications and timely reordering of medications.
Deficiencies (2)
Failed to ensure residents received medications per physician orders for 5 of 6 residents reviewed for medication administration.
Failed to ensure a resident's medication was available for administration for 1 of 6 residents reviewed for medication availability.
Report Facts
Residents reviewed for medication administration: 6
Residents with medication administration failure: 5
Medication dose missed: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Interviewed regarding medication administration failures and medication reorder responsibilities | |
| Administrator | Interviewed regarding medication administration policy and medication reorder responsibilities |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 16, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00437378, IN00437511, and IN00438619.
Complaint Details
The visit was related to complaint investigations IN00437378, IN00437511, and IN00438619, and the facility was found to be in compliance.
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.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 18, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to concerns about pharmaceutical services and dental care at Vernon Health & Rehabilitation.
Complaint Details
This citation relates to Complaint IN00438619 regarding pharmaceutical services and Complaints IN00437378 and IN00437511 regarding dental services.
Findings
The facility failed to ensure proper accounting and reconciliation of controlled substances for one resident, resulting in discrepancies in narcotic counts. Additionally, the facility failed to ensure that three residents received routine and emergency dental care as required.
Deficiencies (2)
Failed to ensure a resident's controlled substances were accounted for and reconciled during shift changes, with discrepancies in diazepam and lorazepam counts.
Failed to ensure residents received routine and emergency dental care for 3 of 3 residents reviewed.
Report Facts
Controlled substance shift changes: 35
Controlled substance cards documented: 19
Diazepam delivered: 60
Diazepam remaining: 45
Lorazepam expected: 28.4
Lorazepam remaining: 22
Residents reviewed for dental care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 6 | Signed pharmacy packing slip and narcotic count forms; involved in narcotic count discrepancies | |
| LPN 21 | Participated in controlled substance reconciliation and reported incomplete documentation | |
| LPN 7 | Attempted narcotic count with RN 6 and reported discrepancies and RN 6's behavior | |
| LPN 14 | Contacted on-call nurse regarding narcotic count discrepancies | |
| Administrator | Interviewed regarding narcotic count discrepancies and dental service issues | |
| MDS Coordinator | Interviewed about shift change procedures for controlled substances | |
| Social Service Director | Interviewed about dental services enrollment and audits |
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 2
Date: Jul 17, 2024
Visit Reason
This visit was conducted for the investigation of four complaints (IN00437378, IN00437387, IN00437511, and IN00438619) concerning alleged deficiencies at Vernon Health & Rehabilitation.
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.
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.
Deficiencies (2)
Failure to ensure controlled substances were properly accounted for and reconciled during shift changes for Resident B.
Failure to ensure residents received routine and emergency dental services for Residents C, E, and F.
Report Facts
Census: 48
Total Capacity: 48
Controlled substance shift changes: 35
Controlled substance cards documented: 19
Diazepam volume discrepancy: 15
Lorazepam volume discrepancy: 6.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 6 | Named in medication discrepancy finding related to controlled substance counts for Resident B | |
| LPN 7 | Named in medication discrepancy finding related to controlled substance counts for Resident B | |
| LPN 14 | Reported medication discrepancies to on-call nurse | |
| Administrator | Interviewed regarding medication discrepancies and dental service enrollment issues | |
| Social Service Director | Interviewed regarding dental service enrollment and audit findings |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 31, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of Complaint IN00433587 completed on May 1, 2024.
Complaint Details
Investigation of Complaint IN00433587 completed on May 1, 2024; facility found in compliance.
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.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 31, 2024
Visit Reason
The inspection was conducted as a paper compliance review related to the Investigation of Complaint IN00432997 completed on April 24, 2024.
Complaint Details
Investigation of Complaint IN00432997 completed on April 24, 2024; facility found in compliance.
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.
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 1
Date: May 1, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00433587 regarding allegations of failure to report changes in a resident's condition.
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.
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.
Deficiencies (1)
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).
Report Facts
Census Bed Type: 49
Total Capacity: 49
Medication administration times: 11.26
Medication 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. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 1, 2024
Visit Reason
The inspection was conducted due to a complaint investigation (Complaint IN00433587) regarding the facility's failure to immediately report changes in a resident's condition.
Complaint Details
This citation relates to Complaint IN00433587. The complaint involved failure to report a significant change in Resident B's physical condition, specifically a dislocated left hip and femur fracture, in a timely manner.
Findings
The facility failed to ensure that changes in Resident B's condition were reported immediately to the charge nurse. Resident B exhibited signs of injury (dislocated left hip and left femur fracture) that were not promptly communicated by staff, resulting in delayed medical evaluation and treatment.
Deficiencies (1)
Failure to immediately report changes in Resident B's condition to the charge nurse.
Report Facts
Medication administration times: 2
Dates of relevant events: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Activity Assistant 5 | Activity Assistant and CNA | Provided care to Resident B on 4/29/24 and observed abnormal signs in Resident B's left leg but delayed reporting. |
| LPN 21 | Licensed Practical Nurse | Received delayed report about Resident B's condition and administered medications; involved in assessment and communication. |
| LPN 45 | Licensed Practical Nurse | Assessed Resident B after LPN 21 and noted the resident's reaction. |
| LPN 33 | Licensed Practical Nurse | Assessed Resident B and called the nurse practitioner to send the resident to the emergency room. |
| DON | Director of Nursing | Interviewed on 5/1/24 regarding the incident and facility policy. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 24, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of improper use of physical restraints on Resident B at Vernon Health & Rehabilitation.
Complaint Details
This citation relates to Complaint IN00432997 regarding the improper use of physical restraints on Resident B.
Findings
The facility failed to ensure Resident B was free from physical restraints, as he was found restrained in an adaptive wheelchair with a chest harness and seat belt without a physician's order. Resident B was mobile but unable to buckle or unbuckle restraints himself. Multiple staff interviews and observations confirmed inconsistent and inappropriate use of restraints, including placement in another resident's wheelchair with restraints applied. The facility policy prohibits unnecessary physical restraints.
Deficiencies (1)
Failure to ensure a resident was free from the use of physical restraints unless medically necessary.
Report Facts
Behaviors documented: 83
Staples: 4
Discoloration size: 20.1
Discoloration size: 8.5
Melatonin dose: 2
Blood sugar: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 6 | Registered Nurse | Observed Resident B in wheelchair with seat belt, involved in care and blood sugar checks, and interviewed regarding restraint use. |
| CNA 17 | Certified Nursing Assistant | Observed Resident B in wheelchair with and without restraints, assisted with care, and provided a detailed statement about events on 4/16/24. |
| CNA 25 | Certified Nursing Assistant | Found Resident B restrained in another resident's adaptive wheelchair and reported to LPN 34. |
| LPN 34 | Licensed Practical Nurse | Reported Resident B restrained in adaptive wheelchair, completed assessments, and notified Administrator. |
| Administrator | Facility Administrator | Conducted investigation, interviewed staff, and suspended nurse in charge related to restraint incident. |
| Physical Therapist 2 | Physical Therapist | Evaluated Resident B and opined on Resident B's ability to buckle/unbuckle seatbelt and climb into wheelchair. |
| Director of Therapy Department | Director of Therapy | Participated in evaluation of Resident B and provided opinion on Resident B's mobility and restraint use. |
| ADON | Assistant Director of Nursing | Provided interview regarding Resident B's mobility and restraint capabilities. |
Inspection Report
Complaint Investigation
Census: 49
Capacity: 49
Deficiencies: 1
Date: Apr 23, 2024
Visit Reason
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.
Complaint Details
Complaint IN00432997 was substantiated with federal/state deficiencies cited at F604 related to physical restraints. 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.
Deficiencies (1)
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.
Report Facts
Census: 49
Total Capacity: 49
Behaviors: 83
Deficiency cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica McKinley | Executive Director | Signed the report |
| RN 6 | Nurse involved in Resident B's care and restraint use; interviewed regarding restraint incidents | |
| CNA 17 | Reported observations of Resident B in wheelchair with restraints; interviewed | |
| CNA 25 | Found Resident B restrained in another resident's wheelchair; reported to LPN 34 | |
| LPN 34 | Received report of restraint use on Resident B; performed assessments | |
| Administrator | Conducted investigation and suspended nurse responsible for residents | |
| QMA 4 | Observed Resident B in wheelchair; interviewed | |
| LPN 29 | Interviewed regarding Resident B's inability to self-restrain | |
| CNA 12 | Interviewed regarding Resident B's restraint status and behaviors | |
| CNA 21 | Interviewed regarding Resident B's inability to self-restrain | |
| CNA 28 | Interviewed regarding Resident B's inability to self-restrain | |
| Director of Therapy Department | Evaluated Resident B's physical abilities related to restraint use | |
| Physical Therapist 2 | Evaluated Resident B's physical abilities related to restraint use | |
| ADON | Interviewed regarding Resident B's abilities and restraint use |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 47
Deficiencies: 0
Date: Apr 15, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00431099 and IN00431178.
Complaint Details
Investigation of Complaints IN00431099 and IN00431178 found no deficiencies related to the allegations.
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.
Report Facts
Census Bed Type: 47
Census Payor Type: 47
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 0
Date: Feb 28, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00427136 and IN00428527.
Complaint Details
Complaint IN00427136 and Complaint IN00428527 were investigated; no deficiencies related to the allegations were cited.
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.
Report Facts
Census: 51
Total Capacity: 51
Payor Type Census: 1
Payor Type Census: 49
Payor Type Census: 1
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 12, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00425880 completed on January 12, 2024.
Complaint Details
Investigation of Complaint IN00425880 completed with findings of compliance.
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.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 12, 2024
Visit Reason
The inspection was conducted in response to Complaint IN00425880 concerning medication errors at Vernon Health & Rehabilitation.
Complaint Details
This citation relates to Complaint IN00425880.
Findings
The facility failed to ensure a resident with a brain injury was free from significant medication errors related to repeated missed doses of the muscle relaxer dantrolene. Multiple missed doses occurred between 12/20/23 and 1/1/24, resulting in the resident experiencing neuro storming, muscle spasms, and hospitalization.
Deficiencies (1)
Failure to ensure a resident was free from significant medication errors related to repeated missed doses of dantrolene.
Report Facts
Missed doses of dantrolene: 15
Dantrolene medication paid for: 33
One-time dose of baclofen: 1
PRN diazepam doses: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NP 2 | Nurse Practitioner | Notified regarding resident's condition and prior authorization status; completed prior authorization for dantrolene. |
| NP 15 | Nurse Practitioner | On call for NP 2; completed prior authorization for dantrolene; unaware of missed doses. |
| RN 13 | Registered Nurse | Reported missed doses over weekend; contacted nurse on call and pharmacy; administered baclofen. |
| DON | Director of Nursing | Provided information on pharmacy prior authorization process and medication availability; confirmed missed doses and attempts to correct records. |
| Administrator | Provided information on insurance cards and medication payments. |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 50
Deficiencies: 1
Date: Jan 11, 2024
Visit Reason
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.
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.
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.
Deficiencies (1)
Failed to ensure a resident with a brain injury was free from significant medication errors related to repeated missed doses of dantrolene.
Report Facts
Census: 50
Total Capacity: 50
Medicare Census: 2
Medicaid Census: 46
Other Payor Census: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jessica McKinley | HFA | Signed the report as Laboratory Director or Provider/Supplier Representative |
| NP 2 | Nurse Practitioner | Notified regarding prior authorization and medication delivery issues for Resident B |
| NP 15 | Nurse Practitioner | Completed prior authorization for dantrolene and provided clinical input on Resident B |
| RN 13 | Registered Nurse | Reported medication delays and resident condition changes related to missed doses |
| DON | Director of Nursing | Provided information on pharmacy communication and medication management |
| Administrator | Provided information on insurance and medication procurement for Resident B |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 51
Deficiencies: 0
Date: Dec 11, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00422069.
Complaint Details
Complaint IN00422069 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 relevant regulations.
Report Facts
Census: 51
Total Capacity: 51
Medicare Residents: 4
Medicaid Residents: 46
Other Payor Residents: 1
Inspection Report
Re-Inspection
Census: 50
Capacity: 50
Deficiencies: 0
Date: Nov 9, 2023
Visit Reason
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.
Complaint Details
Complaint IN00415964 was investigated and found to be corrected.
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.
Report Facts
Census SNF/NF beds: 50
Census total residents: 50
Census Medicare residents: 2
Census Medicaid residents: 47
Census other payor residents: 1
Inspection Report
Life Safety
Census: 48
Capacity: 119
Deficiencies: 0
Date: Sep 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.
Report Facts
Facility capacity: 119
Census: 48
Inspection Report
Complaint Investigation
Census: 48
Capacity: 48
Deficiencies: 4
Date: Sep 15, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including the Investigation of Complaints IN00415964 and IN00416015.
Complaint Details
Complaint IN00415964 resulted in federal/state deficiencies related to the allegations. Complaint IN00416015 had no deficiencies related to the allegations.
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.
Deficiencies (4)
Failed to develop and implement individualized activities programming to meet individual resident needs for 6 of 7 residents with developmental disabilities.
Failed to securely store medications during a random observation of 1 of 2 medication carts utilized for the east end of the 300 Hall.
Failed to provide recommended dental services to 1 of 2 residents reviewed for nutrition.
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.
Report Facts
Census: 48
Total Capacity: 48
Deficiencies 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 |
Inspection Report
Routine
Census: 12
Deficiencies: 1
Date: Sep 15, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with individualized activities programming for residents with developmental disabilities.
Findings
The facility failed to develop and implement individualized activities programming to meet the needs of 6 of 7 residents with developmental disabilities. Observations and interviews revealed residents were often not engaged in activities, lacked sensory or manipulative devices, and were not actively included in group activities.
Deficiencies (1)
Failed to provide individualized activities programming to meet resident needs for 6 of 7 residents with developmental disabilities.
Report Facts
Residents affected: 6
Residents observed in lounge: 6
Residents observed in lounge: 9
Residents observed in lounge: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Indicated Resident D and Resident F used wheelchairs and were totally dependent on staff assistance for mobility and locomotion; also provided information about Resident H and Resident I. | |
| CNA 4 | Indicated Resident D, Resident F, Resident H, Resident I, and Resident J used wheelchairs and required staff assistance to move about. | |
| Housekeeper 1 | Provided information about Resident H and Resident I's usual behaviors and mobility. | |
| Activity Director | Provided information about residents' participation in activities and sensory device use. | |
| Social Services Designee | Provided information about Resident C's behavior of scooting on the floor and entering other residents' rooms. |
Inspection Report
Routine
Deficiencies: 4
Date: Sep 15, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to individualized activities programming for residents with developmental disabilities and other care standards.
Findings
The facility failed to develop and implement individualized activities programming to meet the needs of 6 of 7 residents with developmental disabilities. Observations showed residents were often not engaged in activities, lacked sensory or manipulative devices, and were not offered appropriate assistance or modifications. Additionally, medication storage was found unsecured, dental services were not provided timely to a resident needing dentures, and arbitration agreements were not presented as voluntary to several residents.
Deficiencies (4)
Failed to develop and implement individualized activities programming to meet individual resident needs for 6 of 7 residents with developmental disabilities.
Medication cart was unlocked and unattended, allowing access to medications.
Failed to provide recommended dental services to a resident needing dentures.
Residents and/or their representatives were not required to sign arbitration agreements voluntarily; no option to decline was provided.
Report Facts
Residents affected: 6
Residents affected: 1
Residents affected: 6
Residents observed in lounge: 12
Residents observed in lounge: 9
Residents observed in lounge: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 3 | Licensed Practical Nurse | Interviewed regarding residents' mobility and activity participation |
| CNA 4 | Certified Nursing Assistant | Interviewed regarding residents' mobility and activity participation |
| LPN 5 | Licensed Practical Nurse | Locked medication cart after observation of unsecured cart |
| LPN 6 | Licensed Practical Nurse | Provided information about medication cart storage |
| DON | Director of Nursing | Interviewed about medication cart security and dental services follow-up |
| Corporate Clinical Support Nurse | Provided policies and information about medication storage and dental services | |
| Activity Director | Interviewed regarding residents' activity participation and observations | |
| Social Services Designee | Interviewed regarding residents' activity participation and admission agreements | |
| Administrator | Interviewed regarding arbitration agreements and admission process | |
| Housekeeper 1 | Interviewed regarding residents' mobility and activity participation |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 54
Deficiencies: 0
Date: Mar 24, 2023
Visit Reason
This visit was conducted for the Investigation of Complaint IN00404319 and included a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00404319 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 relevant federal and state regulations regarding the complaint investigation and COVID-19 infection control.
Report Facts
Census SNF/NF beds: 54
Census total residents: 54
Census Medicare residents: 3
Census Medicaid residents: 51
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 24, 2023
Visit Reason
The inspection was conducted as a standard annual survey of the nursing home facility to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 0
Date: Feb 2, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00400368 and IN00399977.
Complaint Details
Complaint IN00400368 - Substantiated with no deficiencies cited. Complaint IN00399977 - Unsubstantiated due to lack of evidence.
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.
Report Facts
Census SNF/NF beds: 52
Census total residents: 52
Medicare residents: 1
Medicaid residents: 51
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 0
Date: Dec 15, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00393943 and IN00397093.
Complaint Details
Complaint IN00393943 - Substantiated with no deficiencies cited. Complaint IN00397093 - Unsubstantiated due to lack of evidence.
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.
Report Facts
Census: 52
Total Capacity: 52
Medicare Census: 1
Medicaid Census: 51
Inspection Report
Complaint Investigation
Census: 52
Capacity: 52
Deficiencies: 0
Date: Oct 3, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00388462.
Complaint Details
Complaint IN00388462 was investigated and found to be unsubstantiated due to lack of evidence.
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.
Report Facts
Census Bed Type: 52
Census Payor Type: 52
Inspection Report
Life Safety
Census: 52
Capacity: 119
Deficiencies: 0
Date: Sep 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.
Report Facts
Facility capacity: 119
Census: 52
Inspection Report
Re-Inspection
Census: 52
Capacity: 52
Deficiencies: 0
Date: Sep 6, 2022
Visit Reason
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: 52
Census Payor Type Medicaid: 51
Census Payor Type Other: 1
Inspection Report
Renewal
Census: 56
Capacity: 56
Deficiencies: 3
Date: Aug 1, 2022
Visit Reason
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.
Deficiencies (3)
Failed to ensure the MDS assessment accurately identified a resident's leg wounds for 1 of 4 residents reviewed for wounds (Resident 9).
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).
Failed to ensure fall prevention interventions were consistently implemented for 1 of 2 residents reviewed for falls (Resident 51).
Report Facts
Census: 56
Total Capacity: 56
Survey Dates: 5
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Aug 1, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, pressure ulcer care, and fall prevention at Vernon Health & Rehabilitation.
Findings
The facility was found deficient in ensuring accurate Minimum Data Set (MDS) assessments for wounds, consistent implementation of pressure ulcer prevention interventions, and adequate fall prevention measures for residents. Several residents had wounds or pressure injuries that were not properly assessed or managed, and fall prevention protocols were inconsistently followed.
Deficiencies (3)
Failed to ensure the MDS assessment accurately identified a resident's leg wounds for 1 of 4 residents reviewed for wounds (Resident 9).
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).
Failed to ensure fall prevention interventions were consistently implemented for 1 of 2 residents reviewed for falls (Resident 51).
Report Facts
Residents reviewed for wounds: 4
Residents reviewed for pressure injuries: 4
Residents reviewed for falls: 2
Wound size: 0.75
Wound size: 0.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN 7 | Accompanied wound observation for Resident 9 | |
| RN 5 | Accompanied wound observation for Resident 9 | |
| LPN 50 | Provided information about low air loss mattress and wound care for Resident 7 | |
| LPN 71 | Provided information about Resident 32's positioning and pressure relief | |
| LPN 75 | Observed Resident 32's ear condition and assisted during interview | |
| Administrator | Indicated use of consulting company for MDS assessments | |
| DON | Indicated no policy for MDS assessments, referred to RAI manual | |
| Wound Nurse | Provided expectations for mattress function and pillow availability | |
| Activity Director | Provided information about bed height for Resident 51 |
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