Inspection Reports for
Vernon Health & Rehabilitation

This citation relates to Intake 1753947.3.

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.

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.

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).

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.

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.

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.

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.

Complaint IN00441262 was substantiated with federal/state deficiencies cited at F726 and F755 related to medication administration and medication availability.

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 IN00441262 related to medication administration and availability errors.

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.

This citation relates to Complaint IN00438619 regarding pharmaceutical services and Complaints IN00437378 and IN00437511 regarding dental services.

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.

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.

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 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.

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.

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.

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.

This citation relates to Complaint IN00432997 regarding the improper use of physical restraints on Resident B.

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.

Complaint IN00432997 was substantiated with federal/state deficiencies cited at F604 related to physical restraints. Complaint IN00433003 had no deficiencies cited.

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.

This citation relates to Complaint IN00425880.

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.

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.

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 IN00415964 resulted in federal/state deficiencies related to the allegations. Complaint IN00416015 had no deficiencies related to the allegations.

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.

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.

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.

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.

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.