Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vernon Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A facility failed to obtain a timely physician order for a CPAP machine for a resident with respiratory failure and COPD. Despite the resident's care plan and assessments indicating CPAP use, no physician order was found. The DNS confirmed the absence of documentation, contrary to the facility's policy requiring such an order.
A resident with heart failure experienced a significant weight gain, but the facility failed to notify the physician as required by the care plan. Despite a documented weight gain of 4.6 pounds, there was no nursing note or documentation of physician notification on the day of the weight gain. The APRN was informed the following day, and the facility could not provide a heart failure management policy.
A resident with cerebral infarction and dysphagia experienced significant weight loss over several months, but the facility failed to notify the dietician as required by policy. Despite a weight loss of over 8% from March to June, the dietician was only informed in late July. Nursing staff were responsible for monitoring and reporting weight changes but did not do so in a timely manner, leading to a deficiency in care.
The facility failed to update care plans for two residents, one experiencing significant weight loss and another on anticoagulant therapy. A resident with cerebral infarction and dysphagia lost a substantial amount of weight over several months without the care plan being revised. Another resident on warfarin for atrial fibrillation had their anticoagulation focus prematurely resolved, leading to a lack of monitoring for potential adverse effects.
The facility failed to follow physician orders for a resident requiring arm protectors and did not document weekly weights for another resident with significant weight loss. Observations showed the absence of arm protectors, and interviews revealed inconsistencies in their application. Additionally, weights were marked as taken without proper documentation, indicating a breakdown in the recording process.
A facility failed to provide a resident with prescribed range of motion (ROM) exercises due to inaccurate documentation and communication. The resident, with a fractured humerus and congestive heart failure, required the removal of a sling three times daily for active ROM exercises, as per physician's orders. However, the Treatment Administration Record did not reflect this requirement, and staff were not prompted to perform the exercises due to an incorrect order entry.
The facility failed to implement timely interventions for two residents experiencing significant weight loss and hydration issues. One resident with dysphagia experienced severe weight loss without adequate response from the dietician or APRN. Another resident on IV hydration had inconsistent documentation of intake and output, despite physician orders. The facility's policies on weight change reporting and intake/output documentation were not followed, leading to deficiencies in care.
A resident was mistakenly administered digoxin upon readmission to a facility after hospitalization for digoxin toxicity. The error occurred due to a lack of awareness by the RN entering medication orders, incomplete documentation of the drug regimen review, and the facility's policy not requiring double-checking of re-admission orders during the night shift. The pharmacist identified this as a major medication error, indicating a deficiency in the transition of care.
A facility failed to coordinate and document hospice services for a resident admitted for comfort care. The resident's clinical record lacked essential hospice documentation, including a signed hospice election form, physician certifications, and a detailed care plan. Communication with the hospice provider was primarily verbal, and the facility did not have a policy for hospice care coordination, leading to significant gaps in the resident's care plan.
A resident with vascular dementia and significant cognitive impairment sustained a left hand fracture and eye bruising, which were not reported to the state agency in a timely manner. Despite the resident's self-report of a fall, facility staff doubted this due to the resident's inability to rise independently. The facility's policies required immediate reporting of such injuries, but this protocol was not followed, leading to a deficiency in timely reporting and investigation.
A resident with a Halal dietary requirement was not provided appropriate meals by the facility, despite the care plan indicating this need. The dietician and Director of Dietary were unaware of the requirement, leading to the resident's family bringing in Halal food. The facility's policy on Cultural Competent Care was not followed.
Failure to Obtain Timely Physician Order for CPAP Machine
Penalty
Summary
The facility failed to obtain a timely physician order for the use of a continuous positive airway pressure (CPAP) machine for a resident diagnosed with respiratory failure with hypoxia and COPD. The resident was identified as alert and oriented and was using a CPAP machine upon admission. Despite the resident's care plan and admission assessments indicating the use of a CPAP machine, a review of the clinical records revealed no physician order for its use. Interviews and record reviews with the Director of Nursing Services (DNS) confirmed the absence of documentation for a CPAP machine order. The facility's Noninvasive Ventilation Policy requires obtaining a physician order for CPAP use, which was not adhered to in this case. The DNS was unable to provide an explanation for the lack of an order, highlighting a deficiency in following the facility's policy for noninvasive ventilation.
Failure to Notify Physician of Significant Weight Gain
Penalty
Summary
The facility failed to ensure the clinical record for a resident with heart failure was complete and accurate, specifically regarding the notification of a physician about a significant weight gain. The resident, who was alert and oriented, was on diuretics and had a care plan in place to monitor weight gain and edema, with instructions to notify the physician or APRN of any weight gain exceeding three pounds in 24 hours. Despite a documented weight gain of 4.6 pounds between two consecutive days, there was no nursing note or documentation indicating that the physician or APRN was notified on the day the weight gain was identified. Interviews and record reviews revealed that the APRN was only notified the day after the weight gain was documented, and the Director of Nursing Services confirmed the lack of documentation for the required notification. Additionally, the facility was unable to provide a policy on heart failure management, and their Documentation in Medical Record policy mandates accurate and timely documentation of residents' experiences. This deficiency highlights a failure in adhering to physician orders and maintaining accurate medical records.
Failure to Notify Dietician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the dietician of a significant weight loss in a resident, leading to a deficiency in care. Resident #96, who had diagnoses including cerebral infarction, dysphagia, and cholecystitis, experienced a notable weight loss over several months. Despite the facility's policy requiring that any verified weight change of 5 lbs. or greater be reported to both the dietician and the practitioner, the dietician was not informed of the resident's weight loss from March 2024 through June 2024. The resident's weight decreased from 141.2 lbs. to 128.8 lbs. over this period, representing an 8.78% loss, yet the dietician was only notified on July 29, 2024. Interviews with facility staff revealed that nursing was responsible for monitoring weights and notifying the dietician and provider of any concerns. However, Registered Nurse #5 was unable to confirm that the dietician had been notified before July 29, 2024. The Advanced Practice Registered Nurse (APRN) was aware of the weight loss but did not deem medical consultation necessary. The dietician confirmed that she was not informed of the weight loss until late July. This oversight in communication and adherence to policy resulted in a delay in addressing the resident's nutritional needs effectively.
Failure to Revise Care Plans for Weight Loss and Anticoagulation
Penalty
Summary
The facility failed to revise the Resident Care Plan (RCP) for Resident #96 following significant weight loss. Resident #96, diagnosed with cerebral infarction, dysphagia, and right-sided hemiplegia and hemiparesis, experienced a notable weight loss over several months. Despite an initial nutritional evaluation and a care plan that included dietary interventions, the RCP was not updated to address the weight loss. The dietician was only notified of the weight loss pattern months later, indicating a lack of timely intervention and reassessment as per the facility's Weight Assessment and Intervention Policy. Additionally, the facility did not include an anticoagulation focus in the RCP for Resident #706, who was on warfarin for atrial fibrillation. The RCP failed to reflect the anticoagulant therapy, and a dose was held without proper documentation. An LPN resolved the anticoagulation focus prematurely due to a misunderstanding of the resident's medication orders. This oversight was contrary to the facility's policy on high-risk medications, which requires monitoring for adverse effects and risks associated with anticoagulants.
Failure to Follow Physician Orders and Document Resident Care
Penalty
Summary
The facility failed to adhere to a physician's order for Resident #46, who was diagnosed with dementia and other mental health conditions, to wear bilateral arm protectors at all times. Despite the care plan and nurse aid care card indicating the need for these protectors, observations on multiple occasions revealed that the resident was not wearing them. Interviews with staff indicated a lack of clarity and consistency in applying the arm protectors, and the facility did not have a policy in place for their use. Additionally, the Treatment Administration Record inaccurately reflected that the protectors were applied when they were not. For Resident #96, who had a history of cerebral infarction and dysphagia, the facility failed to document weekly weights as ordered by an Advanced Practice Registered Nurse. The resident's care plan required regular weight monitoring due to significant weight loss, but documentation was missing for several weeks. Interviews with nursing staff revealed a breakdown in the process of recording weights, with weights being marked as taken without actual documentation in the electronic medical record. The facility's policy required weights to be recorded in both the electronic medical record and the unit's weight record chart, which was not followed. The deficiencies highlight a lack of adherence to physician orders and facility policies, resulting in inadequate monitoring and documentation of resident care. The absence of arm protectors for Resident #46 and the failure to document weights for Resident #96 indicate systemic issues in communication and process adherence within the facility.
Failure to Provide Prescribed Range of Motion Exercises
Penalty
Summary
The facility failed to provide appropriate range of motion (ROM) exercises for a resident with limited mobility and specific medical needs. The resident, who had a fracture of the right humerus and congestive heart failure, was cognitively intact but had very limited mobility and required moderate assistance. The resident's care plan and physician's orders specified that the right upper extremity should remain in a sling at all times, but the sling should be removed three times daily to perform active range of motion (AROM) exercises for the right elbow, wrist, and fingers. However, observations and interviews revealed that the sling was not being removed as required, and the resident was not receiving the prescribed AROM exercises. The deficiency was further compounded by a lack of proper documentation and communication within the facility. The Treatment Administration Record (TAR) did not direct the nursing staff to remove the sling and provide AROM exercises, and the order was inaccurately entered into the computer system. Interviews with facility staff, including a Licensed Practical Nurse (LPN) and the Director of Nurses, confirmed that the nursing staff was not prompted to provide the necessary AROM exercises due to the incorrect entry of the order. Additionally, the facility was unable to provide a policy for Physical Therapy when requested.
Deficiencies in Nutrition and Hydration Management
Penalty
Summary
The facility failed to implement necessary interventions for two residents experiencing issues with nutrition and hydration. One resident, diagnosed with cerebral infarction, cholecystitis, and dysphagia, experienced significant weight loss over several months. Despite being on a mechanically altered diet and having a care plan that included nutritional assessments and supplements, the resident's weight continued to decline. The dietician and APRN failed to address the resident's significant weight loss and below-normal albumin levels in their progress notes, and interventions were not timely implemented. Another resident, diagnosed with dementia, malnutrition, and small bowel obstruction, was on intravenous hydration due to poor oral intake and hypernatremia. The facility failed to consistently document the resident's intake and output, with numerous omissions in the records. Despite physician orders for IV hydration, the intake and output worksheets often lacked documentation of IV intake, output, and 24-hour totals. The DNS acknowledged the missing documentation and stated that both oral and IV intake, as well as output, should be recorded, but could not explain the omissions. The facility's policies required that any significant weight change be reported to the dietician and practitioner, and that intake and output be documented for residents on IV therapy. However, these policies were not followed, leading to deficiencies in the care provided to the residents. The lack of timely interventions and proper documentation contributed to the residents' ongoing nutritional and hydration issues.
Medication Error Following Hospital Readmission
Penalty
Summary
The facility failed to ensure that a resident, who was previously hospitalized for digoxin toxicity, did not receive the same high-risk medication upon readmission. The resident, who had diagnoses including atrial fibrillation and congestive heart failure, was discharged from the hospital with instructions to stop taking digoxin. However, a physician's order was entered to administer digoxin, and it was given to the resident the following morning. The error occurred because the Registered Nurse (RN) responsible for entering the medication orders into the electronic medical record (EMR) was unaware of the resident's recent hospitalization for digoxin toxicity. The RN completed a drug regimen review (DRR) with a covering Nurse Practitioner (NP) but did not document the completion of the DRR in the nursing progress notes. The Assistant Director of Nursing Services (ADNS) co-signed the nursing admission assessment but did not perform the DRR, assuming it was done by the RN. The facility's policy did not require re-admission orders to be double-checked during the night shift, and the error was only identified during the morning report. The facility's pharmacist identified the administration of digoxin as a major medication error, highlighting a deficiency in the transition of care. The Licensed Practical Nurse (LPN) who administered the medication did so based on the EMR's directive and did not recall the specific circumstances. The facility's medication policy required all medications to be ordered by a physician and dispensed using the correct protocol, but a policy for Drug Regimen Review was not provided.
Lack of Coordination with Hospice Services
Penalty
Summary
The facility failed to effectively collaborate and communicate with the contracted hospice provider for a resident who was admitted for comfort care and hospice services. The resident, who had diagnoses including major depressive disorder, dementia, and anxiety, was admitted with a directive to notify hospice of any changes in condition. However, the facility did not have a comprehensive hospice care plan in place, and the resident's care plan lacked coordination with the hospice provider. The clinical record for the resident was missing critical hospice documentation, such as a signed hospice election form post-admission, initial and recertification physician certifications, and a detailed hospice care plan. The facility's social worker assumed responsibility for coordinating hospice services but failed to ensure proper documentation and communication with the hospice team. The Director of Nursing Services (DNS) was unaware of the hospice provider's involvement and the frequency of visits, indicating a lack of coordination and documentation. Interviews with facility staff revealed that communication with the hospice provider was primarily verbal, and there was no clear process for documenting hospice visits and care plans. The facility did not have a policy for hospice care coordination, leading to significant gaps in the resident's clinical record and care plan. Despite attempts to contact the hospice nurse, the facility was unable to provide a comprehensive account of the hospice services provided to the resident.
Failure to Timely Report Injuries of Unknown Source
Penalty
Summary
The facility failed to report injuries of unknown source to the state agency (SA) in a timely manner for a resident diagnosed with vascular dementia, osteoarthritis, and a fracture of the left hand. The resident was significantly cognitively impaired and required substantial assistance with daily activities. The resident's care plan identified a risk for skin injuries and falls, with interventions to inspect the skin daily and encourage the resident to call for assistance. Despite these measures, the resident was found with bruising on the left eye and hand, and later diagnosed with a fracture of the left hand. The facility's APRN noted the bruising and ordered an x-ray, which confirmed the fracture. The resident self-reported a fall, but due to their advanced dementia and inability to rise independently, the APRN doubted the fall as the cause of the injuries. The DNS acknowledged that the injuries were of unknown source and should have been reported as a possible allegation of mistreatment, but this was not done in a timely manner. The facility's policy required immediate reporting of such injuries to the SA, but this protocol was not followed. Interviews with facility staff, including the Medical Director and DNS, revealed uncertainty about the cause of the injuries and a lack of timely investigation and reporting. The facility's policies on abuse and unexplained injuries directed that injuries of unknown source should be reported and investigated according to abuse procedures, but these steps were not adequately executed. The DNS, who was not in the role at the time of the incident, could not provide a reason for the delay in reporting the injuries to the SA.
Failure to Provide Halal Diet for Resident
Penalty
Summary
The facility failed to ensure that the dietary needs of a resident, who followed a Halal cuisine diet, were met. The resident was admitted with diagnoses including cerebral infarction, dysphagia, and right-sided hemiplegia and hemiparesis. Despite the Resident Care Plan indicating the need for Halal cuisine, the dietician did not identify or accommodate this dietary requirement in the initial Nutritional Evaluation. Observations revealed that the resident was served meals inconsistent with Halal dietary practices, such as pumpkin dump cake and egg salad sandwiches, and the meal ticket incorrectly noted a vegetarian diet. Interviews with facility staff, including the Director of Dietary and the dietician, revealed a lack of awareness regarding the resident's Halal dietary needs. The Director of Dietary stated that she could have accommodated the request if she had been informed. The dietician also acknowledged being unaware of the requirement, despite the care plan's indication. The social worker confirmed that the resident's family brought in Halal food every evening because the resident did not consume the facility-provided meals. The facility's policy on Cultural Competent Care was not followed, as the resident's cultural dietary needs were not incorporated into the care plan or meal preparation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Vernon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Fox Hill | 2.3 mi | ★★★★★ | 12 | 0 |
| Woodlake At Tolland | 3.5 mi | ★★★★★ | 20 | 0 |
| Manchester Rehabilitation And Healthcare Center | 6.9 mi | ★★★★★ | 17 | 0 |
| Westside Care Center | 7.3 mi | ★★★★★ | 2 | 0 |
| Touchpoints At Manchester | 7.3 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.