Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Health & Rehabilitation during CMS and state inspections, most recent first.
Failure to Notify Provider of Weight Gains A resident with heart disease, CHF, edema, and CKD had daily weights ordered with NP notification for specified gains, but the record showed multiple weight increases without documented provider notification. Staff interviews confirmed that when ordered weight parameters were met, the NP or MD should have been notified and the communication documented in the progress notes.
Medication error rate exceeded 5% when an LPN administered two ordered meds by the wrong route for a resident with g-tube orders. The LPN crushed aspirin and ferrous sulfate and gave them orally with pudding, even though current physician orders required both meds to be given via g-tube. The DON stated the resident had previously received crushed meds orally, but that order had been discontinued.
Discontinued eye drops remained in a medication cart for two residents. An LPN found opened, undated bottles of GenTeal Tears and Blink Tears in the cart, with no current matching order or change-of-directions label. Record review showed both eye drop orders had been discontinued, and staff stated completed eye drops should be discarded and discontinued meds removed from the cart.
Bare-Hand Contact With Food During Meal Service: During meal service, a CNA handled a piece of bread with bare hands, removed it from a storage bag, buttered it, folded it, and handed it to a resident, who took a bite before placing it back on the plate. The CNA later stated she probably touched the bread with her bare hands, and the DON stated staff should not touch food with bare hands and should wear gloves when handling food.
Failure to Offer Current Pneumococcal Vaccine: Two residents with significant medical histories, including heart/lung disease, CKD, and DM, had records showing prior pneumococcal immunizations but no consent or declination for the current PCV20 or PCV21 per CDC guidance. The ADON/IP stated the residents had not been offered the updated vaccine, and the DON and Corporate Consultant Nurse could not locate documentation of consent or refusal.
A resident with multiple complex diagnoses did not receive diazepam as ordered, despite documentation on the MAR indicating administration. The narcotic count sheet showed the medication was not removed for two scheduled doses, and staff interviews confirmed the required documentation on the controlled medication log was missing, suggesting the medication was not actually given.
A resident with multiple complex medical conditions was transferred to the hospital on three occasions for evaluation and treatment. Although the resident's representative was notified of each transfer and the bed hold policy was discussed, there was no documentation that written notification of transfer/discharge appeal rights was provided, as confirmed by staff interviews and record review.
Two residents with epilepsy and other conditions were sent to day programs without ensuring their required medications were available at the school or that their care plans had been approved. Facility staff, including an LPN and the Social Services Director, acknowledged that residents were transported before the school had received medications or authorization, resulting in the school requesting the residents be picked up. The facility lacked a policy for managing residents attending outside programs.
The facility failed to prevent resident-to-resident abuse involving four residents with various mental and physical health issues. Despite care plans and interventions, incidents of physical contact and aggression occurred, resulting in minor injuries. The facility's lack of adequate supervision and intervention led to repeated occurrences of abuse, contrary to its policy on protecting residents from harm.
The facility failed to include the right to rescind arbitration agreements within 30 days in the admission documents for three residents. Although the Social Services Director verbally explained this right during admissions, it was not documented in the agreements, and the facility lacked a policy on arbitration.
A facility failed to provide privacy during incontinence care for two residents, as observed when a CNA did not fully pull privacy curtains, leaving residents visible to others. Interviews confirmed the expectation of privacy during care, but the facility lacked a specific policy on this matter.
A resident with multiple health issues experienced an acute medical decline due to the facility's failure to implement ordered interventions. Despite orders for insulin and antibiotics, the necessary treatments were not administered timely, leading to the resident's hospitalization for septic shock. Communication issues and lack of timely intervention contributed to the deficiency.
A facility failed to ensure that a QMA was qualified to perform GJ-tube care for a resident with complex medical needs. The QMA was observed preparing and attaching a new bag of formula, which was not within their allowed duties according to facility policy. The DON confirmed that QMAs were not permitted to perform these tasks, highlighting a deficiency in staff competency and adherence to facility protocols.
The facility failed to ensure proper shift-to-shift narcotic count and reconciliation for two medication carts. Observations revealed missing narcotic counts and reconciliation signatures on several dates in October. LPNs indicated that counts were to be completed during shift changes, but discrepancies were found. The DON confirmed that staff were required to complete the narcotic sheet log after every shift, as per facility policy.
A resident with multiple diagnoses, including hypertension, was prescribed atenolol with specific parameters to hold the medication if certain vital signs were not met. However, the resident received the medication daily without the required monitoring of blood pressure or pulse. An LPN admitted to not checking vital signs before administration, and the DON confirmed the oversight, which was against the facility's medication administration policy.
A facility failed to maintain a medication error rate below 5%, resulting in a 5.56% rate due to improper administration. An LPN administered atenolol without checking required vital signs and gave levothyroxine with other medications, against guidelines. Staff interviews revealed non-adherence to physician orders and facility policy.
A facility failed to administer medications as ordered for five residents, including those with complex medical conditions like cerebral palsy and epilepsy. Medications were found in the medication cart, not administered, yet documented as given in the MAR. The DON confirmed the lapse, which involved an agency nurse, and the facility's policy on documenting missed medications was not followed.
A resident with complex medical needs did not receive a scheduled dose of diazepam due to the facility's failure to secure a refill prescription. Attempts to contact the NP for a renewed prescription were initially unsuccessful, leading to the missed dose. The DON noted that it was the responsibility of nurses to reorder medications and alert management if issues arose.
A resident's controlled substances were not properly accounted for during shift changes, leading to discrepancies in medication counts. The facility failed to document liquid and bottle counts for 35 shift changes, resulting in missing amounts of diazepam and lorazepam for a resident with complex medical needs. Staff interviews revealed confusion and lack of adherence to the facility's policy requiring a physical inventory of controlled medications by two licensed personnel.
The facility failed to provide necessary dental services for three residents with significant medical conditions, as they had not seen a dentist since 2022. The Social Service Director discovered that half of the residents were not enrolled for dental services due to a lack of oversight and audits, despite the facility's policy to assist residents in obtaining dental care.
A resident with anoxic brain damage and tracheostomy status experienced a delay in medical intervention due to staff failing to report an abnormality in the resident's leg immediately. The resident was later found to have a dislocated left hip and a left femur fracture.
Failure to Notify Provider of Resident Weight Gains
Penalty
Summary
The facility failed to consistently notify the nurse practitioner or physician of a resident's weight gain as ordered. Resident 3 had diagnoses including atherosclerotic heart disease, chronic atrial fibrillation, acute on chronic combined systolic and diastolic heart failure, cardiomegaly, ischemic cardiomyopathy, edema, and stage 3 chronic kidney disease. Current orders included bumetanide 2 mg twice daily, metolazone 2.5 mg every Monday, and daily morning weights with notification to the NP for a 3-pound weight gain in 24 hours or 5 pounds in 48 hours. The care plan also directed daily weights and notification of the MD/NP for a 3-pound gain over one day or 5 pounds over 3 days. The resident's records showed multiple weight gains, including 5.6 pounds on 11/6/25, 4.2 pounds on 11/13/25, 4 pounds on 11/15/25, 10 pounds on 11/17/25, 7.8 pounds on 12/6/25, and 3 pounds on 12/8/25, but the clinical record lacked documentation that the physician or NP was notified on those days. During interviews, LPN 12, LPN 7, RN 11, the DON, and the Corporate Nurse Consultant indicated that when ordered parameters were met, the NP or physician should be notified and the notification documented in the progress notes, but they were unable to find such documentation for the resident's weight gains.
Medication Given by Wrong Route
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5% when 2 of 34 observed medication administration opportunities involved medications being given by the wrong route, resulting in a 5.88% medication error rate. During a medication administration observation, an LPN prepared aspirin 81 mg and ferrous sulfate 325 mg for Resident 17 by removing both medications from the medication cards, placing them into a plastic sleeve to be crushed, crushing them with a pill crusher, and mixing them with vanilla pudding before administering them orally. Resident 17’s current physician orders directed aspirin 81 mg daily via gastrostomy tube and ferrous sulfate 325 mg daily via gastrostomy tube. During interview, the LPN stated Resident 17 did not have an order to receive medications orally and that both medications should have been administered via the g-tube. The DON later stated Resident 17 had previously been given crushed medications orally, but that order had been discontinued, and the two medications should have been administered via the resident’s g-tube per physician orders. The facility policy on medication administration required medications to be given as ordered and to follow the six rights of medication administration, including the right route.
Discontinued eye drops remained in medication cart
Penalty
Summary
The facility failed to remove discontinued medications from the Kalor Court medication cart for 2 of 15 residents whose medications were stored in the cart. During observation, an undated and opened bottle of GenTeal Tears eye drops for one resident was found in the top right-hand drawer of the medication cart, even though the resident’s current orders did not include GenTeal Tears and prior orders for that medication had been discontinued. At the same time, an undated opened bottle of Blink Tears eye drops for another resident was also found in the same drawer, with no change-of-directions sticker or writing on the label. The LPN present stated that when the last dose of the eye drops was given, they should have been discarded. Record review showed that the first resident had two prior GenTeal Tears orders that were both discontinued, and the second resident had a current Artificial Tears order while the Blink Tears order had been started for two days and then discontinued. Staff interviews indicated that if an eye drop order was completed, it should be discarded, and if an order changed, a sticker could be placed on the label to reflect the change. An RN stated that once an eye drop order was discontinued, the eye drops should be removed from the medication cart, and the order on the medication administration record should match the order on the medication. The facility policy titled Destruction of Unused Drugs stated that unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed.
Bare-Hand Contact With Food During Meal Service
Penalty
Summary
The facility failed to ensure food was served under safe sanitary conditions during meal service for one resident who received meals orally. During a lunch service observation, a CNA touched a piece of bread inside a storage bag with bare hands, removed the bread from the bag with bare hands, placed it on the resident’s plate, buttered it, then picked up the bread again with bare hands, folded it in half, and handed it to the resident. The resident took a bite of the bread before placing it back on the plate. When interviewed, the CNA stated she did not recall pulling the bread from the plastic bag with her bare hands and said she probably touched the bread with her bare hands when she folded it and handed it to the resident. The DON stated staff should not be touching food with their bare hands and should wear gloves before touching food. The facility policy titled "Serving a Meal" stated to avoid handling unwrapped food items with bare hands and that gloves must be worn if handling the food is necessary.
Failure to Offer Current Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer eligible residents and/or their representatives the current pneumococcal immunization according to CDC guidelines for 2 of 5 residents reviewed. One resident had diagnoses including tracheostomy status, heart failure, obstructive sleep apnea, chronic pulmonary edema, and emphysema. That resident’s immunization record showed a Prevnar 13 (PCV13) dose on 12/11/23, but the record lacked consent or declination for a Prevnar 20 (PCV20) or PCV21 as recommended by the CDC. Another resident had diagnoses including shortness of breath, chronic kidney disease stage 4, and type 2 diabetes mellitus. That resident received a PCV13 on 9/4/18 and a Pneumovax 23 (PPSV23) on 11/28/18 before facility admission. Although a pneumonia vaccination consent signed by the resident’s representative on 11/19/25 referenced PCV13 and PPSV23 and noted the resident had already received the pneumococcal vaccine on 11/28/18, the record lacked consent or declination for a PCV20 or PCV21. The ADON/Infection Preventionist stated the two residents had not been offered PCV20 or PCV21 as far as she knew, and the DON and Corporate Consultant Nurse were unable to find consents or declinations for either vaccine.
Failure to Administer Medication According to Physician Order and Documentation Requirements
Penalty
Summary
A deficiency occurred when a resident with diagnoses including spastic quadriplegic cerebral palsy, dysphagia, and scoliosis did not receive medication as ordered. The resident had a physician's order for diazepam 2.5 mg to be administered four times daily. According to the June Medication Administration Record (MAR), four doses of diazepam were documented as given on a specific date. However, the corresponding narcotic count sheet indicated that the medication was not removed for the morning and noon doses on that date. Interviews with facility staff confirmed that the medication was signed off as administered on the MAR but was not signed out on the controlled medication log, as required by facility policy. Review of the records suggested that the medication may not have actually been administered to the resident, despite documentation to the contrary. Facility policy requires that controlled substances be signed out on the narcotic sheet after administration, which was not done in this instance.
Failure to Provide Written Notification of Transfer/Discharge Appeal Rights During Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of transfer/discharge appeal rights to a resident's representative during three separate hospital transfers. The resident in question had multiple complex medical diagnoses, including cerebral palsy, a left lower leg fracture, failure to thrive, Cauda Equina syndrome, severe intellectual disabilities, osteoarthritis, congenital foot deformities, and diabetes. On three occasions, the resident was transferred to the hospital for evaluation and treatment following incidents such as a left hip fracture, bruising and swelling of the left hand, wrist, and shoulder, and shortness of breath unresponsive to treatment. In each instance, while the resident's representative was notified of the transfer and the facility's bed hold policy was discussed, there was no documentation that written notification of the resident's transfer/discharge appeal rights was provided. Interviews with facility staff, including the Social Services Director, LPNs, the DON, and the Regional Nurse Consultant, confirmed that the appeal rights information was not discussed or provided in writing to the resident's representative during these transfers. The facility's policy required preparation of a transfer form and documentation of notifications, but did not specify the requirement to provide written appeal rights notification. The clinical record and staff interviews consistently lacked evidence of compliance with this regulatory requirement.
Failure to Ensure Medication and Care Plan Approval for Residents Attending Day Programs
Penalty
Summary
The facility failed to follow physician orders and ensure proper continuation of care for two residents who were transported to day programs. Staff sent both residents to school without confirming that the school had received the required medications or that the residents' care plans had been approved. Interviews revealed that an LPN sent one resident to school without checking if the medications were at the school, and the school immediately called for the resident to be picked up as he was not approved to attend. The DON confirmed that although documents and medication orders were sent to the school, the medication supply had not yet been delivered, and staff sent a resident to school before these requirements were met. The Administrator and CNA also confirmed that residents were sent to school prematurely and had to be retrieved after the school notified the facility of the oversight. Resident B had diagnoses including epilepsy, convulsions, lack of coordination, and contracture of the right ankle, with orders for multiple anti-seizure medications to be provided during day services. Resident C had diagnoses of autism, epilepsy, and anxiety, with similar orders for anti-seizure medications. Both residents had care plans indicating a risk for seizures and required medications as ordered. Facility staff and the Social Services Director acknowledged that residents were sent to school without the necessary medications on hand and before care plan approval, contrary to the instructions from the school nurse. The facility did not have a policy in place regarding the process for residents attending school outside the facility.
Inadequate Supervision Leads to Resident-to-Resident Abuse
Penalty
Summary
The facility failed to provide adequate supervision and intervention to prevent physical resident-to-resident abuse involving four residents. Resident 43, who has a history of spastic quadriplegic cerebral palsy, PTSD, depression, and other mental health issues, exhibited aggressive behaviors towards other residents. Despite having care plans in place to manage her behaviors, Resident 43 was involved in multiple incidents where she made physical contact with other residents, including scratching and hitting. These incidents were documented in progress notes and resident-to-resident investigations, indicating a pattern of behavior that was not effectively managed by the facility. Resident 21, diagnosed with spastic quadriplegic cerebral palsy and profound intellectual disabilities, also exhibited aggressive behaviors. She was involved in altercations with other residents, resulting in physical contact and injuries. The care plan for Resident 21 included interventions to manage her aggression, but the facility failed to prevent her from engaging in unsafe interactions with other residents. Similarly, Resident 19, with severe intellectual disabilities and impulse disorder, was involved in incidents where she made contact with other residents, resulting in scratches and other minor injuries. Resident 44, who is cognitively intact but diagnosed with anxiety disorder and major depressive disorder, was involved in an incident with Resident 43. The interaction resulted in physical contact between the two residents, leading to minor injuries. Despite the presence of staff in the vicinity, the incident occurred quickly and without warning, highlighting the facility's failure to provide adequate supervision and intervention to prevent such occurrences. The facility's policy on abuse and neglect emphasizes the protection of all residents from harm, yet the repeated incidents of resident-to-resident abuse indicate a deficiency in adhering to this policy.
Failure to Include Rescission Right in Arbitration Agreements
Penalty
Summary
The facility failed to provide an arbitration agreement that included the right for residents or their representatives to rescind the agreement within 30 days of signing. This deficiency was identified for three residents who were admitted after February 1, 2024. During the entrance conference, the Administrator confirmed that arbitration agreements were part of the admission packet. However, upon review, the admission agreements for Residents 26, 44, and 97 did not mention the right to rescind the arbitration agreement within 30 days. Interviews with the Administrator and the Social Services Director (SSD) revealed that while the SSD explained the arbitration process and the right to rescind verbally during admissions, this information was not documented in the written agreement. The Administrator acknowledged that the admission agreement lacked this critical information and confirmed that the facility did not have a policy on arbitration. This oversight led to the deficiency being cited during the survey.
Failure to Ensure Privacy During Incontinence Care
Penalty
Summary
The facility failed to ensure privacy during incontinence care for two residents, leading to a deficiency in maintaining resident dignity. During a random observation, a CNA was seen providing care to a resident without pulling the privacy curtain, making the resident visible from the room door window. The CNA admitted to not pulling the curtain due to being in a hurry. The resident's clinical record indicated a need for personal assistance with care, and the MDS assessment confirmed the resident's dependency on staff for various personal care tasks. In another instance, the same CNA assisted another resident in a wheelchair to his room and partially pulled the privacy curtain, leaving the resident visible to other occupants in the room during incontinence care. Interviews with other CNAs and the DON confirmed that privacy should be provided during resident care, but the facility lacked a specific policy on this matter. The clinical record of the second resident also indicated a need for assistance with personal care, and the MDS assessment showed dependency on staff for personal hygiene and dressing.
Failure to Implement Ordered Interventions for Resident
Penalty
Summary
The facility failed to implement ordered interventions for a resident experiencing an acute medical decline, leading to a deficiency. Resident 18, who had multiple diagnoses including spastic quadriplegic cerebral palsy, severe intellectual disabilities, idiopathic epilepsy, hyperglycemia, and chronic kidney disease, was dependent on staff for all care needs. The resident's care plan included enhanced barrier precautions due to a suprapubic catheter. Despite a nurse practitioner's order for insulin and a hemoglobin A1C test following a high blood glucose level, the test was not performed, and there was no documentation of a required blood glucose check. On a subsequent day, the resident's condition worsened, with elevated blood glucose levels and signs of respiratory distress. The nurse practitioner ordered immediate interventions, including antibiotics and additional insulin. However, the antibiotic Rocephin was not administered due to the unavailability of a 1-inch needle, and the nurse was occupied with other tasks. The resident's condition continued to deteriorate, requiring increased oxygen support, and eventually, the resident was transferred to a hospital where they were intubated and diagnosed with septic shock. Interviews with facility staff revealed communication issues and a lack of timely intervention. The nurse practitioner emphasized the critical nature of administering antibiotics at the first signs of sepsis, but the delay in treatment contributed to the resident's rapid decline. The facility's policy required documentation of changes in a resident's condition, but the failure to administer ordered treatments and document vital signs as required led to the deficiency.
Unqualified Staff Performing GJ-Tube Care
Penalty
Summary
The facility failed to ensure that staff were qualified to perform GJ-tube care for a resident, identified as Resident 42, who was reviewed for feeding tubes. Resident 42 had multiple diagnoses, including anoxic brain damage, gastrostomy malfunction, and a disorder of the autonomic nervous system. The resident was prescribed Pedia-Sure Enteral Formula through a gastrojejunostomy (GJ-tube) with specific instructions for administration. However, during an observation, a Qualified Medication Aide (QMA) was seen performing GJ-tube care, including preparing and attaching a new bag of formula, which was not within the scope of their orientation or allowed duties according to facility policy. The QMA was observed flushing the GJ-tube with tap water, which initially did not flow properly, but she expressed no concern over the slow drainage. The facility's Director of Nursing (DON) later confirmed that QMAs were not permitted to hang new bags of formula or change the tubing, contradicting the actions observed. The facility's QMA Orientation document also indicated that QMAs were not trained for these tasks. This discrepancy between the facility's policy and the QMA's actions led to the deficiency noted in the report.
Failure in Narcotic Count and Reconciliation
Penalty
Summary
The facility failed to ensure proper shift-to-shift narcotic count and reconciliation for two of the five medication carts reviewed, specifically on Kalor Hall and another hall. During a medication storage observation on Kalor Hall, it was found that the Narcotic Sheet Log/Tracking Form lacked shift-to-shift count and reconciliation signatures for several dates in October 2024. These dates included missing narcotic card, liquid, and/or bottle counts, as well as missing reconciliation signatures. LPN 4, who was present during the observation, indicated that the narcotic count was supposed to be completed by the oncoming and offgoing nurses during shift changes. Similarly, during a medication storage observation on another hall, the Narcotic Sheet Log/Tracking Form also lacked shift-to-shift count and reconciliation signatures for certain dates in October 2024. The Director of Nursing (DON) confirmed that staff were required to complete the narcotic sheet log after every shift. The facility's current policy on Controlled Medication Storage, provided by the DON, stated that a physical inventory of all controlled medications should be conducted by two licensed/certified personnel at the change of custody and documented accordingly.
Failure to Monitor Vital Signs Before Medication Administration
Penalty
Summary
The facility failed to ensure the monitoring of vital signs parameters as ordered for a resident during medication administration. Resident 27, who has diagnoses including autistic disorder, essential hypertension, hypothyroidism due to medicaments, and iron deficiency anemia, was prescribed atenolol, an antihypertensive medication. The physician's order specified that the medication should be withheld if the resident's systolic blood pressure was less than 110 mmHg or if the heart rate was less than 55. However, the Medication Administration Report for October 2024 showed that the resident received atenolol daily from October 1 to October 21 without the required monitoring of blood pressure or pulse. During an observation on October 21, an LPN was seen administering atenolol to Resident 27 without checking the vital signs beforehand. In subsequent interviews, the LPN admitted to not checking the resident's blood pressure or heart rate before administering the medication. The Director of Nursing confirmed that vital signs were not completed as per the physician's order, and the MDS Coordinator acknowledged the necessity of checking medication parameters before administration. The facility's policy on medication administration, which mandates adherence to physician orders, was not followed in this instance.
Medication Administration Errors Result in 5.56% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 5.56% due to improper medication administration. During an observation, an LPN was seen preparing and administering atenolol to a resident without checking the required blood pressure and heart rate parameters, as specified in the physician's orders. The LPN admitted to not checking these vital signs before administering the medication. Additionally, the LPN administered levothyroxine along with eleven other medications, including famotidine and ferrous sulfate, contrary to guidelines that recommend levothyroxine be taken separately. Interviews with facility staff, including another LPN, the DON, and the MDS Coordinator, revealed a lack of adherence to physician orders and medication administration guidelines. The DON confirmed that there was no order to administer levothyroxine with other medications, and the MDS Coordinator noted that medication parameters should be followed as per the physician's orders. The facility's policy on medication administration requires adherence to written orders, but this was not followed in the observed instances. The facility's medication administration practices were reviewed in previous months without any recommendations for changes, indicating a potential oversight in identifying and addressing these issues.
Medication Administration Failure in LTC Facility
Penalty
Summary
The facility failed to ensure that residents received medications as per physician orders, affecting five residents. The clinical records for Residents E, F, H, J, and K indicated that their prescribed medications were not administered as ordered. For instance, Resident E's medications, including baclofen and ferrous sulfate, were found in the medication cart instead of being administered. Similarly, Resident F's medications, such as magnesium oxide and valproate, were also found in the cart, despite being documented as given in the Medication Administration Record (MAR). The deficiency was discovered when a progress note indicated that the noon medications for these residents were found in the top drawer of the medication cart, suggesting they were not administered. The Director of Nursing (DON) confirmed that the medications were not given during the specified time frame by an agency nurse. The facility's Medication Administration policy requires that any missed or refused medication be documented as such in the electronic MAR, which was not adhered to in this case. The residents involved had complex medical histories, including conditions such as spastic quadriplegic cerebral palsy, epilepsy, and intellectual disabilities, which necessitated strict adherence to medication schedules. The failure to administer medications as ordered was not documented correctly, as the MAR inaccurately indicated that the medications were given. This discrepancy highlights a significant lapse in the facility's medication administration process, as confirmed by interviews with the DON and the Administrator.
Medication Availability Failure for a Resident
Penalty
Summary
The facility failed to ensure the availability of a resident's medication, resulting in a missed dose for one of the residents reviewed for medication availability. Resident G, who has a complex medical history including spastic quadriplegic cerebral palsy, cardiomegaly, and anxiety disorder, did not receive a scheduled dose of diazepam 15 mg on the morning of 9/7/24. The medication was not administered because the facility had not secured a refill prescription, and the pharmacy required a new prescription from the provider. Attempts to contact the Nurse Practitioner (NP) for a renewed prescription were initially unsuccessful, leading to the missed dose. The Director of Nursing (DON) indicated that it was the responsibility of all nurses to reorder medications as needed and to alert management if there were issues. The facility's policy on medication administration, dated 6/17/21, states that medications should be administered as prescribed and in accordance with written orders. Despite this policy, the staff's inability to promptly secure a prescription refill resulted in the medication error. The DON acknowledged that there had been two incidents of medication errors within the past 30 days, and Resident G was one of the six residents affected by these errors.
Controlled Substance Reconciliation Failure
Penalty
Summary
The facility failed to ensure that a resident's controlled substances were properly accounted for and reconciled during shift changes. Resident B, who has a history of anoxic brain damage, cognitive communication deficit, and other medical conditions, had medication orders for lorazepam and diazepam to manage anxiety and muscle spasms. However, during a controlled substance reconciliation, it was discovered that the narcotic log/tracking form for the month of July did not document the counts of liquids or bottles for 35 shift changes, indicating a lack of proper documentation and accountability. The issue was further highlighted when a discrepancy was found in the diazepam count for Resident B. A pharmacy packing slip indicated that 60 mls of diazepam was delivered, but during a count, only 45 mls were found in the bottle. Additionally, the lorazepam count was also incorrect, with 22 mls remaining instead of the expected 28.4 mls. Interviews with staff revealed that the shift change form was not being completed correctly, and there was confusion and lack of communication among the staff regarding the narcotic counts. The facility's policy required a physical inventory of all controlled medications by two licensed personnel at the change of custody, but this was not adhered to. The Administrator and other staff members acknowledged the discrepancies and the failure to properly document and track the controlled substances. The facility was still investigating the missing amounts of lorazepam and diazepam for Resident B, indicating ongoing issues with medication management and accountability.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to ensure that residents were receiving necessary dental services, as evidenced by the lack of dental care for three residents with significant medical conditions. Resident C, who has spastic quadriplegic cerebral palsy and profound intellectual disabilities, had not seen a dentist since May 2022, despite being dependent on staff for oral hygiene and having obvious dental issues. Similarly, Resident E, with similar medical conditions, had not received dental care since March 2022, even though she required sedation for a Full Mouth Debridement due to severe dental issues. Resident F, also with spastic quadriplegic cerebral palsy and profound intellectual disabilities, had not had a dental visit since May 2022, despite needing regular dental care. The deficiency was further highlighted during an interview with the Social Service Director, who revealed that the new dental services provider, which took over in early 2023, was responsible for enrolling residents for dental services. However, an audit revealed that half of the residents were not enrolled, and the Social Service Director had not conducted audits to ensure residents were receiving dental services. The facility's policy on dental services was not effectively implemented, leading to the failure to provide necessary dental care for the residents.
Failure to Report Changes in Resident's Condition
Penalty
Summary
The facility failed to ensure changes in a resident's condition were reported immediately to the charge nurse. Resident B, who had diagnoses including anoxic brain damage and tracheostomy status, was observed to have an abnormal left leg during a shower by an Activity Assistant. Despite noticing the abnormality, the Activity Assistant did not report it immediately to the nurse, as she did not work with the resident often and the resident did not cry during the shower. Later, when repositioning the resident, the Activity Assistant noticed the resident cried out in pain and reported it to LPN 21, who initially attributed the behavior to the resident's medication schedule and did not take immediate action to assess the leg further. LPN 21 eventually assessed Resident B's leg after the resident continued to show signs of distress and consulted with another LPN. The resident was later sent to the emergency room, where it was confirmed that he had a dislocated left hip and a left femur fracture. The delay in reporting and assessing the resident's condition led to a significant delay in treatment. The facility's policy on Notification of Changes was not followed, as the staff did not report the significant change in the resident's physical condition immediately. Interviews with the staff, including the Activity Assistant and LPN 21, revealed that there was a misunderstanding and miscommunication regarding the resident's symptoms and the urgency of the situation. The Director of Nursing acknowledged that the nurse should have been informed about the abnormality in the resident's leg earlier in the day. The facility's failure to adhere to its policy on reporting changes in a resident's condition resulted in a delay in medical intervention for Resident B.
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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 Wabash
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Ridge Rehabilitation Centre | 2 mi | ★★★★★ | 4 | 0 |
| Waters Of Wabash Skilled Nursing Facility West | 2.8 mi | ★★★★★ | 8 | 0 |
| Wellbrooke Of Wabash | 2.8 mi | ★★★★★ | 12 | 0 |
| Waters Of Wabash Skilled Nursing Facility East The | 2.9 mi | ★★★★★ | 5 | 0 |
| Rolling Meadows Health Care Center | 8.8 mi | ★★★★★ | 0 | 0 |
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