Above average — CMS composite of the measures below.
A standard survey is most likely before 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 Advanced Rehabilitation And Healthcare Of Vernon during CMS and state inspections, most recent first.
A nurse failed to administer medications as ordered and left multiple medication cups with pills on a resident's bedside table for self-administration, contrary to facility policy. The resident, who had multiple complex medical conditions, reported that this was a routine practice. Staff interviews confirmed that medications should not be left unattended and that the facility policy requires direct observation of medication administration.
The facility did not obtain food from approved or satisfactory sources and failed to store, prepare, distribute, or serve food according to professional standards, as observed by surveyors.
Discharge Documentation and Notice Deficiency: A resident with MI, AKI, sepsis, dehydration, and acute pulmonary edema was discharged to hospice because pain could not be controlled, but the record lacked documentation of the discharge, the MD basis for the discharge, and the specific needs that could not be met in the facility. RN and DON interviews confirmed the discharge instructions and required discharge details were not documented, and the required written notice with appeal rights was not shown in the record.
A CNA failed to change gloves and perform hand hygiene while providing incontinence care to a resident with frequent incontinence and physical debility. The CNA handled clean briefs and disposed of waste with visibly soiled gloves, contrary to the facility's infection control policy and standard precautions. The lapse was acknowledged by the CNA and confirmed by the DON during interviews.
A facility failed to invite a resident and their representative to care plan meetings, including comprehensive and quarterly reviews. The resident, with a BIMS score of 00 and conditions like atherosclerotic heart disease and vascular dementia, was not involved in care planning, and no documentation explained their absence. The Social Worker, responsible for arranging these meetings, was out sick, leading to the oversight. The facility's policy requires resident and representative participation, which was not followed.
The facility failed to provide individualized activity programming for two residents, leading to a lack of engagement and potential isolation. One resident, with multiple health issues, had a care plan that did not address her preference for in-room activities, while another resident with cognitive impairment had no activity programming plan. The Activity Director did not document individual activities or maintain a list of residents needing in-room visits, highlighting a deficiency in supporting residents' activity needs.
The facility failed to maintain complete and accurate medical records for eight residents, leading to discrepancies in physician orders and Out of Hospital - Do Not Resuscitate (OOH-DNR) forms. A resident did not have a completed order for dialysis, and several residents had incomplete OOH-DNR forms missing critical information such as the physician's signature date, printed name, and license number. Interviews revealed a lack of clear procedures and oversight in handling these forms.
A facility failed to ensure accurate MDS documentation for a resident, incorrectly indicating the presence of a feeding tube. The resident, with a history of cerebral infarct, hypertension, and atrial fibrillation, was on a mechanical soft diet with no feeding tube orders. The MDS Coordinator admitted to a documentation error, and the DON emphasized the importance of accurate assessments as per the RAI Manual.
An RN left a medication cart unlocked and unattended in a hallway while administering medications to a resident, contrary to facility policy. The DON confirmed that medication carts should be locked when not in use. This oversight was attributed to the RN being busy and nervous during the survey.
A CNA failed to follow proper hand hygiene protocols during incontinence care for a resident with muscle weakness, hemiplegia, and diabetes, leading to a potential risk of cross-contamination. The CNA did not sanitize her hands between glove changes, despite understanding the importance of this practice. The DON confirmed that staff are expected to adhere to standard precautions, including hand hygiene, as outlined in the facility's policy.
Medications Left Unattended and Not Administered per Physician Orders
Penalty
Summary
A deficiency was identified when a nurse failed to administer medications to a resident according to physician orders and left multiple medication cups containing tablets and capsules on the resident's bedside table for the resident to take at her discretion. Observations revealed that the resident, who had a complex medical history including right below knee amputation, muscle weakness, bipolar disorder, acute kidney failure, and peripheral vascular disease, had several medication cups with pills on her bedside table. The resident stated that nurses routinely left her medications in this manner so she could take them when she wanted, and that all the medications present were from that morning. Further observations on a subsequent day found additional medication cups with pills left unattended in the resident's room while she was not present. Interviews with nursing staff, including LVNs and RNs, confirmed that the facility's expectation was for staff to observe residents taking their medications and not to leave medications unattended. Staff acknowledged that leaving medications in a resident's room without supervision was not in accordance with facility policy and could result in medications not being taken as ordered. A review of the facility's medication administration policy confirmed that medications are to be administered according to physician orders and documented immediately after administration. The facility was unable to provide documentation of in-service training or skills review forms related to oral medication administration prior to the survey exit.
Failure to Follow Professional Standards in Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified through surveyor observation and review of facility practices related to food procurement and handling. No additional details regarding specific residents, staff, or incidents were provided in the report.
Discharge Documentation and Notice Deficiency
Penalty
Summary
The facility failed to ensure that Resident #2’s transfer or discharge was documented in the medical record and that appropriate information was communicated to the receiving healthcare institution or provider. Resident #2 was admitted with diagnoses including myocardial infarction, acute kidney failure, thrombocytopenia, sepsis due to MRSA, dehydration, and acute pulmonary edema. His admission MDS showed a BIMS score of 13, indicating he was cognitively intact, with adequate hearing, clear speech, no behavioral problems, and dependence with most ADLs. Record review and staff interviews showed that Resident #2 was discharged to a hospice agency because the facility was unable to control his pain. The ADON stated she communicated with the resident’s family during the discharge, but she was not the nurse who completed the discharge. RN A stated she was responsible for the resident and discharged him, but she did not document the discharge instructions, including special instructions or precautions for ongoing care, or comprehensive care plan goals. She also stated she did not have documentation for the basis for discharging the resident or the specific resident needs that could not be met at the facility. The DON stated she checked the record and did not see documentation from the MD regarding the facility-initiated discharge, noting this may have been because the resident was expected to return. The facility’s policy required documentation of the reasons for transfer or discharge, including specific resident needs that could not be met in the facility, facility attempts to meet those needs, and the services available at the receiving facility. The policy also required written notice to the resident and representative with the reason for discharge, effective date, location, and appeal rights.
Failure to Follow Infection Control Protocols During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow proper infection prevention and control practices during incontinence care for a resident. The CNA washed her hands before donning gloves and removed a soiled brief from the resident, who was a 78-year-old female with age-related debility, muscle weakness, and frequent incontinence. However, after cleaning the resident, the CNA did not change her gloves or perform hand hygiene before handling a clean brief and placing it under the resident. The gloves were visibly soiled with urine, and the CNA continued to handle clean items and dispose of waste without changing gloves or performing hand hygiene until the end of care. The resident's care plan required maintaining cleanliness and being odor-free, and the facility's infection control policy mandated hand hygiene and glove changes according to standard precautions. During interviews, the CNA acknowledged the lapse in infection control, attributing it to nervousness, and the DON confirmed expectations for staff to follow standard precautions. The facility's policy and staff training requirements were reviewed, but the observed actions did not align with established infection control protocols.
Failure to Include Resident and Representative in Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident and their representative were invited to participate in care plan meetings, including both comprehensive and quarterly review assessments. This deficiency was identified for a resident who was unable to complete an interview due to a BIMS score of 00, indicating non-interviewable status. The resident, who had a history of atherosclerotic heart disease, dysphagia, and vascular dementia, was not invited to participate in care plan meetings, and there was no documentation explaining the absence of the resident or their representative. The resident's Power of Attorney (POA) confirmed not being invited to a care plan meeting for a significant period. Interviews with facility staff revealed that the Social Worker, responsible for arranging care plan meetings, had been out sick, leading to the oversight. The Administrator acknowledged that the care plan was reviewed internally by facility staff, including the doctor, MDS nurse, and Business Office Manager, but without the resident or their representative. The facility's policy mandates the inclusion of the resident and their representative in care plan meetings to the extent practicable, but this was not adhered to, potentially leaving the resident's family uninformed about the care plan.
Failure to Provide Individualized Activity Programming
Penalty
Summary
The facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities, as well as independent activities. This deficiency was identified for two residents, who did not have in-room activity plans developed and implemented to meet their individual interests, abilities, and needs. The lack of a system to identify residents requiring one-to-one individual activity programming was also noted, which could place residents at risk for isolation, cognitive decline, and decreased feelings of well-being. Resident #19, a female with multiple diagnoses including chronic atrial fibrillation, hypertension, and diabetes, was found to have a care plan that did not address her lack of participation in group activities or include the option of one-to-one individual activity programming. Despite her preference for staying in her room and watching television, there were no recent activity progress notes documenting efforts to engage her in activities. Observations revealed that she spent most of her time in bed, with little interaction or engagement in activities. Resident #105, a male with cognitive impairment and other health issues, did not have a care plan addressing activity programming and participation. His admission activity evaluation was incomplete, and observations showed him spending time in bed or seated in a wheelchair with minimal engagement. The Activity Director admitted to not having a list of residents for in-room visits or documenting individual activity programming, indicating a lack of structured activity support for residents who do not participate in group activities.
Incomplete Medical Records and OOH-DNR Forms
Penalty
Summary
The facility failed to maintain complete and accurate medical records for eight residents, leading to discrepancies in physician orders and Out of Hospital - Do Not Resuscitate (OOH-DNR) forms. For Resident #57, the facility did not have a completed physician order for hemodialysis treatments, despite the resident receiving dialysis three times a week. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) acknowledged that the order was incomplete due to a failure in the electronic health record system and oversight during morning meetings. For Residents #8, #43, #68, #82, #100, #105, and #261, the facility failed to ensure that the OOH-DNR forms were properly completed. These forms were missing critical information such as the physician's signature date, printed name, and license number. In some cases, the forms were not signed in the correct sections, which could lead to the residents' end-of-life decisions not being honored. The DON and other staff members admitted that they did not always verify the completeness of these forms before entering them into the residents' electronic health records. Interviews with facility staff revealed a lack of clear procedures and oversight in handling advanced directives and OOH-DNR forms. The previous Social Service Director, who was not a social worker, was responsible for explaining these forms to residents and their families, but there was no formal policy in place. The Business Office Manager and the Administrator acknowledged gaps in the process, including the absence of a facility policy for completing these forms. The AIT, who had experience in social services, also noted that the forms were considered valid even with missing information, indicating a misunderstanding of the legal requirements.
Inaccurate MDS Documentation for Resident's Feeding Tube Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) for a resident accurately reflected his status, specifically regarding the presence of an enteral feeding tube. The resident, a male with a history of cerebral infarct, hypertension, and atrial fibrillation, was admitted to the facility and had an MDS completed that incorrectly indicated he had a feeding tube. However, the resident was on a mechanical soft diet with no orders for a feeding tube, and during an interview and observation, he confirmed he never had a feeding tube. The MDS Coordinator admitted to making a documentation error by not paying attention, which led to the inaccurate MDS entry. The Director of Nursing (DON) stated that the MDS should accurately reflect the resident's condition, and the MDS RN Coordinator was responsible for ensuring this accuracy. The facility follows the RAI Manual for completing resident assessments, which requires that assessments accurately reflect the resident's status and involve direct observation and communication with the resident and staff.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to ensure that drugs and biologicals were secured and stored in locked compartments, as observed with the Hall 4 medication cart. During an observation and interview, it was noted that the medication cart was left unlocked and unattended in the hallway by an RN while she entered a resident's room to administer medications. This occurred in the presence of a housekeeping staff member in the area, and the RN acknowledged that she should not have left the cart unlocked. She attributed her oversight to being busy and nervous due to the presence of the surveyor. The Director of Nursing (DON) confirmed in an interview that the expectation is for nurses to keep medication carts and rooms locked at all times when not in use and unattended. The facility's policy on medication storage, dated January 20, 2021, specifies that all drugs and biologicals must be stored in locked compartments and that only authorized personnel should have access to the keys. The policy also requires that medications be under direct observation or locked during medication passes. The failure to adhere to these guidelines could result in drug diversion or residents accessing medications not intended for them.
Infection Control Lapse During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by an incident involving a certified nursing assistant (CNA) who did not follow proper hand hygiene protocols during incontinence care for a resident. The resident, a female with muscle weakness, hemiplegia, and diabetes, required partial to moderate assistance with activities of daily living and was frequently incontinent. During the care, the CNA did not sanitize her hands between changing gloves after removing a soiled brief, which could lead to cross-contamination and infection. The CNA acknowledged the lapse in hand hygiene, understanding that it could result in infection for the resident. The Director of Nursing (DON), who is responsible for infection control, confirmed that staff are expected to follow standard precautions, including hand hygiene after glove changes. The facility's policy mandates hand hygiene before and after removing personal protective equipment, including gloves. Despite annual and spot competency checks, this incident highlights a failure in adhering to established infection control practices.
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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) |
|---|---|---|---|---|
| Vernon Rehabilitation And Nursing Center | 0.2 mi | — | 0 | 0 |
| Electra Healthcare Center | 24.2 mi | ★★★★★ | 9 | 0 |
| Crowell Nursing Center | 26.5 mi | ★★★★★ | 8 | 0 |
| English Village Skilled Nursing And Therapy | 34 mi | ★★★★★ | 0 | 0 |
| Magnolia Creek Skilled Nursing And Therapy | 35 mi | ★★★★★ | 1 | 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.