Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Nursing Center during CMS and state inspections, most recent first.
A facility failed to protect residents from neglect during an emergency transfer, resulting in residents being stranded in extreme heat without adequate care. The transfer was conducted without nursing staff or medications, leading to hospitalizations for heat-related illnesses. The facility lacked communication and planning, with staff and family members uninformed about the closure and transfer process.
A facility failed to prevent neglect during a resident transfer, resulting in three residents being stranded in extreme heat for six hours without adequate care. The residents, who had severe cognitive impairments and health issues, were transported in a van that broke down and lacked necessary staff and provisions. Two residents required hospitalization for heat-related conditions, and one was found unresponsive. The facility did not notify families or agencies of the closure and lacked a proper closure plan.
During an emergency closure, the facility failed to ensure a safe transfer of residents, leading to a van breakdown in extreme heat without adequate care or water. Residents were given only 24 hours' notice, and the facility lacked a closure plan, resulting in hospital admissions for heat-related issues and inadequate support for residents and families.
The facility failed to notify two residents, their representatives, and the State LTC Ombudsman about their transfer or discharge. One resident's RP was informed of the facility's closure the day before, with no assistance offered for relocation. Another resident's RP was not notified by the facility and had to learn about the transfer from a family member. The DON was out of town and unable to provide policies, and the facility's owner confirmed an emergency closure due to staffing issues, with residents notified only a day prior.
The facility failed to implement an effective discharge planning process for two residents, leading to a deficiency in meeting their discharge goals and needs. One resident, with severe cognitive impairment, was transferred without proper notification to the family, causing distress. Another resident was informed of the facility's closure only a day before, leaving the family to arrange alternative accommodation without assistance. The DON was unaware of the transfers and expressed concerns about staffing shortages and lack of communication. The facility's policy on transfer and discharge was not followed.
The facility failed to maintain sufficient nursing staff, compromising resident safety and well-being. Despite efforts to address the issue, the owner acknowledged the staffing shortage, leading to the facility's closure. A nurse was unable to leave her shift due to lack of relief, and a bus driver, not a CNA, transported residents without nursing staff, violating the facility's staffing policy.
A facility failed to administer evening medications to three residents during transport to a new facility. One resident, with severe cognitive impairment, was hospitalized after not receiving his medication. Two other residents, with moderately impaired cognition, did not receive their medications due to a lack of nursing staff during transport. This failure to follow medication administration policy placed residents at risk of not receiving therapeutic benefits.
Two residents did not receive a normal evening meal during their transfer to another facility due to an emergency temporary closure caused by staffing issues. Instead, they were given half a sandwich, and no nursing staff accompanied them on the van. The van broke down, leaving the residents stranded for hours without adequate food. The facility's emergency disaster policy did not address the specific needs during the transfer.
The facility was without a licensed Administrator for 1.5 weeks, leading to mismanagement and unpaid bills affecting essential services like pest control and dietary supplies. The Owner, not licensed in Texas, failed to notify state authorities about closure plans. The DON and former Administrator reported significant operational issues, and the Medical Director was unpaid for over six months but continued to provide care.
The facility failed to have a licensed Administrator, as the Owner, who was acting in this role, did not hold a Texas license. The previous Administrator quit without notice, and the Owner did not notify HHSC or seek a replacement. The facility planned to close, transferring residents to a sister facility, while the DON assumed the role of Abuse Coordinator.
The facility failed to provide timely written notification of closure to residents and their representatives, affecting three residents. A resident with severe cognitive impairment was upset about the move, and his representative received no assistance in finding a new placement. Another resident learned about the closure from a peer, and his representative also received no guidance. A third resident's representative decided to take the resident home after being informed by an aide. The facility did not adhere to its closure policy, which required immediate notification to authorities and residents.
The facility failed to have a closure plan, resulting in abrupt notification to residents, families, and staff about the closure. The Owner, lacking a state Administrator license, decided to close the facility without notifying regulatory authorities or providing assistance to residents for relocation. Residents and their representatives were left to make their own arrangements, and the facility Medical Director was not informed until the day of closure.
The facility failed to provide timely access to personal funds for two residents with schizoaffective disorder, causing stress and financial difficulties. Both residents experienced significant delays in receiving their funds due to the resignation of the Business Office Manager and the facility's financial issues, which hindered their ability to manage their financial affairs as per the facility's policy.
The facility failed to maintain food service safety standards, with a dietary aide not wearing a hair net, dirty exhaust vent filters, and improperly labeled leftovers. Financial difficulties led to inadequate food supplies, with the Dietary Manager limited to $1000 per week and no emergency supplies maintained. Meals were improvised daily without a set menu, as confirmed by staff interviews.
The facility did not have a licensed administrator after the previous one quit without notice, and the owner, not licensed in Texas, failed to notify HHSC. The owner decided to close the facility and transfer residents, citing financial issues as the reason for the administrator's departure.
Neglect During Emergency Resident Transfer
Penalty
Summary
The facility failed to protect residents from neglect, resulting in an emergency transfer of residents without adequate preparation or notice. The facility lacked sufficient staff to provide care, leading to a hasty decision to transfer residents to another facility with only 24-hour notice to residents and their families. During the transfer, residents were placed in a van that was not in good repair, which broke down, leaving them stranded on the roadside for approximately six hours in extreme heat conditions. The transfer was conducted without nursing staff, medications, or provisions for resident care during the journey. As a result, two residents required hospitalization for heat-related illnesses after being exposed to high temperatures for an extended period. Another resident was found unresponsive due to the heat and lack of water, necessitating emergency medical services intervention. The facility's actions placed residents at risk of physical and emotional harm, as they were not adequately cared for during the transfer. Interviews with staff and family members revealed a lack of communication and planning regarding the facility's closure and resident transfers. The facility did not have an administrator, and the owner admitted to being aware of staffing issues for over a week before the closure. The facility's neglect policy and emergency closure policy were not followed, leading to a chaotic and unsafe transfer process for the residents.
Neglect During Resident Transfer Leads to Hospitalization
Penalty
Summary
The facility failed to implement its policies and procedures to prevent neglect, resulting in significant harm to three residents during a transfer. The residents were transported in a van that was not in good repair and broke down, leaving them stranded on the roadside for approximately six hours. The van lacked necessary staff, medications, and provisions for resident care, exposing the residents to extreme heat without water or adequate supervision. Resident #1, a male with severe cognitive impairment and multiple health issues, including Alzheimer's disease and congestive heart failure, experienced syncope and was admitted to the hospital for heat exhaustion and possible seizure activity. Resident #3, also with severe cognitive impairment and dehydration, was lethargic and required hospitalization for dehydration and acute kidney injury. Resident #2, a female with dementia and cognitive decline, was found unresponsive due to heat exposure and required emergency medical services for evaluation. The facility's administration failed to notify residents, families, or state agencies of the emergency closure and transfer, and there was no closure plan in place. The Director of Nursing and other staff were informed of the closure only a day before the transfer, and the facility lacked an administrator and sufficient staff to manage the situation. The owner admitted to the lack of preparation and staffing issues, which led to the hasty and unsafe transfer of residents.
Unsafe Resident Transfer During Emergency Closure
Penalty
Summary
The facility failed to ensure a safe and orderly transfer or discharge of residents during an emergency closure, resulting in significant deficiencies. Residents were transferred in a van that was not in good repair, leading to a breakdown on the roadside for approximately six hours. This incident occurred in extreme heat conditions, with outside temperatures reaching up to 107 degrees Fahrenheit. The residents were left without water and adequate care during this time, leading to heat-related episodes and hospital admissions for some residents. The facility did not provide sufficient notice or assistance to residents and their families for the transfer. Residents and their responsible parties were only given 24 hours' notice of the facility's closure, leaving them with inadequate time to make necessary arrangements. Additionally, the facility did not have a closure plan in place, and there was a lack of communication with residents, families, and state agencies. The facility also failed to provide emotional and psychological support to residents and families during the relocation process. Specific residents were adversely affected by these deficiencies. One resident, with severe cognitive impairment and multiple health issues, was transferred without the responsible party being notified. Another resident, also with severe cognitive impairment, was found unresponsive on the van due to prolonged heat exposure. The facility's lack of preparation and coordination during the emergency closure placed residents at risk of physical and emotional harm, hospitalization, and death.
Failure to Notify Residents and Ombudsman of Transfer or Discharge
Penalty
Summary
The facility failed to provide timely notification to residents, their representatives, and the State Long-Term Care Ombudsman regarding the transfer or discharge of residents. Specifically, the facility did not send a copy of the notice of transfer or discharge and the reasons for the transfer or discharge in writing to the Ombudsman for two residents reviewed for transfer and discharge. This lack of communication could affect residents by placing them at risk of being discharged without proper advocacy services, discharge options, and appeal processes. Resident #12, a male with multiple health issues including hepatic encephalopathy and chronic kidney disease, was informed by his responsible party (RP) that the facility was closing the next day. The RP stated that no staff offered assistance in finding a new place, and she had to arrange for an apartment for the resident herself. Similarly, Resident #1, a male with severe cognitive impairment and paraplegia, was not notified by the facility about his transfer. His RP learned about the move from another family member and had to leave work to assist with the transfer. The Director of Nursing (DON) was out of town and unable to provide facility policies when requested by the surveyor. The DON expressed concerns about staffing shortages and stated that the facility had not notified families about the closure. The facility's owner confirmed an emergency temporary closure due to staffing issues, but residents were only notified the day before the closure. The Ombudsman was also unaware of the facility's closure, highlighting a significant communication breakdown.
Inadequate Discharge Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for two residents, leading to a deficiency in meeting the residents' discharge goals and needs. Resident #1, a male with severe cognitive impairment and multiple health issues, was not provided with a discharge plan. His responsible party was not informed about his transfer to another facility, causing distress and lack of preparation for the family. The facility did not give the family enough time or options to find a suitable place closer to them. Similarly, Resident #12, a male with significant health conditions, was also affected by the facility's inadequate discharge planning. The responsible party for Resident #12 was informed only a day before the facility's closure, leaving them to arrange alternative accommodation without assistance from the facility. The facility staff were unaware of the closure plans, and no help was offered to the resident or their family in finding a new place. The Director of Nursing (DON) was out of town and unable to provide the facility's policies when requested by the surveyor. The DON expressed concerns about staffing shortages and was not informed about the residents' transfers until shortly before they were scheduled. The facility's policy on transfer and discharge was not followed, as there was no documentation of resident or representative notice, comprehensive care plans, or communication with receiving facilities. The physician for the residents was also unaware of the transfers and expressed concerns about the facility's administration and staffing issues.
Insufficient Staffing Leads to Facility Closure
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, compromising their safety and well-being. This deficiency was identified through observations, interviews, and record reviews. The owner acknowledged the staffing issue, which had persisted for approximately 1.5 weeks, and despite efforts to contact agency staffing, use staff from a sister facility, and hire a recruiter, the facility was unable to secure adequate staffing. This lack of staffing was cited as the primary reason for the decision to close the facility. During the investigation, it was noted that a registered nurse was unable to leave her shift due to the absence of a relieving nurse, indicating a severe shortage of nursing staff. Additionally, a bus driver, who was not a certified CNA, was responsible for transporting 13 residents to a sister facility without any accompanying nursing or CNA staff. This situation highlighted the facility's failure to adhere to its staffing policy, which mandates adequate staffing to meet resident care needs, including the presence of licensed nursing staff and CNAs on each shift.
Failure to Administer Medications During Resident Transport
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of three residents, resulting in them not receiving their prescribed evening medications. Resident #1, a male with severe cognitive impairment and multiple health conditions, was admitted to the hospital after experiencing syncope and suspected seizures. His Medication Administration Record (MAR) indicated he was due for an evening dose of Divalproex Sodium, which he did not receive due to the facility's failure to administer it. Resident #13, who had moderately impaired cognition and required total assistance with most activities of daily living (ADLs), was also affected. He was being transported to a new facility when the van broke down, and he did not receive his evening medications, including antibiotics, anxiety, and opioid medications. This lapse occurred because there was no nursing staff present during the transport to administer medications or provide care. Similarly, Resident #14, with moderately impaired cognition and various health issues, did not receive his evening medications while being transported to a new facility. The facility's policy on medication administration was not followed, as medications were not administered within the required time frame, and there was no staff to ensure medication administration during the transport. This oversight placed the residents at risk of not receiving the intended therapeutic benefits of their medications.
Failure to Provide Adequate Meals During Resident Transfer
Penalty
Summary
The facility failed to provide at least three meals daily at regular times or in accordance with resident needs for two residents, Resident #5 and Resident #6, during their transfer to another facility. On 08/07/24, both residents were being transferred at 6:00 p.m. and did not receive a normal evening meal. Instead, they were given half a sandwich to take on the van. This action was due to an emergency temporary closure of the facility caused by staffing concerns, as revealed by the owner. Resident #5, a male with schizoaffective disorder, schizophrenia, cognitive communication deficit, and generalized anxiety disorder, was on a mechanical soft diet due to being edentulous. His care plan aimed to maintain adequate nutritional status. Resident #6, a male with multiple health conditions including diabetes mellitus and being edentulous, also had a care plan goal to maintain adequate nutritional status. Both residents were moderately cognitively impaired, as indicated by their BIMS assessment scores. During the transfer, the facility did not provide any nursing staff on the van to administer medications or provide care if needed. The van broke down, leaving the residents stranded for several hours without adequate food. Resident #5 expressed hunger and was observed buying snacks from a vending machine at a rest station. The facility's emergency disaster policy, which was presented instead of a dietary policy, outlined a 3-day menu for emergencies but did not address the specific needs of residents during the transfer.
Facility Mismanagement and Lack of Licensed Administrator
Penalty
Summary
The facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently, impacting the well-being of its residents. The facility was without a licensed Administrator for approximately 1.5 weeks, as the previous Administrator had resigned due to financial mismanagement and unpaid bills. The Owner, who was not licensed in Texas, was aware of the staffing issues and had attempted to address them by contacting agencies and using staff from a sister facility. However, the Owner did not hire a new Administrator or notify state licensing authorities about the facility's closure plans, citing a lack of knowledge on how to contact them. The Director of Nursing (DON) and the former Administrator reported significant operational issues, including unpaid vendors leading to a lack of essential services such as pest control, HVAC maintenance, and dietary supplies. The DON began notifying residents and families of a potential closure despite the lack of formal communication from the Owner. The Medical Director also reported not being paid for over six months but continued to provide care. These issues were compounded by the Owner's failure to follow proper procedures for emergency closure and resident transfer, contributing to the facility's decline and the deficiency noted in the report.
Facility Lacks Licensed Administrator
Penalty
Summary
The facility failed to ensure that it had a licensed Administrator responsible for its management, as required by state regulations. The Owner, who was acting as the Administrator, did not possess an active Texas Administrator license. The facility had been without a licensed Administrator for approximately 1.5 weeks after the previous Administrator quit without notice. The Owner, who was licensed in another state, did not actively seek a replacement Administrator and did not notify the Health and Human Services Commission (HHSC) about the absence of a licensed Administrator. Interviews conducted with the Owner and the Director of Nursing (DON) revealed that the facility was planning to close, and residents were to be transferred to a sister facility. The DON assumed the role of the designated Abuse Coordinator in the absence of an Administrator. A review of the facility's records confirmed the employment and termination dates of the former Administrator, who had worked at the facility for a brief period before resigning. The governing body list indicated that the Owner was the sole contact, highlighting the lack of a structured management team.
Failure to Provide Timely Closure Notification
Penalty
Summary
The facility failed to provide written notification of an impending closure to residents and their legal representatives at least 60 days prior to the closure date, affecting three residents reviewed for discharge notice. This failure was identified through interviews and record reviews, revealing that residents and their representatives were not informed in a timely manner, which could impact their access to advocacy services, continuity of care, and appropriate discharge options. The facility's Emergency Nursing Home Closure Policy was not followed, as it required immediate notification to regulatory authorities and written notice to residents and families ideally within 24 hours. Resident #1, a male with severe cognitive impairment and multiple medical diagnoses, was visibly upset about the move and expressed a desire to stay near family. His representative was informed only a day before the planned transfer and received no assistance from the facility in finding a new placement. Similarly, Resident #8, with schizoaffective disorder and other conditions, learned about the closure from another resident and informed his representative, who also received no guidance from the facility. Resident #12's representative was informed by an aide and decided to take the resident home, arranging hospice care independently. The facility's lack of communication and support in these cases highlights the deficiency in adhering to closure notification requirements.
Failure to Notify and Plan for Facility Closure
Penalty
Summary
The facility failed to have policies and procedures in place that outline the duties of the Administrator in the event of a facility closure. This deficiency was identified through interviews and record reviews, revealing that the facility did not notify the State Survey Agency, the State Long-Term Care Ombudsman, residents, their legal representatives, or the facility Medical Director about the closure. The facility's operation was being conducted by the Owner, who did not hold a state Administrator license, and there was no Licensed Administrator since 7/26/24. Interviews with the Director of Nursing (DON) and the Ombudsman indicated that the decision to close the facility was made abruptly, with the Owner informing the staff on 8/5/24 and deciding on 8/6/24 that the facility would close the next day. Residents were to be moved to a sister facility 2.5 hours away without prior notice to residents, families, or state agencies. The DON confirmed that there was no closure plan in place, and the process was improvised. Residents and their representatives were informed of the closure through informal channels, such as other residents or aides, rather than official communication from the facility. Some residents' representatives had to make their own arrangements for relocation, as the facility did not provide assistance or a list of alternative placements. The facility Medical Director was also unaware of the closure until informed by the DON on the day of the closure.
Failure to Provide Timely Access to Resident Personal Funds
Penalty
Summary
The facility failed to ensure that residents who authorized the facility to manage their personal funds had access to those funds when requested. This deficiency affected two residents, both diagnosed with schizoaffective disorder and other medical conditions, who experienced delays in receiving their personal funds. Resident #4 reported being unable to access her money as scheduled, which caused stress and prevented her from purchasing essential items. She was informed that the Business Office Manager (BOM) had quit, leaving no one to disburse the funds, resulting in a delay of over two weeks before she received her money. Similarly, Resident #5 experienced a delay of about 17 days in receiving his monthly personal funds, which he depended on for his financial needs. He expressed dissatisfaction with the situation, as it hindered his ability to manage his financial affairs timely. The former Administrator confirmed that the BOM had quit and that the facility was experiencing financial difficulties, which affected the disbursement of residents' funds. The facility's policy on resident trust accounts was not adhered to, as the monitoring systems failed to ensure funds were handled according to state regulations.
Deficiencies in Food Service Safety and Supply Management
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. A dietary aide was found not wearing a hair net while in the kitchen, which is a basic requirement for maintaining hygiene. Additionally, the exhaust vent filters of the range hood were observed to be dirty, with a sticky, brown-colored substance identified as grease, indicating a lack of regular cleaning. The facility also failed to properly label and dispose of leftovers in the refrigerator, with several containers of food found unlabeled. Furthermore, the facility did not maintain the required 7 days of staple supplies and 2 days of perishable foods for emergencies, and was not following a set menu, which could lead to food contamination and foodborne illness. Interviews with staff revealed financial difficulties impacting the facility's ability to procure food supplies. The Dietary Manager (DM) reported that food orders were being cut due to unpaid bills, and she was limited to spending $1000 per week, forcing her to make daily trips to a local grocery store for supplies. The DM confirmed the lack of emergency supplies and the absence of a set menu, with meals being improvised daily. The Director of Nursing (DON) acknowledged the financial struggles and the use of local stores for supplies, but noted that residents' weights were maintained and there were no complaints about the dietary services. A resident mentioned that while the food was good, they were unaware of the menu until mealtime.
Failure to Maintain Licensed Administrator and Notify HHSC
Penalty
Summary
The facility failed to comply with Federal, State, and local laws and regulations by not having a licensed nursing facility administrator in place. The deficiency occurred when the facility's administrator quit without notice, and the owner, who is not licensed in Texas, did not immediately notify Health and Human Services (HHSC) of the vacancy. The owner, who is the only governing body contact, did not actively seek a new administrator and decided to close the facility, transferring residents to a sister facility. The former administrator cited unpaid bills as the reason for leaving, having raised concerns with the owner, who responded that there was no money available.
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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) |
|---|---|---|---|---|
| Advanced Rehabilitation And Healthcare Of Vernon | 0.2 mi | ★★★★★ | 0 | 0 |
| Electra Healthcare Center | 24 mi | ★★★★★ | 9 | 0 |
| Crowell Nursing Center | 26.6 mi | ★★★★★ | 8 | 0 |
| English Village Skilled Nursing And Therapy | 34.1 mi | ★★★★★ | 0 | 0 |
| Magnolia Creek Skilled Nursing And Therapy | 35.1 mi | ★★★★★ | 1 | 0 |
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