Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Vernon Manor during CMS and state inspections, most recent first.
Facility failed to document COVID-19 vaccine education, offer, consent, declination, or vaccination status for 4 of 4 staff reviewed, including the DON, an LPN, a CNA, and an RCA. The IP stated posters were placed in the break room, but she did not document which staff received education or maintain employee records for vaccination status, consent, or declination, and the DON was unaware the records were not being maintained.
Failure to respond to resident grievances about bedrail removal. Several cognitively intact residents reported that bedrails were removed without prior notice, leaving them unable to reposition, sit up, or feel secure in bed. Residents stated they raised concerns through Resident Council and directly to the Administrator and DON, but received no verbal or written response. Staff confirmed the concerns were discussed and that the grievance process was not followed.
A resident with moderate cognitive impairment and a legal guardian had a POST form indicating DNR status that was signed by the PA but not by the guardian. Staff stated the form was incomplete without the responsible party signature, and records showed no documented review of the resident’s code status in care plan or social service notes. The facility’s policy required advance directive documents to be complete with signatures and reviewed during the RAI process and with significant changes in condition.
Failure to issue SNF ABN forms when skilled therapy ended. Two residents with Medicare A coverage, including one admitted for aspiration pneumonia and another admitted for sepsis due to pneumonia, UTI, and paroxysmal AFib, did not receive SNF ABNs advising of potential non-coverage for continued skilled services. SS confirmed no ABNs had been issued, and the Administrator stated the notices were required for post-Medicare stays.
Failure to Timely Report Abuse Allegations: The facility did not report two allegations of physical abuse to the State agency within the required timeframe. In one event, a CNA found a resident stating another resident had hit her and tried to push her wheelchair; in another, an AA observed a resident striking another resident’s wheelchair and then hitting the resident on the arm. Staff notified the DON and LPN, but the Administrator at the time directed that the incidents not be externally reported, and the reports were not submitted until months later.
Expired COVID-19 antigen tests were found in the only med storage room during an observation with the IP. Surveyors saw three boxes of iHealth COVID-19 tests past expiration, including one opened box with three tests already used; the IP confirmed the tests were expired and said three tests from the expired box had been used the prior day. The facility policy required checking open dates and expiration before administration, and the IP stated she expected no expired meds or biologicals in the facility.
A resident with severe cognitive impairment and a history of aggressive behavior threw a metal spoon at another resident during an activity, resulting in physical abuse. The staff failed to remove the spoon and intervene promptly, despite the resident's known behaviors.
A facility failed to timely report an allegation of verbal abuse involving a resident who was cognitively intact. The incident occurred when a CNA allegedly yelled at the resident while assisting her with a bedpan. Although the incident was reported to a nurse on the following day, it was not communicated to the Social Service Director or the Director of Nursing until two days later, resulting in a delay in notifying the State Agency and Local Law Enforcement, contrary to the facility's policy.
A resident with severe cognitive impairment attempted to hit another resident with a spoon during an activity session. The Activities Assistant intervened but the resident threw the spoon, hitting another resident. The DON confirmed that no thorough investigation was conducted, as required by the facility's abuse policy, which mandates interviews with witnesses and involved parties.
The facility failed to develop comprehensive care plans for two residents, neglecting to address critical care areas such as pain management, incontinence, and wandering behavior. Despite assessments indicating these needs, the care plans were not updated, leading to deficiencies in resident care.
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak, with staff not wearing PPE, outdated policies, and inadequate testing and screening. A staff member worked while COVID-19 positive, and the Medical Director was not notified of the outbreak.
A facility failed to report a resident-to-resident physical altercation to law enforcement, as required by policy. An LPN witnessed a resident with dementia hitting another resident with severe cognitive impairment. Although the incident was self-reported, the police were not notified, contrary to the facility's policy. The social worker confirmed that the previous NHA did not find it necessary to inform the police, despite acknowledging the requirement.
Missing COVID-19 Vaccine Documentation for Staff
Penalty
Summary
Facility failed to ensure that when the COVID-19 vaccine was available, each resident and staff member was offered the vaccine unless medically contraindicated or already immunized. The deficiency was identified for 4 of 4 staff reviewed and was stated to have the potential to affect all 46 residents residing in the facility. Review of the facility policy titled COVID-19 Vaccinations dated 07/03/2025 showed that residents and staff were to be offered immunizations against infectious diseases, that vaccine information was to be given and explained to staff before receiving a vaccine, and that staff were required to sign a consent form prior to administration, with the completed record filed in the employee medical file. Review of the employee files and infection control records for the DON, LPN1, CNA1, and RCA1 showed no documentation of COVID-19 vaccination status, no documentation that staff had been educated about the COVID-19 vaccine, no signed consent form for staff requesting vaccination, and no signed declination statement for staff refusing the vaccine. During interview, the IP stated that informational posters had been placed in the break room regarding COVID-19 vaccination, but she acknowledged she did not document which staff received education and did not maintain employee records for staff vaccination status, consent, or declination. The DON stated she was not aware that the IP was not maintaining this documentation.
Failure to Respond to Resident Grievances About Bedrail Removal
Penalty
Summary
The facility failed to document and respond to residents’ grievances regarding the removal of bedrails for five residents, including R6, R8, R23, R26, and R42. The facility’s grievance policy stated that it would make prompt efforts to resolve grievances and keep residents apprised of progress toward resolution, but the residents reported that no verbal or written response was provided after their concerns were raised. R26, who was cognitively intact with a BIMS score of 14/15, stated that the side rails were removed and that he was unable to turn himself in bed. R8, also cognitively intact with a BIMS score of 13/15, stated the rails were removed and that he had difficulty turning, sitting on the side of the bed, and feared falling without something to hold onto. R6, with a BIMS score of 15/15, stated the rails were taken away, that she had no use of her left hand, and that she used her right hand to hold the rails for positioning in bed. R6 also stated she had asked the Administrator and DON for a written response about the removal and had not received one. During Resident Council, R42 stated the rails were removed because the Administrator said Federal Regulations prohibited any use of bed rails, and all five residents stated they had received no prior notice and no response to the grievance filed by the Resident Council President. Staff interviews confirmed that concerns about bedrails had been discussed among residents and families, that the rails were removed around late December 2025 to early January 2026, and that numerous residents and families continued to express concerns. The Administrator acknowledged that a response should be provided when a grievance was filed, but also stated she had not provided anything in writing to R6 and that the letter sent on 02/05/26 was sent to families, not residents.
Incomplete POST Form for Resident with Guardian
Penalty
Summary
The facility failed to ensure that one of two residents reviewed for advance directives had a valid advance directive in place. Resident 43 was admitted with a court-appointed guardian, Family Member 2, and had a quarterly MDS showing a BIMS score of 10 out of 15, indicating moderate cognitive impairment. The resident’s chart contained a POST form dated 04/24/25 that was signed by the PA and indicated DNR status, but it was not signed by the guardian. The facility’s policy required advance directive documents to be complete with signatures and to be reviewed during the quarterly RAI process and with significant changes in condition. Review of the record showed the resident had a prior POST dated 10/17/23 that was signed by both the PA and the guardian, and a physician note from 02/22/24 documented that the guardian requested DNR. However, the current DNR physician order originated on 09/28/25, and the later POST in the paper chart lacked the guardian’s signature. Social services staff stated they were responsible for ensuring POST forms were complete on admission, but did not review POST forms after the initial form was completed. During interviews, an LPN stated the POST form had not been signed by the guardian and should have been. The DON stated that if changes were made later, the resident or decision maker would sign the new form along with the physician and it would be placed in the paper chart, and the Administrator stated POST forms should have both signatures before being placed in the chart. Review of care plan notes and social service notes from 05/09/24 through 02/27/26 showed no documented evidence that the resident’s code status had been reviewed.
Failure to Issue SNF ABN When Skilled Therapy Ended
Penalty
Summary
The facility failed to ensure that 2 of 3 residents reviewed for beneficiary notices, R58 and R59, received Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) of Non-Coverage forms when skilled therapy was being discontinued. The report states that Medicare requires SNFs to issue the SNF ABN to Original Medicare beneficiaries before providing care that Medicare usually covers but may not pay for in this instance, so the beneficiary can decide whether to receive the care and assume financial responsibility. R58 was admitted with aspiration pneumonia and had Medicare A benefits beginning on 01/19/26 with an end date of 01/30/26. R59 was admitted with diagnoses of sepsis due to pneumonia, urinary tract infection, and paroxysmal atrial fibrillation, and had Medicare A benefits beginning on 12/19/25 with an end date of 01/16/26. Review of the NOMNC and SNF ABN forms showed that neither resident was issued a SNF ABN advising of the cost of skilled services if they chose to continue after Medicare discharge from skilled services. Social Services confirmed that no ABN had been issued to either resident and stated the facility had not issued ABN forms; the Administrator later stated that SS2 was not doing the SNF ABN notice and that the form is required when a resident remains in the facility for a post-Medicare stay.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to ensure that all incidents and allegations of abuse were reported immediately, and no later than two hours, to the State Survey Agency for two residents involved in separate altercations with another resident. The facility policy stated that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, must be reported immediately, but not later than two hours after the allegation is made. In both incidents, the State Agency was not notified at the time the allegations were made and the reports were not submitted until more than eight months later. One incident involved a resident with dementia with agitation and anxiety disorder and another resident with schizophrenia and intellectual disability. On 05/03/25, a CNA heard yelling and found the resident in the sunroom stating that another resident had hit her on the right upper arm and tried to push her wheelchair into the hallway. The investigation summary documented that the State Agency had not been notified. Staff interviews later confirmed that the allegation was treated as physical abuse, but the DON stated it was not reported because the Administrator at the time decided not to report it. A second incident involved a resident with dementia who later died and whose closed record was reviewed. On 05/08/25, an AA observed another resident striking the resident’s wheelchair and then hitting the resident on the right arm under the shoulder. An LPN was notified and the resident was moved from the activity room, but the State Agency was not contacted. The facility’s misconduct incident report stated staff had been directed by the CEO in place at that time not to submit the required external report to the Department of Health Services, and the VP of Health Services later stated the previous Administrator decided not to report either incident until current administration reviewed them months later.
Expired COVID-19 Tests Stored in Medication Room
Penalty
Summary
The facility failed to ensure that one of one medication storage room was free of expired COVID-19 tests. During observation with the Infection Preventionist, surveyors found three of three boxes of iHealth COVID-19 Antigen Rapid Test with an expiration date of 09/02/25 in the only medication storage room. The Infection Preventionist confirmed the tests were expired, and observation showed one box had been opened with three tests already used. The Infection Preventionist stated that three tests from the expired box were used the previous day. Review of the facility's Medication Administration Policy, dated 02/2019, stated that medications should be checked for open dates and expiration before administration. During interview, the Infection Preventionist stated it was her expectation that there would not be any expired medications or biologicals in the facility.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident, R22, from physical abuse by another resident, R15, during an activity session. R15, who was admitted with unspecified dementia and had a history of physical and verbal behaviors, threw a metal spoon at R22, hitting her on the back of the head. R15 had a BIMS score indicating severe cognitive impairment and was known to exhibit altered behaviors. Despite these known behaviors, R15 was allowed to enter the activity room with a metal spoon, which was against facility policy. During the activity, R15 attempted to hit R22 with the spoon but was initially unsuccessful. The Activities Assistant (ACT1) moved R15 to another table but did not remove the spoon. Subsequently, R15 threw the spoon, hitting R22. The incident was reported to LPN1, who acknowledged that R15 had a previous incident of hitting another resident and should not have been allowed to take a metal spoon out of the dining room. The Director of Nursing confirmed that the incident was substantiated and that ACT1 should have intervened earlier.
Failure to Timely Report Verbal Abuse Allegation
Penalty
Summary
The facility failed to timely report an allegation of verbal abuse involving a resident, identified as R33, to the State Agency (SA). The incident occurred when Certified Nurse Aide 5 (CNA5) allegedly yelled at R33 while assisting her with a bedpan on 09/14/24. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, reported the verbal abuse. The incident was initially reported by CNA6 to Registered Nurse 1 (RN1) on 09/15/24, but RN1 did not inform the Social Service Director (SSD) or the Director of Nursing (DON) until 09/17/24. Consequently, the SA and Local Law Enforcement were not notified until 09/17/24, which exceeded the facility's policy requirement to report such incidents immediately, and not to exceed 24 hours. The facility's policy on Resident Abuse, revised on 01/15/24, mandates that the Nursing Home Administrator determines the reportability of incidents, with reportable incidents to be reported immediately, and not to exceed 24 hours. The DON, who confirmed her role as one of the facility's Abuse Coordinators, stated during an interview that she was unaware of the situation until it was reported on 09/17/24. This delay in reporting the verbal abuse incident led to the deficiency identified during the survey.
Failure to Investigate Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an incident of resident-to-resident abuse involving a resident with severe cognitive impairment and another resident with no cognitive impairment. The incident occurred when the resident with severe cognitive impairment attempted to hit another resident with a spoon during an activity session. The Activities Assistant intervened by removing the resident from the group circle and attempting to redirect them with magazines. Despite these efforts, the resident threw a spoon at another resident, which was heard by the Activities Assistant when it hit the ground, and the other resident exclaimed 'Ouch.' The Director of Nursing confirmed that a thorough investigation was not conducted, as no interviews were held with staff or residents who witnessed the incident. The facility's policy on resident abuse mandates that any suspicious events be investigated thoroughly, including interviewing alleged victims, witnesses, and other residents to determine if they have been abused. The policy also requires interviewing staff from the same and other shifts, as well as family members or others who may have knowledge of the incident. The failure to conduct these interviews led to the deficiency noted in the report.
Deficiency in Person-Centered Care Planning
Penalty
Summary
The facility failed to develop a person-centered care plan for two residents, leading to deficiencies in addressing their specific care needs. For one resident, who was admitted with a diagnosis of malignant carcinoid tumor of the ileum and was cognitively intact, the care plan did not include essential care areas such as pain management, urinary incontinence, and psychotropic drug use, despite these areas being triggered by the Minimum Data Set (MDS) assessment. The MDS Coordinator confirmed that these care areas were expected to be included in the care plan but were not addressed. For another resident diagnosed with unspecified dementia and exhibiting severe cognitive impairment, the care plan failed to document the resident's wandering behavior, despite staff observations and the implementation of a door alarm to manage this behavior. The care plan only mentioned the use of a door alarm under a self-care deficit problem but did not address the wandering behavior itself. Interviews with staff, including the MDS Coordinator and the Director of Nursing, revealed a lack of communication and responsibility in updating the care plan to reflect the resident's current condition and behaviors.
Inadequate Infection Control During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak, which was identified when a staff member tested positive. The facility did not complete line listings contemporaneously, and the lists lacked symptomology. Staff were observed not wearing source control, and the facility did not track community transmission rates or hospital admissions. The outbreak was not recognized, and COVID-19 procedures were not implemented, including screening all residents for signs and symptoms of COVID-19. The facility allowed a staff member who tested positive for COVID-19 to work, contrary to infection control policies. Testing of residents and staff was not conducted once a confirmed case was identified. The facility's infection control policies and procedures were outdated and did not reflect current CDC guidance. Additionally, the Medical Director was not notified of the outbreak, and the facility failed to complete screening of residents for signs and symptoms of COVID-19 during the outbreak. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) admitted to not updating line listings daily and not recognizing the outbreak due to a misunderstanding of the criteria. The facility's policies were not reviewed or updated regularly, and the ADON/IP was following outdated practices. The facility began testing residents and staff only after the survey team's intervention, with no additional positive cases identified at that time.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of a crime, as required by section 1150B of the Act, in one of three reportable incidents. On March 19, 2024, a physical altercation occurred between two residents, R1 and R2, where R2 was observed hitting R1 with a closed fist in the back of the head. Despite the facility's policy mandating immediate investigation and reporting of such incidents, the altercation was not reported to local law enforcement. The facility's policy, last reviewed on January 15, 2024, outlines the necessity of notifying law enforcement or other official agencies in cases of abuse, neglect, or mistreatment. R2, who was admitted with diagnoses including dementia, coronary artery disease, chronic obstructive pulmonary disease, and transient ischemic attack, was involved in the incident. R1, assessed with severe cognitive impairment, was the victim of the altercation. The incident was self-reported by an LPN who witnessed the event and ensured the safety of both residents. However, the social worker confirmed that the police were not notified, as the previous nursing home administrator did not deem it necessary, despite acknowledging that they should have been informed.
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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 Viroqua
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Norseland Nursing Home | 6.3 mi | ★★★★★ | 0 | 0 |
| Soldiers Grove Health Services | 14.2 mi | ★★★★★ | 0 | 0 |
| Hillview Health Care Ctr | 21.2 mi | ★★★★★ | 15 | 0 |
| Bethany St Joseph Care Ctr | 21.2 mi | ★★★★★ | 0 | 0 |
| Benedictine Manor Of Lacrosse | 22.3 mi | ★★★★★ | 8 | 1 |
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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 August 2026) and official state health department websites.