Vernon Green Nursing Home

In the surveyor’s words

From the most serious findings on record at Vernon Green Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Dec 4, 2023

  Based on observation, staff interview, and record review, the facility failed to ensure that resident environments were free of accident hazards related to safe handwashing water and bathing water temperatures. The facility failed to have an adequate water temperature monitoring process in place that resulted in critically high water temperatures in resident rooms and in a shower/tub room. These failures resulted a likely risk of serious burns to residents and created an immediate jeopardy situation. Findings include: Per observation on 11/27/23 at 11:45 AM, the water from the resident handwashing faucet in room [ROOM NUMBER] was too hot to use when this surveyor went to wash their hands following resident interview. […]

• Actual harm, isolatedF600Dec 4, 2023

  Based on observations, interviews, and record review, the facility failed to protect the resident's right to be free from sexual abuse by a resident for 1 of 25 residents in the sample (Resident # 19), and the facility failed to protect the resident's right to be free from neglect for 1 of 25 residents in the sample (Resident #33). Findings include: 1. Per record review, Resident #19 has diagnoses that include major depressive disorder, advanced dementia with behavioral disturbances, and delusional disorders. Resident # 19's Activities of Daily Living (ADL)/Rehab Potential care plan reflects that s/he requires extensive to total staff assistance with ADLs. Review of Resident #19's Behavioral Symptoms care plan reveals that s/he wanders about the unit in her/his wheelchair. […]

• Actual harm, isolatedF686Dec 4, 2023

  Based on observations, interviews, and record reviews the facility failed to ensure that 1 of 25 residents in the applicable sample (Resident #3) received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing. As a result, Resident #3 developed two stage 2 (partial-thickness loss of skin with exposed dermis) pressure ulcers after admission to the facility. Findings include: Per record review Resident #3 was admitted to the facility on [DATE] with diagnoses that include heart failure, atrial fibrillation (an irregular, often rapid heart rate), and peripheral vascular disease (circulation disorder). […]

• Actual harm, isolatedF689Nov 18, 2022

  Based on staff interview and record review the facility failed to provide adequate supervision for 1 of 4 residents who were at risk for falls in the applicable sample (Resident #39). Findings include: Per record review Resident #39's care plan reflects that s/he is at risk for falls. On 12/20/2021 after s/he experienced a fall, a care plan intervention was added that states ensure the resident is in line of sight of staff when out of room. S/he has since experienced falls on the following dates; 01/03/2022, 2/24/2022, 2/26/22, 2/28/22, 6/30/22, 7/3/22, 7/21/22, 7/29/22, 8/3/2022, 8/15/22 10:40 am, and 1:00 PM. The fall on 8/15/2022 resulted in a hip fracture. Review of the care plan reflects that the resident is at risk for falls. […]

• No harm, potential for more than minimal, widespreadF726Jan 14, 2026

  Based on interview and record review the facility failed to ensure there were competent nursing staff for one of five nurses and five of five Licensed Nursing Assistants in the sample. Findings include:1.Review of the State of [NAME]'s Title 26 : Professions and Occupations- Chapter 028 : Nursing Subchapter 004 : NURSING ASSISTANTS, A person shall not practice nursing or nursing-related functions as defined in section 1641 of this subchapter without being licensed by the Board.The State of [NAME] definitions include Nursing assistant means an individual who performs nursing or nursing-related functions under the supervision of a licensed nurse and Nursing or nursing-related functions means nursing-related activities as defined by rule, which include basic nursing and restorative duties for… […]