Vernon Manor

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Aug 28, 2023

  Based on interview and record review, the facility did not ensure residents were free from significant medication errors for 2 of 2 sampled residents (R65 and R265) reviewed for medication errors. R65 had an order to receive 12.5 mcg (micrograms) of levothyroxine. The medication was transcribed into the facility's Electronic Health Record (EHR) as 125mcg. R65 received 45 doses in 46 days of the incorrect dose of levothyroxine. R65 died in the hospital as a result of the medication error which caused Thyrotoxicosis. The facility's failure to ensure that residents were free from a significant medication error created a finding of immediate jeopardy that began on [DATE]. NHA A (Nursing Home Administrator) was notified of the immediate jeopardy on [DATE] at 3:00 PM. […]

• No harm, potential for more than minimal, widespreadF887Feb 27, 2026

  Based on document review, interview and policy review, facility failed to ensure that when COVID-19 vaccine is available to the facility, each resident and staff member is offered the COVID-19 vaccine unless the immunization is medically contraindicated or the resident or staff member has already been immunized for 4 of 4 staff reviewed. This has the potential to affect all 46 residents residing within the facility.Facility failed to have documentation of staff COVID-19 vaccination status, that staff were educated about the COVID-19 vaccine, the COVID-19 vaccine was offered and signed consents of accepting the vaccine or declining the vaccine for the following four staff Director of Nursing (DON), Licensed Practical Nurse (LPN)1, Resident Care Assistant (RCA)1 and Certified Nurse Aide… […]

• No harm, potential for more than minimal, widespreadF880Jul 31, 2024

  Based on observation, interview, and record review, the facility failed to ensure it maintained an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections such as COVID-19. This had the potential to affect all residents residing within the facility at the time of the outbreak on 7/25/24. As of 7/25/24, the facility was in a COVID-19 outbreak with 1 staff positive for COVID-19. - The facility line listings were not completed contemporaneously, and the line lists did not contain symptomology. - During the survey, staff were observed throughout the facility not wearing source control. - The facility did not track community transmission rates and hospital admissions. […]

• No harm, potential for more than minimal, patternF585Feb 27, 2026

  Based on observation, interview, record review, and policy review, the facility failed to document and respond to residents' grievance regarding removal of their bedrails for five of five residents (R6, R8, R23, R26 and R42). R6, R8, R23, R26 and R42 voiced grievances regarding their bedrails, and the facility did not follow their grievance policy. Findings include: Reviewed facility's undated policy titled, Grievance indicated, Facility will make prompt efforts to resolve grievances a resident may have. […]

• No harm, potential for more than minimal, patternF578Aug 28, 2023

  Based on interview and record review, the facility failed to ensure that residents advance directive was signed by resident or resident representative for 4 of 17 residents (R32, R54, R56, and R1) reviewed for code status of total sample of 24. The code status preference form for R32, R54, R56, and R1 is not signed by the resident or legal representative. Findings include The facility commonly uses a Provider Orders for Scope of Treatment (POST) form to distinguish resident code status. Under section E, the form states, Signature of Patient/Agent/Guardian (either patient/agent/guardian must sign or health care professional must initial). […]