Vernon Manor: COVID Outbreak Mismanaged, Sick RN Worked - WI
That belief shaped everything that followed.
DON B, as she is identified in inspection records, worked a floor shift from 2:00 AM to 6:00 AM on July 25, tested positive at 6:00 AM before leaving, and then returned to work on July 28 — three days after her positive test. The Assistant Director of Nursing and Infection Preventionist, identified as ADON/IP C, told the surveyor that DON B worked from her office that Sunday and did not come out on the floor. The reason given: a Med Tech was working and needed a registered nurse in the building.
There was a problem with that explanation. When the surveyor asked ADON/IP C to pull out the actual policy, ADON/IP C read it aloud and discovered the policy required an LPN or RN, not specifically an RN. "I guess she didn't need to be," ADON/IP C said.
The surveyor then asked ADON/IP C directly whether the facility was currently in a COVID-19 outbreak, given that a staff member had tested positive. ADON/IP C said no. When asked how many positive cases would constitute an outbreak, ADON/IP C said three. The surveyor showed her current guidance. Under that guidance, one confirmed case in a facility is enough.
"Yes," ADON/IP C said. The facility was in an outbreak.
That conversation happened at 11:10 AM on July 31. By that point, the facility had not screened residents for COVID-19 symptoms, had not notified the medical director, had not begun widespread testing of residents or staff, and had not required staff to wear masks. ADON/IP C confirmed all of this. On the question of whether staff should be wearing PPE during an outbreak, she said yes. On whether they were wearing it: they were not. Surveyors observed staff throughout the building without any PPE.
Two residents were already showing signs of illness. One, identified as R4, had symptoms that staff attributed to bilateral pleural effusions. Another, R5, had been diagnosed with pneumonia. The line list the facility kept, meant to track residents and staff with symptoms or positive tests, did not include R5 at all, and showed no symptoms listed for that resident, no notation of whether R5 had ever been tested for COVID-19. At least two other residents who were experiencing symptoms had never been added to the line list either. One of them had been tested and came back negative, but was still never recorded.
ADON/IP C acknowledged to the surveyor that infection control tracking should be conducted daily and that line listings should be completed contemporaneously. When asked why they weren't, she said: "I was just following what the following IP was doing before she left."
The facility's infection control policies were undated. ADON/IP C told the surveyor they should be reviewed yearly at minimum and should reflect current CDC guidance. They did not. She said she was new to the role and was going by what had been done previously.
The facility also was not monitoring community transmission rates. ADON/IP C told the surveyor the local health department had advised using state-level transmission rates, which she said were below baseline. The surveyor checked. COVID-19 hospitalizations were growing across the entire state. In the western region of Wisconsin, where Viroqua sits, both wastewater surveillance and hospital admission rates were trending upward.
Nobody had told the medical director any of this. ADON/IP C confirmed there had been no contact with the medical director about the outbreak. "We did not believe we were in an outbreak," she said.
By the time the survey team was preparing to leave the facility, Vernon Manor had begun testing residents and staff. No additional positive cases were identified.
The residents with pneumonia and pleural effusions were already in the building when that testing started.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Vernon Manor from 2024-07-31 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
VERNON MANOR in VIROQUA, WI was cited for violations during a health inspection on July 31, 2024.
That belief shaped everything that followed.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.