Health inspection·April 10, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cause), and blindness of the right eye. The care plan goals indicated Resident 1 would be free of falls through review date of 6/05/2025. The care plan nursing interventions included to anticipate and meet Resident 1's needs, be sure to place call light within reach and encourage Resident 1 to use it for assistance as needed and follow the fall protocol. During a review of Resident 1's Change of Condition Evaluation , dated 3/14/2025 at 1:10 p.m., theEvaluation indicated Resident 1 had a fall. The Change of Condition Evaluation summarized that Resident 1 was found on the floor on her right side next to her bed. Resident 1 stated she was trying to go to the bathroom; however, she slipped and fell and complained of right shoulder pain. The physician was notified and ordered an X-ray (a type of electromagnetic radiation used in medical imaging to create detailed images of internal structures, such as bones, organs, and blood vessels) of the right shoulder. During a review of Resident 1's Radiology Results Report , dated 3/14/2025 at 7:44 p.m., the report indicated no evidence of acute fracture or dislocation. During a review of Resident 1's Fall Risk Evaluation , progress note dated 3/14/2025 at 1:09 p.m., the Evaluation indicated Resident 1 had a history of 1-2 falls in the past three months, had a mental status of alert (oriented X 3) or comatose, and ambulatory and continent. The Fall Risk Evaluation progress note indicated Resident 1 had a change in gait pattern when walking through a doorway and jerking or unstable when making turns. The Evaluaton further indicated Resident 1 currently takes 3-4 medications and has a high fall risk score of 14.0. During a review of Resident 1's untitledcare plan, dated 3/14/2025, the care plan indicated Resident 1 had an actual fall with minor injury related to the slip and fall incident. The care plan goal indicated Resident 1 will resume usual activities without further incident through the review date of 6/05/2025. The nursing care plan included interventions to continue interventions on the at-risk plan (floor mats, low height bed, etc.), conduct neuro-checks (evaluates brain and nervous system functioning), keep resident floor clean and dry, and carry out physician orders for x-ray to the right shoulder. During a review of Resident 1's Change of Condition Evaluation , dated 3/20/2025, at 12:50 p.m., theEvaluation indicated Resident 1 had a fall. Resident 1 was witnessed by her certified nursing assistant (CNA) standing by her bedroom closet. Resident 1 walked back to her bed and stumbled to the floor, landing on her buttocks. Resident 1 had one slipper on her foot made of rubberymaterial. During a review of the Fall Risk Evaluation progress note dated 3/20/2025 at 3:16 p.m., the Evaluation indicated Resident 1 had no history of falls in the past threemonths, which is incorrect because Resident 1 had an actual fall on 3/14/2025. The Fall Risk Evaluation indicated Resident 1's level of consciousness alert (oriented X 3) or comatose and Resident 1 is ambulatory and continent, and no predisposing (risk factors that make a person more susceptible to developing a disease) disease. The Fall Risk Evaluation progress note indicated Resident 1 had a change in condition in the last 14 days related to anemia and behavior. The evaluation further indicated Resident 1 has a balance problem while walking and currently takes three to four medications. Resident 1 has had a change in medication (or medication classes) or change in dosage in the past five days. Resident 1's fall score is 10.0. On admission, Resident 1 had an initial fall risk score of 19.0, and after the first fall the fall risk score was 14.0, and now after the 2nd fall, the fall risk score was 10.0. During a review of Resident 1's untitledcare plan, dated 3/20/2025, the care plan indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055167 If continuation sheet Page 2 of 3 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055167 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Vernon Healthcare Center 1037 W. Vernon Avenue Los Angeles, CA 90037 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 had an actual fall with no injury, related to poor balance and unsteady gait. Resident 1 was ambulating in her room and stumbled. The care plan goal indicated Resident 1 will resume usual activities without further incident through review date 6/05/2025. The care plan nursing interventions included to perform neuro checks as indicated, monitor/document/report as needed for 72 hours signs and symptoms of pain, bruises, change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Monitor labs and notify the medical doctor of abnormal results and conduct a physical therapy consult for strength and mobility. During a review of Resident 1's Change of Condition Evaluation , dated 3/22/2025, at 7:55 p.m., the Evaluation indicated Resident 1 had a fall, staff witnessed Resident 1 fall out from her wheelchair landing on the floor with her buttocks. The physician was notified and ordered staff to monitor Resident 1. During a review of the Fall Risk Evaluation progress note, dated 3/22/2025 at 8:44 p.m., the progress noteindicated Resident 1 had one to two falls in the past three months. Resident 1 has had threefalls in nine days. The Fall Risk Evaluation indicated Resident 1's level of consciousness is alert (oriented X 3) or comatose and Resident 1 is ambulatory, continent, and had no predisposing disease. The Fall Risk Evaluation progress note indicated Resident 1 had a change in condition in the last 14 days. Resident 1 had a balance problem while walking and currently takes three to four medications. The Fall Risk Evaluation Progress note indicated Resident 1 has had a change in medication (or medication classes) or change in dosage in the past five days and has a fall risk score of 10.0. During a review of Resident 1's untitled care plan, dated 3/22/2025, indicated Resident 1 had an actual fall with no injury, the fall was related to poor balance, unsteady gait. The care plan further indicated Resident 1 tried to transfer from the wheelchair unsuccessfully. The care plan goal indicated Resident 1 would resume usual activities without further incident through the review date 06/05/2025. The care plan interventions included to continue interventions on the at-risk plan, for no apparent acute injury, determine and address causative (a specific effect or is responsible for a particular event or result) factors of the fall and take blood pressure lying/sitting/standing X 1 in the first 24 hours. During an interview on 4/10/2025 at 2:15 p.m. with the Director of Nursing (DON), the DON acknowledged Resident 1 had 3 falls and IDT meetings were not conducted after each fall. The DON stated failure to conduct an IDT meeting post falls and implement safety measures to prevent falls jeopardizedResident 1's safety. The DON stated the inaccurate fall scores were due to incorrect information documented in the computer and may jeopardize Resident 1's safety. During a review of the facility's policy and procedure titled Fall Management Program , dated March 13, 2021, the policy indicated the purpose of the policy is to provide residents a safe environment that minimizes complications associated with falls. The IDT will initiate, review and update the Resident's fall risk status and care plan at the following intervals: on admission, quarterly, annually, upon identification of a significant change of condition post falls and as needed. The IDT will investigate the fall including a review of the Resident's medical record, post huddle and review of the incident and Accident report. The IDT will review the circumstances surrounding the fall then summarize their conclusions on an IDT note. In an effort to prevent more falls, the IDT will review and revise the care plan as necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055167 If continuation sheet Page 3 of 3