Health inspection·June 6, 2025

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few review of this care plan indicated the facility canceled the care plan on 5/13/2025.A review of the Resident 1's medical record indicated there was no Behavior or Schizophrenia care plan in place from 5/13 5/26/2025.During a review of Resident 1's History and Physical (H&P), dated 5/13/2025, the H&P indicated Resident 1 could not make medical decisions due to impaired judgement.During a review of Resident 1's MDS, dated [DATE], the MDS indicated Resident 1 had the ability to express ideas and wants, and the ability to understand others. The MDS indicated the resident had trouble falling or staying asleep or sleeping too much for about 7-11 days over the last two weeks. The MDS indicated Resident 1 did not exhibit any physical or verbal behaviors directed towards others, which contradicted the April 2025 COC.During a review of Resident 1's COC dated 5/26/2025, the COC indicated Resident 1 was restless, taking trash from the trashcan and throwing it on the floor. The COC indicated Resident 1 was informed that his behavior was inappropriate and unacceptable. The COC indicated Resident 1 laughed hysterically and continued with the disruption. Nurse Practitioner (NP) 1 was notified of Resident 1's behavior.A review of Resident 1's Behavior Management related to New Disruptive behavior care plan dated 5/26/2025 indicated interventions to ensure safety of resident and others and to initiate visual supervision during acute episode. This care plan did not indicate Resident 1's diagnosis of Schizophrenia.A review of Resident 2's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia (a subtype of schizophrenia with prominent delusions and hallucinations often involving false beliefs of being watched or targeted), depression (persistent sadness and loss of interest in activities), and muscle weakness.During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had the ability to express ideas and wants, and the ability to understand others. The MDS indicated the resident needed partial assistance from another person to complete activities.During a review of Progress Notes dated 5/27/2025 at 1:46 pm, the progress notes indicated Resident 1 was restless, removing linens off roommates' bed and throwing away card games off tables in the activities room. The progress note indicated Resident 1 was reluctant when redirected.A review of Resident 1's COC dated 5/27/2025 at 10 pm, indicated Resident 1 and Resident 2 had a physical altercation. The COC indicated Resident 1 had an outburst of anger and hit Resident 2 in the chest. Resident 1 was administered Ativan, Haldol and Benadryl intramuscular for aggressive behavior.A review of the facility's Fax Document sent to the Department, dated 5/28/2025, indicated there was an altercation involving Resident 1 and Resident 2 on 5/27/2025 at around 10 pm. The fax document indicated after the residents were separated, Resident 1 was assigned a 1:1 sitter (a care giver who provides one on one constant observation and support, a safety measure for residents at risk of harming themselves or others) and Resident 2 had no injury.A review of the Progress Note dated 5/29/2025 indicated Resident 1 was transferred to the General Acute Care Hospital (GACH) for acute psychiatric care.During an interview on 6/5/2025 at 11:35 am, Certified Nursing Assistant (CNA) 1 stated that on 5/27/2025 during the morning shift (7 am - 3 pm), Resident 1 was behaving erratically (unpredictable), throwing blankets and plates on the floor.During an interview on 6/6/2025 at 12:45 pm, Licensed Vocational Nurse (LVN) 1 stated documentation for Resident 1's behavior should have been done more often because Resident 1 was constantly disruptive and verbally aggressive toward staff.During a concurrent interview and record review on 6/6/2025 at 1:30 pm with the Director of Nursing (DON), Resident 1's care plan dated 5/26/2025 titled Behavior Management related to New Disruptive behavior was reviewed. The care plan did not include any individualized person-centered interventions for Resident 1, such as how or how often staff were to monitor Resident 1. The DON stated the interventions were not appropriate or effective for Resident 1's behaviors and staff were required to evaluate care plan interventions for their effectiveness and update (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 06/06/2025 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 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete or revise the interventions based on resident's behavior and needs. The DON stated the potential outcome of not developing a person-centered care plan with effective interventions for a resident with aggressive behavior were safety issues and harm.During an interview on 6/6/2025 at 1:55 pm, the Administrator (ADM) stated Resident 1's behavior was mostly outbursts. The ADM stated, He writes on walls and takes down the facility's decorations. To ensure safety of residents and others, we ask people to give him space until he works through his episodes. The ADM stated she was the facility's Abuse Coordinator and did not know what could have been done to keep the residents safe.A review of the facility policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised November 2018, indicated the facility would ensure that a comprehensive person-centered care plan was developed for each resident. The P&P indicated the facility would provide care that reflected best practice standards for meeting psychosocial, behavioral and safety needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being. The care plan indicated additional changes or updates to the residents' comprehensive care plan would be made on the assessed needs of the resident. The comprehensive care plan would be periodically reviewed and revised after each MDS assessment as required.A review of the facility P&P titled, Resident To Resident Altercations, Revised November 2015, indicated facility staff observed residents for aggressive or inappropriate behavior toward other residents, family members, visitors, or facility staff. The P&P indicated the facility would act promptly and conscientiously to prevent and address altercations between residents.A review of the facility P&P titled, Behavior/Psychoactive Drug Management, revised November 2018, indicated the facility provided a therapeutic environment to meet the safety and behavioral needs of patients, and to obtain or maintain the highest physical, mental, and psychosocial well-being of the patients.A review of the facility P&P titled, Abuse - Prevention, Screening, & Training Program, revised July 2018, indicated the facility would prevent and did not condone any form of abuse or neglect. The P&P indicated the ADM as the abuse prevention coordinator was responsible for the coordination and implementation of the facility's abuse prevention, program policies and that the facility established a safe environment that reasonably supports residents. Event ID: Facility ID: 055167 If continuation sheet Page 3 of 3