Health inspection·September 12, 2025

F 0627 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to:1 1. Ensure one of three sampled residents (Resident 1) who was transferred to a General Acute Care Hospital (GACH) on 8/15/2025 due to altered mental status ([AMS] - a significant change in a person's awareness, consciousness, and cognitive function, such as confusion, disorientation, drowsiness, or unresponsiveness) was readmitted to the facility when the GACH cleared him to return to the facility on 8/29/2025. This deficient practice resulted in Resident 1 remaining in the hospital for 14 days beyond the initial date of discharge. Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included liver cirrhosis (a chronic liver disease characterized by the formation of scar tissue in the liver), chronic obstructive pulmonary disease ([COPD] a chronic lung disease causing difficulty in breathing), and bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs). During a review of Resident 1's History and Physical (H&P), dated 7/7/2025, the H&P indicated, Resident 1 could make needs known but could not make medical decisions. During a review of Resident 1's Social Services Assessment, dated 7/28/2025, The Social Services Assessment indicated, Resident 1 had no active discharge plan to return to the community and to remained as long-term care resident. During a review of Resident 1's Minimum Data Set ([MDS] - a resident assessment tool), dated 8/15/2025, the MDS indicated, Resident 1 had modified independence in cognitive skills (problems with ability to think, use judgment, and reason) for daily decision making. The MDS indicated, Resident 1 was independent (resident completes the activity with no assistance from a helper) with eating, oral hygiene, and personal hygiene. During a review of Resident 1's Progress Notes, dated 8/15/2025 at 4:20 p.m., the Progress Notes indicated, Resident 1 was transferred to the GACH for altered mental status ([AMS] - a significant change in a person's awareness, consciousness, and cognitive function, such as confusion, disorientation, drowsiness, or unresponsiveness). During a review of Resident 1's GACH Discharge Planning Progress Note, dated 8/29/2025, the GACH Discharge Planning Progress Note indicated, Resident 1 had a discharge order to be back to the facility. The GACH Discharge Planning Progress Note, indicated the facility admission Director (AD) denied Resident 1 to be readmitted to the facility because there was no male bed available. During a review of Resident 1's GACH Discharge Planning Progress Note, dated 8/31/2025, the GACH Discharge Planning Progress Note indicated, the facility denied Resident 1 to be readmitted because there was no male bed available. During a review of Resident 1's GACH Discharge Planning Progress Note, dated 9/2/2025, the GACH Discharge Planning Progress Note indicated, the facility AD denied Resident 1 to be readmitted because there was no male bed available.During a review of Resident 1's GACH Discharge Planning Progress Note, dated 9/3/2025, the GACH Discharge Planning Progress Note indicated, the facility AD denied Resident 1 to be readmitted because there was no male bed available.During a review of (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055167 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 09/12/2025 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)