Health inspection·December 9, 2025

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to document a change of condition (COC) assessment for one of six sampled Residents (Resident 6) when Resident 6 refused psychotropic medications. This deficient practice had the potential to result in Resident 6 not receiving proper monitoring and treatment for behavior changes and placed Resident 6 at risk for hospitalization. Findings:During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included schizoaffective disorder, bipolar disorder, epilepsy (a chronic neurological condition marked by recurrent, unprovoked seizures, which are sudden bursts of abnormal electrical activity in the brain).During a review of Resident 6's History and Physical (H&P) dated 12/4/2025, the H&P indicated Resident 6 had the capacity to make needs known but could not make medical decisions.During a review of Residents 6's Minimum Data Set (MDS - a resident assessment tool) dated 11/25/2025, the MDS indicated Resident 6 had severe cognition impairment. The MDS indicated Resident 6 required supervision or touching assistance from staff with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer and mobility.During a concurrent observation and interview on 12/9/2025 at 9:45 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 was passing medication to Resident 6. Resident 6 refused to take all the medications. LVN 2 stated Resident 6 would often refuse medications. LVN 2 stated on 12/8/2025 and 12/9/2025 when Resident 6 refused medications, LVN 2 documented Resident 6 refused but did not document a COC.During an interview on 12/9/2025 at 11:05 a.m. with Resident 6, Resident 6 stated she did not take medications, and she did not need medication.During an interview on 12/9/2025 at 3:00 p.m. with LVN 2, LVN 2 stated refusing medications was a change in condition and must be documented. LVN 2 stated that if Resident 6 was not taking her medications, she could be at risk of mood changes and that could exacerbate her behavior and may cause transfer to the hospital. LVN 2 stated it was important to monitor her behavior on a continuous basis.During a concurrent interview and record review on 12/19/2025 at 4:50 a.m., with Director of Nursing (DON), Resident 6's COC was reviewed. The DON stated Resident 6 did not have a COC regarding refusal of medications. The DON stated the purpose of the COC was to ensure the nurses were aware of Resident 6's current condition and to monitor Resident's behavior. The DON stated by not having a COC, Resident 6 was at risk of not getting the care and monitoring that she required.During a review of the facility's policies and procedure (P&P) titled, Change of Condition dated 8/25/2022, the P&P indicated the licensed nurse would assess the change of condition and determined what nursing interventions are appropriate. The P&P indicated the licensed nurse would notify the residents' Physician and legal representative or an appropriate family member when there was any untoward response or reaction by patient to medications or treatment. Page 1 of 5 055167 055167 12/09/2025 Vernon Healthcare Center 1037 W. Vernon Avenue Los Angeles, CA 90037

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure a person-centered care plan was developed for one of six residents (Resident 6) who had been refusing to take medications. This failure had the potential for poor communication and result in the resident not receiving the necessary care and services to maintain its highest practicable physical, mental and psychosocial well-being. Findings:During a concurrent observation and interview on 12/9/2025 at 9:41 a.m., with Resident 6, Resident 6 was observed laying on bed covered with blankets. Resident 6 stated, I do not take medications but the nurses want me to take it. Resident 6 stated, I am okay, I do not need medication.During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included schizoaffective disorder (mental illness that is characterized by disturbances in thought), bipolar disorder (mood swings that range from the lows of depression to elevated periods of emotional highs), epilepsy (a chronic neurological condition marked by recurrent, unprovoked seizures, which are sudden bursts of abnormal electrical activity in the brain).During a review of Resident 6's H&P dated 12/4/2025, the H&P indicated Resident 6 had the capacity to make needs known but cannot make medical decisions.During a review of Residents 6's Minimum Data Set (MDS - a resident assessment tool), dated 11/25/2025, the MDS indicated Resident 6 had severe cognitive impairment. The MDS indicated Resident 6 required supervision or touching assistance with ADLs.During a review of Resident 6's Physicians Orders dated 12/2/2025, Resident 6's physician's orders indicated Aripiprazole tablet 10 milligrams (mg- a unit of measurement), 1 tablet by mouth at bedtime for schizoaffective disorder, Haloperidol oral tablet 10 mg tablet twice a day (BID) for schizoaffective disorder, Levetiracetam oral solution 100 mg, 5 milliliters (ml- a unit of measurement) by mouth BID for seizures, Divalproex Sodium oral solution 250mg/ 5 ml, 10ml by mouth BID for Bipolar.During a review of Resident 6's Care Plan on 12/9/2025. There is no care plan created for Resident 6's refusal of medications.During an interview on 12/9/2025 at 9:30 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated Resident 3 has a routine of refusing medications. LVN 2 stated Resident 3 needed to be encouraged to take medications several times so he will take it. LVN 2 stated the policy of the facility is to develop a care plan for refusal of medications.During an interview on 12/9/2025 at 9:45 a.m., with LVN 2 stated Resident 6 refused medication often.During an interview on 12/9/2025 at 3:00 p.m. with LVN 2, LVN 2 stated when residents refused medications, the medications should be re-offered at least 3 times and educate the residents about the consequence of refusing medicines. LVN 2 stated a care plan should be created when residents refuse medications so the nurses will be aware and implement the interventions outlined in the plan of care. the During an interview and record review on 12/9/2025 at 4:50 p.m., with Director of Nursing (DON), the DON stated care plan should have been developed for Resident 6 regarding the refusals to take medications. During a review of the facility's policies and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 8/24/2023, the P&P indicated updates to the resident's comprehensive care plan should be made based on the assessed needs of the resident. The P&P indicated the comprehensive care plan should be reviewed and revised to address changes in care. 055167 Page 2 of 5 055167 12/09/2025 Vernon Healthcare Center 1037 W. Vernon Avenue Los Angeles, CA 90037

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to: 1). Ensure three (3) of six (6) sampled residents' (Residents 1, 4, and 6) medications were administered timely. This failure resulted in delayed interventions and had the potential to exacerbate (worsen) the residents' conditionand can cause resident transfer to the general acute care hospital. 2). Ensure the Controlled Drugs-Count Record (Narcotic [medications that are regulated by law due to their potential for misuse or harm] count sheet), for two (2) of 3 medication carts at the facility, were completely filled-up. This deficient practice had the potential for loss of accountability, drug diversion, or theft.Findings:a). During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest) and hypertension (HTN-high blood pressure).During a review of Resident 1's History and Physical (H&P) dated 6/16/2025, the H&P indicated Resident 1 had fluctuating capacity to understand and make decisions.During a review of Residents 1's Minimum Data Set (MDS - a resident assessment tool) dated 11/2/2025, the MDS indicated Resident 1 had moderate cognition impairment. The MDS indicated Resident 1 required supervision or touching assistance with activities of daily living (ADLs) such as dressing, toilet use, personal hygiene, transfer and mobility.During a review of Resident 1's doctors' orders dated 12/19/2024, the doctors' orders indicated lithium carbonate (mood stabilize) oral 150 milligrams (mg a unit of measurement) three times (TID) a day for bipolar disorder (a mental condition marked by alternating periods of elation and depression), Lisinopril 5 mg daily for hypertension (HTN), Risperdal oral 1 mg two times a day (BID) for schizoaffective disorder, Gabapentin oral 100 mg twice a day (BID) for neuropathy (nerve damage).During a review of Resident 1's Medications Administration Record (MAR) for the month of 12/2025, the MAR indicated the following schedules for medication administration: 1). Lisinopril at 9:00 a.m. daily2). Risperdal at 9:00 a.m., and 5:00 p.m.3). Gabapentin at 9:00 a.m., and 5:00 p.m.4). Lithium carbonate at 9:00 a.m., 1:00 p.m., and 6:00 p.m.During a review of Resident 1's MAR Audit Report of Lithium carbonate, Lisinopril, Risperdal and Gabapentin dated 12/6/2025 timed 9:00 p.m., the medications were administered on 12/6/2025 at 10:55 a.m. b). During a review of Resident 4's admission Record, the admission Record indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 4's diagnoses included schizophrenia disorder (a mental illness that is characterized by disturbances in thought) type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and HTN.During a review of Resident 4's H&P dated 9/24/2025, the H&P indicated Resident 4 had the capacity to make needs known but cannot make medical decisions.During a review of Residents 4's MDS dated [DATE], the MDS indicated Resident 4 had moderate cognitive impairment. The MDS indicated Resident 4 required partial to moderate assistance with ADLs.During a review of Resident 4's doctors' orders dated 9/23/2025, the doctors' orders indicated Lisinopril oral 5 mg daily for HTN, Empagliflozin oral 10 mg daily for diabetes (abnormal blood sugar levels), Metformin oral 1000 mg BID for diabetes, Risperdal oral 2 mg BID for auditory hallucinations (a condition of hearing voices).During a review of Resident 4's MAR for the month of 12/2025, the MAR indicated the following schedules for medication administration:1). Empagliflozin at 9:00 a.m.2). Lisinopril at 8:00 a.m.3). Metformin at 9:00 a.m., and 5:00 p.m.4). Risperdal at 8:00 a.m., and 5:00 p.m.During a review of Resident 4's MAR Audit Report for Risperdal and lisinopril dated 12/5/2025, 12/6/2025 and 12/7/2025 timed 8:00 a.m., the 055167 Page 3 of 5 055167 12/09/2025 Vernon Healthcare Center 1037 W. Vernon Avenue Los Angeles, CA 90037

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medications were administered on 12/5/2025 at 10:35 a.m., on 12/6/2025 at 11:01 a.m., and on 12/7/2025, was administered at 11:36 a.m. The MAR Audit Report indicated Empagliflozin and Metformin scheduled for 12/5/2025, 12/6/2025 and 12/7/2025 timed 9:00 a.m., were administered on 12/5/2025 at 10:36 a.m., on 12/6/2025 at 11:01 a.m., and 12/7/2025 at 11:36 a.m. c). During a review of Resident 6's admission Record, the admission Record indicated Resident 6 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included schizoaffective disorder, epilepsy (a chronic neurological condition marked by recurrent, unprovoked seizures, which are sudden bursts of abnormal electrical activity in the brain) and dementia (a progressive state of decline in mental abilities).During a review of Resident 6's H&P dated 12/4/2025, the H&P indicated Resident 6 had the capacity to make needs known but cannot make medical decisions.During a review of Residents 6's MDS dated [DATE], the MDS indicated Resident 6 had severe cognitive impairment. The MDS indicated Resident 6 required supervision or touching assistance with ADLs.During a review of Resident 6's Physician's Orders dated 12/2/2025, the physician's orders indicated Levetiracetam oral solution 100 mg/ milliliters (ml- a unit of measurement) 5 ml BID for seizures, Memantine HCL oral 10mg BID for dementia, Haloperidol oral tablet 10 mg BID for schizoaffective disorder, Divalproex Sodium oral solution 250 mg/5ml 10ml by mouth BID for auditory hallucinations.During a review of Resident 6's MAR for the month of 12/2025, the MAR indicated the following schedules for medication administration:1). Levetiracetam at 8:00 a.m. and 5:00 p.m. 2). Memantine HCL at 9:00 a.m., and 5:00 p.m.3). Haloperidol at 9:00 a.m., and 5:00 p.m.4). Divalproex Sodium at 9:00 a.m. and 9:00 p.m.During a review of Resident 6's MAR Audit Report for Levetiracetam dated 12/3/2025, the MAR Audit Report indicated Levetiracetam was administered on 12/3/2025 at 9:28 a.m. The MAR Audit Report for Levetiracetam, Memantine HCL, Haloperidol and Divalproex Sodium dated 12/8/2025 indicated the medications were administered on 12/8/2025 at 10:46 a.m.During an interview on 12/9/2025 at 3:00 p.m., with Licensed Vocational Nurses (LVN) 2, LVN 2 stated the medications were administered more than one hour after the medication schedule. LVN 2 stated it was very important to follow doctors' orders for the effectiveness of the medication. LVN 2 stated not giving residents medications on time placed the residents at risk for behavioral changes. LVN 2 stated residents who do not receive the medication on time could exacerbate their behavior and can cause residents transfer to the hospital for behavior issues.During a concurrent interview and record review on 12/9/2025 at 4:02 p.m., with LVN 4, Resident 1 and Resident 4's MAR audit report for the month of 12/2025 were reviewed. LVN 4 stated the facility protocol in medications administration is to follow the doctors' orders. LVN 4 stated medications can be administered one hour before or after the scheduled time. LVN 4 stated if residents refuse to take medication at the time due, LVN should return and try to give the medication to the residents later. LVN 4 stated Resident 1 and Resident 4's medications were given late because Resident 1 did not want to take her medications on the scheduled time. LVN 4 stated when Resident 1's medications were given later; the actual time the medications were given was not changed. LVN 4 stated that when medication administration were not administered as ordered, resident's moods can be affected. LVN 4 stated medication delays could exacerbate resident symptoms and affect blood pressure, blood glucose levels placing the residents at risk of getting sicker. 2). During a concurrent record review and interview on 12/9/2025 at 11:10 a.m., with LVN 3, the Nurse's Station 2 Medication Cart 2 controlled drugs logbook titled, Controlled Drugs-Count Record, dated 11/28/2025 to 12/8/2024 was reviewed. LVN 3 stated the narcotic count sheet had 3 blank, unsigned spaces by licensed nurses. LVN 3 stated the logbook should be signed at the beginning of the shift once narcotics had been counted. LVN 3 stated the outgoing nurse will sign the narcotic logbook and give the cart keys.During a review of Controlled Drugs-Count 055167 Page 4 of 5 055167 12/09/2025 Vernon Healthcare Center 1037 W. Vernon Avenue Los Angeles, CA 90037

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record, dated 11/28/2025 to 12/8/2024, the narcotic count sheet indicated missing outgoing licensed nurse's signature in the signature box on 12/4/20025, 11 p.m., on 12/7/2025 11:00 p.m. by the in- coming nurse and on 12/8/2025 at 3:00 p.m. by the out-going nurse.During a concurrent record review and interview on 12/9/2024 at 11:20 a.m., of the Nurse station 1 Medication Cart 1 with LVN 1, the narcotic count sheet dated 11/28/2025 to 12/8/2024, indicated 2 blank, unsigned spaces by licensed nurses. LVN 1 stated the narcotic count sheet must be signed every change of shift/ after the nurses count the narcotics. During an interview on 12/9/2025 at 2:43 p.m., with LVN 1, LVN 1 stated the narcotic count sheet are signed at the beginning and of each shift. LVN 1 stated the out-going nurses will check the book and the incoming nurses will count and compare the correct amount of the narcotics counted. LVN 1 stated signing the narcotic before counting the medication is considered falsification of record and should be signed at change of shifts.During a review of the facility's policies and procedure (P&P) titled Medication Administration, dated 6/26/2025, the P&P indicated all medications shall be administrated by licensed nurses' staff according to physicians' orders, current best practice, and federal and state regulations. The P&P indicated the facility should ensure residents receive the correct medications in a timely, safe, and documented manner. The P&P indicated medications must be administrated within one hour before or one hour after the schedule time, unless a specific clinical reason requires a more rigid schedule.During a review of the facility's P&P titled Medication Storage in the Facility, dated 5/2022, the P&P indicated at each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items, should be conducted by two licensed nurses and is documented. 055167 Page 5 of 5