Vernon Healthcare Center
VERNON HEALTHCARE CENTER in LOS ANGELES, CA — inspection on January 9, 2026.
Found 10 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Summary Report, dated 12/18/2025, the physician orders indicated a controlled carbohydrate diet for Resident 82.During an observation on 1/6/2026 at 12:49 p.m., CNA 1 was feeding Resident 82 while standing.
During a concurrent observation and interview on 1/6/2026 at 12:52 p.m., with CNA 1, in Resident 82's room, CNA 1 was feeding standing and leaning over Resident 82 while feeding him. CNA 1 stated the process was to sit with Resident 82 during feedings. CNA 1 stated the reason for sitting with Resident 82 was to make him feel more comfortable while he was eating.
During an interview on 1/7/2026 at 3:08 p.m., with Licensed Vocational Nurse (LVN) 3, LVN 3 stated when feeding the residents the Certified Nursing Assistants were to sit with the resident during feeding so the resident would feel dignified while eating. LVN 3 stated Resident 82 would feel more relaxed, not feel intimidated (behaviors that create fear compromises patient safety and well-being), and feel rushed to eat.During a review of facility's policy and procedures (P&P) titled, Restorative Dining Program, dated 1/2012, the P&P indicated the facility was to provide the opportunity for the residents to attain their highest level of independence in feeding.
The P&P indicated feeding techniques the staff member should sit while assisting or feeding resident.During a review a facility's P&P titled, Residents Rights- Accommodation of Needs, dated 1/2012, the P&P indicated the facility's environment is designed to assist the resident and maintaining the resident's dignity and well-being
055167 01/09/2026
Vernon Healthcare Center 1037 W.
Vernon Avenue Los Angeles, CA 90037
Resident 109, but the service options weren't checked. BOA 1 stated Resident 21 and Resident 109
review of the facility's policy and procedures (P&P), titled Beneficiary Notice Initiative, dated
Medicare beneficiaries of coverage decisions in accordance with Medicare guidelines for Medicare Part A and Part B coverage.
055167 01/09/2026
Vernon Healthcare Center 1037 W.
Vernon Avenue Los Angeles, CA 90037
a routine blood test that measures and evaluates your red blood cells, white blood cells, and platelets)
balance) labs were obtained for one of six sampled residents (Resident 4).This deficient practice had the potential to result in fluid and electrolyte imbalances.Findings:During a review of Resident 4's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 4 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 4's diagnoses included a encephalopathy (a disease in which the functioning of the brain is affected by an infection or toxins in the blood), dysphagia (difficulty swallowing), chronic kidney disease (a disease characterized by progressive damage and loss of function in the kidneys) and vitamin B-12 anemia (a condition where the body can't make enough healthy red blood cells because it lacks vitamin B12).During a review of Resident 4's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 10/23/2025, the MDS indicated Resident 4's cognitive (thinking) skills were severely impaired.
The MDS also indicated Resident 4 was dependent on staff with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During a record review of Resident 4's physician's orders, dated 11/21/2025, the physician's order indicated CBC and CMP.During a review of Resident 4's history and physical (H&P), dated 1/4/2026, the H&P indicated Resident 4 did not have the capacity to make decisions.During a record review of Resident 4's lab results, on 1/7/2026, Resident 4's CBC and CMP lab results couldn't be located in her medical chart or the facility's laboratory services binder.During a concurrent interview and record review, on 01/07/2026 at 2:43 p.m., with Licensed Vocational Nurse 1 (LVN 1), LVN 1 stated the protocol for physician orders are to be noted and carried out for all residents. LVN 1 stated the protocol for lab work order required a licensed nurse to notify the facility's lab company of a resident's new lab order.
LVN 1 stated the lab company would then come to the facility, review lab orders, and draw a resident's labs. LVN 1 stated upon drawing a resident's labs, the facility's lab company would provide a receipt for each resident seen indicating labs were drawn. LVN 1 stated she did not see a receipt for CBC and CMP labs nor results from labs being drawn for Resident 4. LVN 1 stated the risk of not carrying out physician orders for lab work could result in not knowing if the services were provided, a delay in nursing services, not following doctor's order and possible harm to a resident.During a review of the facility's policy and procedures (P&P), titled Laboratory Services, revised 1/1/2012, the P&P indicated, Upon receiving the order, the Licensed Nurse will do the following: Notify the laboratory of the laboratory orders.During a review of the facility's policy and procedures (P&P), titled Physician Orders, dated 12/28/2022, the P&P indicated, Lab orders will include the name of the desired test, the frequency, reason for the test and associated diagnosis.
055167 01/09/2026
Vernon Healthcare Center 1037 W.
Vernon Avenue Los Angeles, CA 90037
During a review of Resident 2's admission Record ([Face Sheet] front page of the chart that contains a summary of basic information about the resident), the Face Sheet indicated Resident 2 was initially admitted to the facility on [DATE] and was readmitted on [DATE]. Resident 2's diagnoses dementia (a progressive state of decline in mental abilities), muscle weakness (a reduced ability to generate force in muscles, impacting strength function, and movement), and chronic obstructive pulmonary disease ([COPD] - a chronic lung disease causing difficulty in breathing).
During a review of Resident 2's History and Physical (H&P), dated 10/22/2025, the H&P indicated, Resident 2 had cognitive impairment (problems with thinking abilities such as memory, concentration, decision-making, and problem solving).
During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 10/31/2025, the MDS indicated Resident 2's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired.
The MDS indicated Resident 2 was partial/moderate dependent (helper does less than half the effort) on staff for personal hygiene, showering, and dressing.
During a concurrent observation and interview on 1/7/2026 at 11:40 a.m., with Resident 2, in Resident 2's room, Resident 2 had a large amount of facial hair on chin and dirty fingernails that were untrimmed. Resident 2 stated she had not been shaved on her chin for a long time and did not want hair on her chin. Resident 2 stated she also would want her nails to be clean and trimmed. Resident 2 stated it was embarrassing to not have her face and nails not clean looking.
During a concurrent observation and interview on 1/7/2025 at 12:00 p.m., with Certified Nursing Assistant (CNA) 2, Resident 2 had a large amount of facial hair on chin and dirty fingernails that were untrimmed. CNA 2 stated Resident 2's did not look groomed due to her having facial hair on her chin and dirty nails. CNA 2 stated Resident 2 needed assistance with personal hygiene. CNA 2 stated the role of the CNAs to provide personal hygiene care to the residents on shower days and as needed.
CNA 2 stated not grooming Resident 2 could make her feel non-presentable.
During a concurrent observation and interview on 1/7/2026 at 1:58 p.m., with Registered Nurse (RN) 1, Resident 2 had a large amount of facial hair on chin and dirty fingernails that were untrimmed. RN 1 stated Resident 2's had facial hair, and her nails were dirty and untrimmed. RN 1 stated it was important for Resident 2 to be groomed and have trimmed clean nails for her overall well-being.
During a review of facility's policy and procedure (P&P) titled Grooming, dated 1/2012, the P&P indicated the facility will work with residents to improve their ability to groom, to promote independence, hygiene, comfort, self-esteem and dignity.
The P&P indicated to assist with shaving and hair grooming.
The P&P indicated nail care with nail brush to remove dirty particles under nail and keep nails short.
055167 01/09/2026
Vernon Healthcare Center 1037 W.
Vernon Avenue Los Angeles, CA 90037
mattress designed to prevent and treat pressure wounds) setting was correct for one of six sampled
breakdown.Findings:During a review of Resident 3's face sheet (front page of the chart that contains a summary of basic information about the resident), the face sheet indicated Resident 3 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 3's diagnoses included a stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle), dysphagia (difficulty swallowing), type 2 diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and urinary tract infection (UTI- an infection in the bladder/urinary tract).During a review of Resident 3's history and physical (H&P) form, dated 10/1/2025, the H&P indicated Resident 3 had the capacity to understand and make decisions.During a review of Resident 3's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 10/15/2025, the MDS indicated Resident 3's cognitive (thinking) skills were cognitively intact.
The MDS also indicated Resident 3 was dependent on staff with Activities of Daily Living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).During an observation, on 1/6/2025 at 10:13 a.m., Resident 3 was observed lying in bed on a low air loss mattress with weight settings at 150 lbs.During a record review, on 1/6/2025 at 1:57 p.m., of Resident 3's weight, Resident 3's weight indicated Resident 3 weighed 206 lbs.During a concurrent observation and interview, on 1/8/2026 at 1:46 p.m., with the Treatment Nurse 1 (TN 1), TN 1 observed and stated Resident 3's low air loss mattress settings were set to 150 lbs.During a concurrent interview and record review, on 1/8/2026 at 2:31 p.m., with TN 1, TN 1 stated all low air loss mattresses settings was based on a resident's weight. TN 1 stated the purpose of low air loss mattresses was to prevent further skin breakdown in residents with pressure ulcers. TN 1 stated that Resident 3 weighed 206 lbs. TN 1 stated Resident 3's low air loss mattress setting was incorrect. TN 1 stated the risk of setting a low air loss mattress on a wrong weight or setting could result in further skin breakdown.During a review of the facility's policy and procedures (P&P), titled Mattresses, dated 1/1/2012, the P&P indicated, The Facility will provide mattresses capable of meeting the following needs of residents: To provide pressure reduction to residents at risk for skin breakdown. To distribute body weight relieving areas of pressure.
055167 01/09/2026
Vernon Healthcare Center 1037 W.
Vernon Avenue Los Angeles, CA 90037
professional principles; and all drugs and biologicals must be stored in locked compartments,
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on
failed to organize stored items in the medication storage room.This failure had the potential to result in staff using expired items for specimen collection and a delay of care for residents while searching for necessary care items.During an observation on [DATE] at 12:33 p.m., in the medication storage room, the following was observed:One open bottle of baby oil in the far-right upper cabinet,Two containers of air freshener, a used face mask, one BD Safety Glide 1mL syringe, and multiple specimen bags were in drawer 1, labeled elastic bandage rollsTwo expired Aptima urine specimen collection kits dated [DATE], (6) 4 mL expired vacutainers, and (1) expired HOLOGIC Aptima 2cc urine specimen container dated [DATE], in the second drawer 2 to the left.
During an interview on [DATE] at 12:50 p.m., with LVN2, in the medication storage room, LVN2 stated that baby oil is not medication and should not be in the medication storage room. LVN2 stated that expired items cannot be used and if they were to be accidentally used there could be a risk of incorrect results if used beyond the expiration date, and when items are not stored in an organized manner, it will take a longer time to provide care.During a review of the Medication Storage in the Facility Policy & Procedure (P&P), dated [DATE], the P&P indicated, medication and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.
Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity.
055167 01/09/2026
Vernon Healthcare Center 1037 W.
Vernon Avenue Los Angeles, CA 90037
During a review of Resident 2's History and Physical (H&P), dated 10/22/2025, the H&P indicated, Resident 2 had cognitive impairment (problems with thinking abilities such as memory, concentration, decision-making, and problem solving).
During a review of Resident 2's Minimum Data Set ([MDS] a resident assessment tool), dated 10/31/2025, the MDS indicated Resident 2's cognition (ability to learn, reason, remember, understand, and make decisions) was moderately impaired.
The MDS indicated Resident 2 was partial/moderate dependent (helper does less than half the effort) on staff for personal hygiene, showering, and dressing.
During a review of Resident 2's Medication Regimen Review (MRR) titled, Consultant Pharmacist's MRR, dated 12/27/2025, the MRR indicated please ensure to obtain CMP (standard blood test to check fluid/electrolyte balance), CBC (test to measure the numbers and size of the different cells in blood), and valproic level (to measure the effective range in the bloodstream during treatment).
During a concurrent interview and record review on 1/8/2026 at 1:40 p.m., with Registered Nurse (RN) 1, the MRR titled, Consultant Pharmacist's MRR, dated 12/27/2025 was reviewed.
The MRR indicated please ensure to obtain CMP, CBC, and valproic level. RN 1 stated there was no documentation and the recommendations were not acknowledged. RN 1 stated when the laboratory recommendations were in place; an order request should have been placed to the physician. RN 1 stated there was a recommendation it should take no more than three days to complete. RN 1 stated Resident 2's blood work was not drawn. RN 1 stated the staff had failed to carry out the recommendations. RN 1 stated this could have potentially affected Resident 2's medication regime and caused a delay in care.
During a review of the facility's policy and procedures (P&P) titled, Consultant Pharmacist Reports, dated 12/2019, the P&P indicated MRR includes evaluation the resident's response to mediation therapy to determine that the resident maintains the highest practicable level of functioning and preventing adverse consequences related to medication therapy.
The P&P indicated recommendations are acted upon and documented by the facility staff.
055167 01/09/2026
Vernon Healthcare Center 1037 W.
Vernon Avenue Los Angeles, CA 90037
serve food in accordance with professional standards.
can of cherry fruit filling, in the dry storage room was disposed. 2.
Four cereal bowls on the shelf in
without use by date (the last day a manufacturer recommends consuming a product for peak quality and safety).4.
The Dietary Aide (DA) 1 had touched the cleaned dishes after touching dirty dishes without removing gloves and washing her hands.These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illness in 87 out of 93 residents who received food from the kitchen.During a concurrent observation and interview on 1/6/2026 at 8:40 a.m., with Dietary Services Supervisor (DSS), in the dry storage room, there was one large can of expired cherry fruit filling and four bowls of dry cereal without a used by date was reviewed.
The DSS stated that the can of cherry fruit filling was expired should have been disposed.
The DDS stated the bowls of cereal did not have a used by date.
The DSS stated these items should have been thrown away so it's not used again.
The DSS stated had the potential to make the residents sick.During a concurrent observation and interview on 1/6/2026 at 8:45 a.m., with the DSS, at the refrigerator (reach in), there were containers of applesauce, juice, and jelly without use by date.
The DSS stated the items did not have a used by date.
The DSS stated the purpose of utilizing the use by date, so the staff knows when to toss the items to prevent illnesses to residents.During a concurrent observation and interview on 1/6/2026 at 9:00 a.m., with the DSS, the Dietary Aide (DA) 1 did not remove gloves nor washed her hands after touching dirty dishes and went to touch clean dishes with the same gloves.
The DSS stated one staff member is responsible for washing the dirty dishes and another dietary aide was responsible for the clean dishes.
The DSS stated DA 1 was to remove her gloves and wash her hands after touching the dirty dishes.
The DSS stated this would prevent cross-contamination and not spread to the residents.During a review of the facility's policy and procedures (P&P) titled, Food Storage and Handling, dated 6/2024, the P&P indicated dry storage area place opened products in storage containers that are labelled and dated.
The P&P indicated canned fruit storage use within 12 months.During a review of the facility's policy and procedures (P&P) titled, Dietary Department- Infection Control, dated 6/2024, the P&P indicated proper hand washing after handling soiled equipment or utensils and immediately before engaging with clean equipment and utensils.
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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
055167 01/09/2026
Vernon Healthcare Center 1037 W.
Vernon Avenue Los Angeles, CA 90037
hygiene (cleansing hands with soap or an alcohol-based rub), at the door of room [ROOM NUMBER],
potential for cross contamination (process by which bacteria or other microorganisms are unintentionally transferred from one object or person to another, with harmful effect) and risk to exposure of residents to infectious organisms (germs).During an observation on 1/8/2026 at 7:47 a.m., at medication cart #1, LVN1 failed to perform hand hygiene before preparing medication cups for medication administration (the action of dispensing, giving, or applying something) .During an interview on 1/8/2026 at 7:50 a.m. with LVN1, LVN1 stated cross contamination (the process by which bacteria or other germs are transferred from one substance or object to another) could occur, or a serious illness could be spread to someone.During a review of the Preparation and General Guidelines IIA2: Medication Administration-General Guidelines Policy & Procedure (P&P), dated May 2022, the P&P indicated the person administering medications adheres to good hand hygiene, which includes washing hands thoroughly: before beginning a medication pass.
055167 01/09/2026
Vernon Healthcare Center 1037 W.
Vernon Avenue Los Angeles, CA 90037
During a review of the facility's waiver request for bedrooms to measure at least 80 sq. ft. per resident letter, dated 10/1/2025, the facility's waiver request submitted by the Administrator (Admin) for 31 out of 34 resident rooms was reviewed.
The waiver request letter indicated the granting of the waiver will not adversely affect the residents' health and safety and in accordance with the special needs of the residents at the facility.
The following rooms provided less than 80 sq. ft per resident:Room NumbersNumber of Residents Square Footage23221.633221.643223.253221.663222.673222.683223.393222.6103222.6113222.6123224.2143222.6153222.6163224.2173224.2183224.2213223.2223224.2233222.6243224.2253222.6263224.2273224.2283222.6293224.2303221.6313224.2323224.2333222.6343222.6353222.6 During an interview on 1/8/2025 at 2:01 p.m. with the Administrator (Admin), the Admin confirmed the facility had rooms less than the required 80 sq. ft. per resident.
The Admin stated there had not been any complaints from residents about the amount of square footage in their rooms nor had it affected residents in an adverse effect regarding health and safety.
The Admin stated staff were also still able to continue to render all residents' care and necessary services without any harm or safety issues due to the lack of necessary footage.The minimum sq. ft. for a three residents capacity bedroom is 240 sq. ft.