LOS ANGELES, CA - A resident with Alzheimer's disease walked away from Avalon Villa Care Center unsupervised on November 24, 2024, and remains missing more than two months later, according to a state inspection that identified serious safety deficiencies at the 12029 Avalon Blvd facility.
Resident Disappears Despite Prior Warning Signs
The January 31, 2025 inspection revealed that Resident 118, who had been diagnosed with Alzheimer's disease and substance-induced dementia, managed to leave the facility undetected for the second time in just 42 days. The resident had previously left the facility without authorization on October 13, 2024, but was found and readmitted on an unspecified date shortly thereafter.
Despite the earlier incident and an assessment showing the resident was at high risk for wandering and elopement, facility staff failed to implement adequate safeguards. State surveyors documented that when staff discovered the resident missing at 3:35 p.m. on November 24, they conducted a thorough search both inside and outside the facility but were unable to locate him. As of the inspection date—66 days after the disappearance—the resident had not been found.
The resident, who required moderate assistance with daily activities like toileting, bathing, and dressing, typically used a walker for mobility. His moderately impaired cognitive function made him particularly vulnerable to the dangers associated with unsupervised wandering.
Critical Lapses in Safety Planning and Staff Communication
Investigators found that after the first elopement in October, the facility failed to develop a comprehensive care plan to address the resident's wandering behavior and prevent future incidents. According to facility staff interviewed during the inspection, care plans serve as essential communication tools that document a resident's problems or risk factors, establish goals, and outline specific interventions staff should implement.
Without such a plan, nursing staff lacked clear guidance on how frequently to monitor the resident, what specific behaviors to watch for, and how to respond if he attempted to leave again. One registered nurse told surveyors that the absence of a care plan meant "the staff was unaware how to properly care for Resident 118."
The facility's communication systems for identifying high-risk residents proved inadequate. Staff reported that information about residents at risk for elopement was only shared during shift-change meetings within individual nursing stations, not facility-wide. Since the building was divided into four separate stations, nurses and nursing assistants working in other areas would not know if a high-risk resident wandered into their section.
One registered nurse explained that if the ambulatory resident "walked to a different station, the staff would not know Resident 118 required close supervision to prevent wandering and elopement." The facility had no visual identification system to help staff quickly recognize residents at elevated risk.
Room Placement Increased Escape Risk
Adding to the safety concerns, when Resident 118 returned to the facility after his first elopement, staff placed him in a room near the lobby exit door—a location that potentially facilitated his second, successful escape attempt. Multiple nurses acknowledged during interviews that the room assignment was inappropriate given his elopement history.
One registered nurse stated the resident "should have been placed in a room closer to the nurse's station so Resident 118 could be easily monitored more closely." Another nurse who handled the readmission said "the idea of a room change crossed her mind due to Resident 118's prior elopement but did not initiate a room change."
This decision directly contradicted basic safety principles that call for placing at-risk residents in locations where staff can provide enhanced supervision. The proximity to an exit door gave the resident easy access to leave the building undetected.
Missing Critical Safety Meetings and Assessments
The facility also failed to conduct an interdisciplinary team meeting after the first elopement—a crucial step that brings together nurses, social workers, therapists, and other staff to analyze why an incident occurred and develop prevention strategies. According to the Minimum Data Set Coordinator, such meetings provide an opportunity to understand why a resident wants to leave, address underlying concerns, educate the resident about safety risks, and create a coordinated plan involving all departments.
"The MDSC stated during the IDT meeting, Resident 118 would have been educated on the importance of safety and encouraged not to elope from the facility due to the risk of getting hit by a car or ultimately death," the inspection report noted.
Additionally, nurses did not complete a required 72-hour monitoring assessment when the resident returned after his first elopement. This assessment helps staff evaluate how a resident is adjusting to the facility and identify concerning behaviors like exit-seeking that require intervention.
Health Risks of Prolonged Absence
When individuals with Alzheimer's disease and dementia wander away from supervised care, they face numerous serious health threats. Cognitive impairment affects their ability to recognize danger, navigate safely, seek help, or remember basic survival needs.
Without access to regular meals and hydration, missing persons with dementia can rapidly develop malnutrition and dehydration—conditions that become life-threatening within days, particularly in elderly individuals with existing health conditions. Dehydration can lead to confusion, electrolyte imbalances, kidney failure, and cardiovascular complications. Malnutrition weakens the immune system and accelerates physical decline.
Environmental exposure presents another critical danger. Depending on weather conditions, missing individuals face risks of hypothermia, heat stroke, and related complications. The inspection report specifically noted the likelihood of "exposure to harsh environmental conditions including excessive cold" as a concern for the missing resident.
Cognitive impairment also increases vulnerability to accidents. Individuals with dementia may wander into traffic, become disoriented in unfamiliar areas, or encounter other hazards they cannot recognize or avoid. The combination of physical frailty, cognitive deficits, and lack of supervision creates conditions where serious injury or death becomes increasingly probable with each passing day.
Immediate Jeopardy Determination and Required Corrections
State surveyors declared the situation an "immediate jeopardy" on January 29, 2025—a designation reserved for the most serious violations that have caused or are likely to cause serious injury, harm, or death to residents. The facility submitted an acceptable removal plan on January 31, which was verified and the immediate jeopardy status was lifted after implementation of corrective measures.
The facility conducted a comprehensive assessment of all current residents and identified three additional individuals at high risk for elopement. Staff developed individualized care plans for these residents with specific monitoring interventions and goals.
To improve identification of at-risk residents, the facility adopted a color-coded system using blue stickers on wristbands and door tags. They created blue-tabbed sections in binders at each nursing station listing high-risk residents, with information to be reviewed during daily shift huddles. Additional binders were placed in activity, dietary, and housekeeping departments for facility-wide awareness.
The facility updated its policies to require interdisciplinary team meetings within two days of identifying wandering behavior or high elopement risk. New protocols mandate hourly monitoring documented on behavior logs, with registered nurses reviewing compliance daily. The facility also established procedures to evaluate room assignments for at-risk residents, particularly those located within 30 feet of exit doors.
Staff education began immediately, with mandatory training covering the updated policies, supervision requirements, identification of high-risk residents, the color-code system, and location of communication binders. The facility committed to completing 100% staff training and providing ongoing education at least quarterly.
Additional Issues Identified
Beyond the elopement failures, inspectors documented several other safety and care concerns:
Inadequate Meal Documentation: Staff inaccurately recorded that one resident consumed 60-70% of meals when the resident actually ate nothing, potentially masking malnutrition risks and preventing appropriate dietary interventions.
Pressure Ulcer Equipment Errors: A low-air-loss mattress designed to prevent and treat pressure ulcers was set for a 150-pound patient when the resident actually weighed 118 pounds, creating excessive pressure that could worsen existing wounds or cause new skin breakdown.
Missing Fall Prevention Equipment: Despite a care plan requiring a floor mat beside the bed of a fall-risk resident with a history of falls, no mat was present during multiple observations over four days.
Incomplete Care Planning: The facility failed to develop care plans addressing multiple residents' safety needs, including those at high risk for wandering, residents using bed rails for mobility assistance, and a resident taking sleep medication requiring monitoring.
Diet Order Violations: A resident with swallowing difficulties did not receive prescribed nutritional supplements and texture-modified foods as ordered during multiple observed meals.
Unreported Security Incident: The facility failed to notify the State Agency after an incident on November 9, 2024, when a resident trespassed on facility premises carrying a large knife.
Unsecured Lighters: Lighters belonging to two residents were not properly secured, creating fire hazards for other residents assessed as unsafe to independently use such items.
The inspection revealed systemic failures in safety monitoring, care planning, staff communication, and risk assessment that extended across multiple areas of facility operations.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Avalon Villa Care Center from 2025-01-31 including all violations, facility responses, and corrective action plans.
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