LOS ANGELES, CALIFORNIA - Federal inspectors documented critical lapses in resident assessments, mental health screenings, and care planning at Avalon Villa Care Center during a January 31, 2025 survey, with violations affecting multiple residents including repeated elopement incidents and medication management failures.
Resident Elopements and Missing Wandering Safeguards
The most concerning finding involved Resident 118, who left the facility without authorization on two separate occasions - October 13, 2025 and November 24, 2024. Despite the first elopement incident, facility staff failed to develop any care plan to prevent future occurrences. This represents a fundamental breakdown in resident safety protocols.
The inspection revealed that not only did Resident 118 lack an elopement prevention plan after the first incident, but three additional residents (Residents 48, 63, and 60) were identified as high risk for wandering and elopement yet had no care plans addressing these risks. Wandering occurs when residents roam around and become lost or confused about their location - a serious safety concern particularly for residents with cognitive impairments.
When residents with dementia or other cognitive conditions wander unsupervised, they face multiple dangers including exposure to weather extremes, traffic accidents, falls, and becoming lost. The facility's failure to implement monitoring and supervision protocols for these four high-risk residents created conditions where serious harm or death could occur. Standard practice requires facilities to conduct comprehensive wandering risk assessments and implement individualized interventions such as door alarms, increased supervision schedules, structured activities, and environmental modifications.
Mental Health Assessment and Screening Failures
Inspectors identified systematic failures in completing accurate mental health assessments for residents with serious psychiatric conditions. The facility failed to properly document schizophrenia diagnoses in critical screening tools for Residents 1 and 36, despite both residents actively receiving antipsychotic medications for this condition.
For Resident 36, multiple clinical documents confirmed diagnoses of both paranoid schizophrenia and major depression. The resident's History and Physical from November 23, 2024 documented depression, and a December 7, 2024 psychiatric note listed both conditions. The resident was prescribed Cymbalta 30mg daily for depression and olanzapine 5mg for paranoid schizophrenia "manifested by striking out at peers."
Despite this clear documentation, the facility's Minimum Data Set (MDS) assessment dated December 10, 2024 failed to include depression as an active diagnosis. Additionally, the PASARR Level I screening dated December 18, 2024 incorrectly indicated the resident did not have a serious mental illness and was not taking psychotropic medications.
Similar documentation failures occurred with Resident 1, whose psychiatric records showed schizophrenia diagnosis and treatment with olanzapine 10mg for "auditory hallucinations as evidenced by hearing voices related to schizophrenia." The PASARR screening dated December 19, 2024 incorrectly stated this resident had no serious mental illness and was not on psychotropic medications.
These assessment failures have serious implications. The PASARR screening determines whether residents need specialized psychiatric services beyond what nursing homes typically provide. Inaccurate screenings can result in residents missing critical mental health interventions, potentially leading to psychiatric decompensation, increased behavioral symptoms, medication non-compliance, and overall decline in quality of life.
Medication and Physical Safety Oversights
The inspection uncovered additional care planning failures affecting resident safety and well-being. Resident 9 was receiving temazepam, a sedative-hypnotic medication used to treat insomnia, without any corresponding care plan to monitor for adverse effects or evaluate effectiveness. Temazepam carries significant risks in elderly populations including increased fall risk, cognitive impairment, respiratory depression, and potential for dependence. Standard protocols require regular assessment of sleep patterns, monitoring for daytime sedation, fall prevention measures, and periodic attempts to taper or discontinue the medication.
Three residents (Residents 75, 42, and 71) were using bed rails without proper care plans documenting the medical necessity, risks, or monitoring protocols. Bed rails can pose entrapment hazards, increase injury severity during falls when residents attempt to climb over them, and may be considered restraints if they prevent voluntary bed exit. Federal regulations require thorough assessment and documentation when bed rails are used, including attempts at less restrictive alternatives.
Resident 99's fall prevention plan specified use of a floor mat beside the bed to reduce injury risk, but inspectors found no mat in place during their survey. Falls remain a leading cause of injury, disability, and death among nursing home residents. When prescribed interventions like fall mats are not consistently implemented, residents face preventable fracture risks, particularly hip fractures which carry mortality rates exceeding 20% within one year for elderly individuals.
Nutritional Care Deficiencies
Resident 11 experienced failures in nutritional care delivery despite having a care plan addressing nutritional problems. The resident was supposed to receive Magic Cups - frozen nutritional supplements providing additional calories and protein - with meals, along with a modified texture diet. Inspectors found these interventions were not being provided as planned.
Malnutrition affects up to 50% of nursing home residents and significantly increases risks of pressure injuries, infections, delayed wound healing, muscle wasting, and mortality. When prescribed nutritional interventions are not delivered consistently, residents can experience rapid weight loss and functional decline. Modified texture diets are typically prescribed for residents with swallowing difficulties to prevent aspiration pneumonia - a leading cause of death in nursing homes.
Additional Issues Identified
The facility's Director of Nursing acknowledged during interviews that the MDS assessments were inaccurate and that proper PASARR screenings would identify residents needing specialized psychiatric services. The DON confirmed that inaccurate assessments could lead to inadequate care planning and potential decline in residents' physical, mental, and psychosocial status.
The facility's own policies required comprehensive assessments within 14 days of admission to plan care allowing residents to reach their highest practicable functioning level. Their antipsychotic medication policy specifically mandated completion of PASARR screenings for residents receiving these medications. Despite having written policies addressing these requirements, implementation failures occurred across multiple residents and assessment types.
The pattern of violations suggests systemic problems with the facility's assessment and care planning processes. When facilities fail to accurately identify and document resident conditions, the entire care delivery system breaks down - from physician orders to nursing interventions to quality monitoring. These cascading failures ultimately compromise resident safety, health outcomes, and quality of life.
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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