Avalon Villa Care Center

During a review of Resident 36's History and Physical (H&P - a record of a comprehensive physician's assessment), dated 11/23/2024, the H&P indicated the resident had the capacity to understand and make decisions.

The H&P indicated Resident 36 also had the diagnosis of depression (a mental disorder characterized by depressed mood, poor appetite, difficulty sleeping, and lack of interest in normally enjoyable activities).

During a review of Resident 36's Psychiatric Note (a medical progress assessment written by a psychiatric care provider) dated 12/7/2024, the psychiatric note indicated the resident's psychiatric diagnoses included paranoid schizophrenia and major depression.

During a review of Resident 36's Physician Order Summary (a monthly summary of all active physician orders), dated 1/29/2025, the physician order summary indicated the resident was prescribed Cymbalta (a medication used to treat depression) 30 milligrams (mg - a unit of measure for mass) by mouth once daily for depression manifested by verbalization of sadness on 11/22/2024.

During a review of Resident 36's Minimum Data Set (MDS, a resident assessment tool) Section I, dated 12/10/2024, the MDS indicated Resident 36 did not have depression as an active diagnosis.

During an interview on 1/29/2025 at 12:51 p.m. with the Director of Nursing (DON), the DON stated Resident 36's MDS section I, dated 12/10/2024, was inaccurate as it did not include depression as one of the resident's active diagnoses.

The DON stated Resident 36 had a diagnosis of depression based on documentation in the medical record, but the MDS assessment indicated Resident 36 did not.

The DON stated there was a risk that a resident's needs may not be adequately addressed through a care plan if the MDS assessment was inaccurate which could lead to a decline in the resident's physical, mental, or psychosocial status.

056023

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056023 B.

Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avalon Villa Care Center 12029 Avalon Blvd Los Angeles, CA 90061

During a review of Resident 117's Admission Record, the Admission Record indicated Resident 117 was admitted on [DATE]. Resident 117's diagnoses included a broken right thigh bone and displacement of internal fixation device of the right thigh bone (when a surgical implant, like a plate, screw, or rod used to stabilize a broken bone, has moved out of its original position).

During a review of Resident 117's History and Physical (H&P), dated 5/7/2024, the H&P indicated Resident 117 had the capacity to understand and make decisions.

During a review of Resident 117's discharge Minimum Data Set (MDS, a resident assessment tool), dated 11/9/2024, the MDS indicated Resident 117 was independent in making decisions regarding tasks of daily life, and his decisions were consistent and reasonable.

The MDS indicated Resident 117 did not exhibit wandering behavior or rejection of care.

The MDS indicated Resident 117 was independent with activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily) and mobility while in and out of bed.

During a review of Resident 117's psychiatric progress note, dated 11/7/2024, the progress note indicated Resident 117 had major depressive disorder (a mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), and verbalized depressive episodes (a period of time when a person experiences a depressed mood and other symptoms of depression for at least two weeks) related to not having a place to stay in the community.

The progress note indicated social services was working on relocating Resident 117 back into the community.

During a review of Resident 117's physician order, dated 10/3/2024, the order indicated Resident 117 was permitted to leave the facility out on pass (OOP), not to exceed four hours.

056023

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056023 B.

Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avalon Villa Care Center 12029 Avalon Blvd Los Angeles, CA 90061

During a review of Resident 117's Admission Record, the Admission Record indicated Resident 117 was admitted on [DATE]. Resident 117's diagnoses included a broken right thigh bone and displacement of

jeopardy to resident health or stabilize a broken bone, has moved out of its original position). safety During a review of Resident 117's History and Physical (H&P), dated 5/7/2024, the H&P indicated Resident

During a review of Resident 117's admission Minimum Data Set (MDS, a resident assessment tool), dated 5/16/2024, the MDS indicated Resident 117 did not have cognitive impairments (problems with a person's ability to think, learn, remember, use judgement, and make decisions).

The MDS indicated Resident 117 was independent with mobility while in bed and was dependent on staff to walk.

During a review of Resident 117's discharge MDS, dated [DATE], the MDS indicated Resident 117 was independent in making decisions regarding tasks of daily life, and decisions were consistent and reasonable.

The MDS indicated Resident 117 could walk independently.

During a review of Resident 117's progress note, dated 11/6/2024, the progress note indicated Resident 117 was non-compliant with facility rules and had displayed aggressive behavior towards facility staff.

During a review of Resident 117's progress note, dated 11/9/2024 at 12:33 a.m., the progress note indicated Resident 117 was out of the facility on a pre-approved four-hour leave, and did not return within four hours.

The progress note indicated Resident 117 was discharged from the facility, and indicated staff attempts to contact Resident 117 were unsuccessful.

During a review of Resident 117's progress note, dated 11/9/24 at 7:15 a.m., the progress note indicated Resident 117 arrived at the facility by bicycle and entered through a back door.

The progress note indicated Resident 117 was informed he was discharged from the facility and was trespassing and indicated Resident 117 refused to leave.

The progress note indicated nursing Registered Nurse (RN) 1 called law enforcement and Resident 117 was escorted from the facility by law enforcement.

During a review of Resident 117's progress note, dated 11/9/24 at 2:26 p.m., the progress note indicated Resident 117 returned to the facility on bicycle, accompanied by a vehicle with two unidentified individuals.

The progress note indicated Resident 117 arrived at the facility through a staff-only gated entrance that required a code.

The progress note indicated Resident 117 knew the code.

The progress note indicated Resident 117 then entered the building through a door used by housekeeping staff and was very aggressive and brandishing a large knife.

The progress note indicated Resident 117 was yelling expletives and indicated law enforcement was contacted but never arrived.

On 1/31/2024 at 9:29 a.m., an attempt was made to contact Resident 117 by telephone. Resident 117's contact number was disconnected.

056023

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056023 B.

Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avalon Villa Care Center 12029 Avalon Blvd Los Angeles, CA 90061

During a review of Resident 118's Admission Record (Face Sheet), the Face Sheet indicated Resident 118 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), psychoactive substance-induced persisting dementia (a deterioration of mental function resulting from the persisting effects of alcohol use), and altered mental status (a change in mental function, such as a decline in awareness, attention, or consciousness).

056023

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056023 B.

Wing 01/31/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Avalon Villa Care Center 12029 Avalon Blvd Los Angeles, CA 90061