What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LOS ANGELES, CA, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AVALON VILLA CARE CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

Health Inspection: Avalon Villa Care Center

FF0550

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise

During a review of the facility's Job Description- Certified Nursing Assistant (CNA), undated, the job description indicated the CNA would perform resident care and services essential to caring for personal needs and comfort of residents.

The P&P indicated CNA would treat all residents fairly, and with kindness, dignity, and respect.

056023 01/31/2025

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

FF0552

Ensure that residents are fully informed and understand their health status, care and treatments.

sections are the right to: .consent to or to refuse any treatment .

The use of psychotropic drugs . shall

056023 01/31/2025

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

FF0558

Reasonably accommodate the needs and preferences of each resident.

falls and injury.

10/2010, the P&P indicated the facility would ensure when the resident was in bed the call light would

056023 01/31/2025

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

FF0609

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper

During a concurrent interview and record review on 1/31/2025 at 10:12 a.m., with the Administrator (ADM), the facility's policy and procedure (P&P) titled, Abuse and Neglect, revised 3/2018, was reviewed.

The P&P indicated, 'Neglect' [means], 'the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.

The ADM stated the facility was supposed to provide services to Resident 118 to prevent him from eloping that included monitoring Resident 118, identifying his inappropriate room placement and his physical abilities to effectively exit the facility, documentation of Resident 118's monitoring and supervision, updating Resident 118's care plans (document that helps nurses and other team care members organize aspects of resident care) with interventions to properly care for Resident 118, conduct an interdisciplinary care team ([IDT], a group of different disciplines working together towards a common goal for a resident) meeting to determine Resident 118's goals and address Resident 118's needs, and address Resident 118's psychosocial wellbeing.

The ADM stated the facility failed to provide routine and frequent monitoring to Resident 118 and failed to follow-up on Resident 118's psychosocial, emotional, and physical needs and concerns.

The ADM stated the facility failed to provide the necessary services to keep Resident 118 from eloping from the facility, which put Resident 118 at risk of exposure to extreme weather, motor vehicle accident, and death.

During a concurrent interview and record review on 1/31/2025 at 10:27 a.m., with the ADM, the facility's P&P titled, Abuse Investigation and Reporting, dated 7/2017, was reviewed.

The P&P indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment, and/or injuries of unknown source shall be promptly reported to local, state, and federal agencies (as defined by current regulations).

The P&P indicated an alleged violation of neglect would be reported immediately but not later than twenty-four hours if the alleged violation did not involve abuse and had not resulted in serious bodily injury.

The ADM stated the facility neglected to provide the necessary services to keep Resident 118 from eloping from the facility on 10/13/2024 and 11/24/2024, which placed Resident 118 at risk for physical harm and death.

The ADM stated Resident 118's elopement on 10/13/2024 was not reported to CDPH, law enforcement, nor the ombudsman.

The ADM stated Resident 118's elopement on 11/24/2024 was not reported to CDPH nor the ombudsman.

The ADM stated the facility was responsible for reporting both incidents to CDPH, law enforcement, and the ombudsman to be provided additional assistance in locating Resident 118 and for an onsite visit to occur to assess the facility's compliance with the current regulations to ensure the safety of not only Resident 118 but all the residents in the facility.

Cross Reference F-F689 and F-F610.

056023 01/31/2025

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

FF0622

Not transfer or discharge a resident without an adequate reason; and must provide documentation and

During a review of the facility P&P titled Discharging a Resident without a Physician's Approval, revised 2012, the P&P indicated that if a resident or their responsible party insisted upon being discharged , the resident and/or their responsible party were supposed to sign a release of responsibility form.

During a review of the facility P&P titled Transfer or Discharge Orientation, revised 9/2012, the P&P indicated it was the facility policy to prepare a resident for transfer or discharge, and staff were to orient the resident of the plan for discharge to ensure a safe and orderly discharge from the facility.

During a review of the facility document titled Leaving Against Medical Advice, undated, the document indicated a resident's, and/or their responsible party's, signature would indicate they had been informed of the risks involved with leaving AMA, and they released the facility from all responsibility and any ill effects that could result from leaving.

During a review of the facility P&P titled Transfer or Discharge Notice, undated, the P&P indicated the facility was to provide the resident with a 30-day written notice of an impending transfer or discharge.

The P&P indicated there were exceptions this notification, and the exceptions did not include failure to return to the facility by midnight while OOP.

During a review of the facility P&P titled Transfer or Discharge, Preparing a Resident for, revised 2013, the P&P indicated it was the facility policy to prepare residents for transfer or discharge.

The P&P indicated staff were to assist the resident with transportation, escort the resident to transportation, prepare a discharge summary, and provide the resident with required documents.

The P&P indicated staff were to inform appropriate departments and others, as necessary, of the resident's discharge.

Cross Reference F-tags F-F689 and F-F623.

056023 01/31/2025

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

FF0623

Provide timely notification to the resident, and if applicable to the resident representative and

During a review of the facility P&P titled Discharging a Resident without a Physician's Approval, revised 2012, the P&P indicated that if a resident or their responsible party insisted upon being discharged , the resident and/or their responsible party were supposed to sign a release of responsibility form.

During a review of the facility P&P titled Transfer or Discharge Notice, undated, the P&P indicated the facility was to provide the resident with a 30-day written notice of an impending transfer or discharge.

The P&P indicated there were exceptions this notification, and the exceptions did not include failure to return to the facility by midnight while OOP.

During a review of the facility P&P titled Transfer or Discharge Orientation, revised 9/2012, the P&P indicated it was the facility policy to prepare a resident for transfer or discharge, and staff were to orient the resident of the plan for discharge to ensure a safe and orderly discharge from the facility.

During a review of the facility P&P titled Transfer or Discharge, Preparing a Resident for, revised 2013, the P&P indicated it was the facility policy to prepare residents for transfer or discharge.

The P&P indicated staff were to assist the resident with transportation, escort the resident to transportation, prepare a discharge summary, and provide the resident with required documents.

The P&P indicated staff were to inform appropriate departments and others, as necessary, of the resident's discharge.

Cross Reference F-tags F-F689 and F-F622.

056023 01/31/2025

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

FF0641

Ensure each resident receives an accurate assessment.

During a review of Resident 36's admission Record (a document containing a resident's diagnostic and demographic information), dated 1/29/2025, the admission record indicated the resident was admitted to the facility on [DATE] and most recently readmitted on [DATE] with diagnoses including paranoid schizophrenia (a mental illness characterized by hearing or seeing things that are not there).

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.

During a review of the facility's undated policy and procedure (P&P) titled Resident Assessment Instrument, the P&P indicated A comprehensive assessment of a resident's needs shall be made within fourteen (14) days of the resident's admission .

Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning .

056023 01/31/2025

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

FF0645

PASARR screening for Mental disorders or Intellectual Disabilities

During a review of Resident 36's MDS Section I, dated 12/10/2024, the MDS indicated schizophrenia was currently an active diagnosis.

During a review of Resident 36's PASARR Level I Screening, dated 12/18/2024, the PASARR indicated the resident did not have a serious mental illness (such as . schizophrenia) and was not prescribed psychotropic medication.

During an interview on 1/29/2025 at 12:30 p.m. with the Director of Nursing (DON), the DON stated the facility failed to accurately complete the PASARR level I screening for Residents 1 and 36 by indicating the residents did not have a severe mental illness and were not taking psychotropic medications despite being diagnosed with (and currently taking psychotropic medications for) schizophrenia.

The DON stated Resident 1 and 36 both currently have schizophrenia which was clearly indicated in their clinical records.

The DON stated, although these residents receive regular psychiatric care at the facility, an accurate PASARR was important to identify whether residents need special services based on mental illness.

The DON stated Resident 1 and 36's inaccurate PASARR increased the risk that they may not have received needed specialized care based on their diagnoses possibly leading to a decline in their health and well-being.

During a review of the facility policy and procedure (P&P) titled Antipsychotic Medication Use, dated March 2017, the P&P indicated .Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use.

The interdisciplinary team will: Complete PASRR screening (preadmission screening for mentally ill and intellectually disabled individuals), if appropriate .

056023 01/31/2025

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

FF0656

Develop and implement a complete care plan that meets all the resident's needs, with timetables and

During a review of the facility's P&P titled Proper Use of Side Rails, revised 12/2016, the P&P indicated facility would ensure safe use of side rails as resident mobility aids.

The P&P indicated the use of side rails as an assistive device would be addressed in the resident care plan.

056023 01/31/2025

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

FF0658

Ensure services provided by the nursing facility meet professional standards of quality.

During an interview on 1/30/2025 at 12:31 p.m., with the Dietary Supervisor (DS), the DS stated he did quarterly nutritional assessments of the facility residents, including an assessment of the residents' usual meal intakes.

The DS stated that the residents' usual intakes are based on the percentages documented by the CNAs.

The DS stated that usual meal intakes below 75% were considered low.

The DS stated this low percentage of meal intake would prompt him and the Registered Dietician to meet with the resident to determine the cause of the low intake.

During an interview on 1/30/2025 at 12:33 p.m., with the Director of Staff Development (DSD), the DSD stated CNAs were trained to alert the charge nurse when a resident consumed 50% or less of any meal.

The DSD stated the percentage of meal eaten was to be documented after the tray was collected and should be accurate.

The DSD stated the importance of accurate CNA charting was to prevent weight loss and malnutrition.

The DSD stated the percentage of meals eaten was also referenced by the Registered Dietician to guide the plan of care.

The DSD stated that if the documentation was not accurate, the resident could sustain potential malnutrition.

During a review of the facility's policy and procedure (P&P) titled Charting and Documentation, revised 4/2018, the P&P indicated all observations were to be documented in the resident's clinical records.

During a review of the facility's job description for CNAs, dated 2023, the job description indicated CNAs were to record resident's food and fluid intake, and report changes in the resident's eating habits.

056023 01/31/2025

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

FF0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

During a concurrent observation and interview on 1/29/2025 at 10:05 a.m., with the TN, at Resident

for a resident weighing 150 lbs., and stated this setting was too high for Resident 99 and was not correct.

The TN stated Resident 99's LALM settings should have been lower.

During a review of the operator's manual for the Med-Aire Melody Low Air Loss and Alternating Pressure Mattress Replacement System, dated 3/2019, the operator's manual indicated there was a Pressure Adjust Knob which was to be adjusted to the required pressure level, with patient weight settings available on the knob perimeter as a guide.

056023 01/31/2025

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

FF0689

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to

During an interview on 1/28/2025 at 2:52 p.m., with the DON, the DON stated the type, the frequency,

would be indicated on the Care Plan and physician's order.

The DON stated without a care plan with specific interventions, Resident 118 would not receive the necessary care and monitoring to prevent Resident 118 from eloping from the facility. e.

During a concurrent interview and record review on 1/27/2025 at 2:16 p.m., with RN 1, Resident 118's Progress Notes were reviewed.

The Progress Notes did not indicate Resident 118 was monitored when readmitted to the facility on [DATE]. RN 1 stated the licensed nurses did not perform and did not document a 72-Hour Monitoring for Resident 118, after the resident eloped on 10/13/2024.

RN 1 stated it was important to conduct the 72 Hour monitoring to assess the resident's adjustment to the facility and other behaviors such as exit-seeking.

During an interview on 1/28/2025 at 2:52 p.m., with the DON, the DON stated the 72-Hour Monitoring when a resident was admitted to the facility was important to see how the resident was adjusting to the facility and if there were any concerns that needed to be addressed. f.

During an interview on 1/27/2025 at 1:44 p.m., with RN 1, RN 1 stated Resident 118 was readmitted on [DATE] and was placed in a room near the lobby exit. RN 1 stated Resident 118's room placement was inappropriate because Resident 118 might have eloped the second time on 11/24/2024, through the lobby exit door. RN 1 stated Resident 118 should have been placed in a room closer to the nurse's station so Resident 118 could be easily monitored more closely. RN 1 stated she did not know how Resident 118 eloped on 10/13/2024.

During an interview on 1/28/2025 at 12:26 p.m., with RN 2, RN 2 stated she readmitted Resident 118 to the facility on [DATE]. RN 2 stated Resident 118's room assignment was predetermined prior to his arrival to the facility. RN 2 stated Resident 118 was placed in a room close to the lobby door and the idea of a room change crossed her mind due to Resident 118's prior elopement but did not initiate a room change. RN 2 stated the conversation of a room change should have been brought up to initiate a [TRUNCATED]

056023 01/31/2025

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

FF0692

Provide enough food/fluids to maintain a resident's health.

During an interview on 1/28/2025 at 4:24 p.m., with the RD, the RD stated that if a substitute was not served with the originally provided side dishes, the substitute alone would not have the same nutritive value as a whole meal.

The RD stated Resident 99 was supposed to receive a fortified tray with double portions, which increased the number of calories and/or nutrients he was supposed to receive.

During a review of the dietary spreadsheet, dated 1/28/2025, the spreadsheet indicated the breakfast, lunch, and dinner meals served on 1/28/2025.

The spreadsheet indicated Resident 99 was supposed to receive two smothered pork chops as his main dish, along with double portions of two side dishes.

During a review of the facility document titled Cycle 1 2025 Winter - Regular Analysis, dated 2002 to 2025, the document indicated two smothered pork chops (double portion) had 384 calories and 43.4 grams of protein, and double portions of the side dishes had a combined total of 362 calories and 9.8 grams of protein. In total, Resident 99's original tray had 746 calories and 53.2 grams of protein from the main dish and side dishes.

The document indicated the bean and cheese burrito Resident 99 received in place of his original tray had 408 calories and 18.2 grams of protein.

056023 01/31/2025

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

FF0695

Provide safe and appropriate respiratory care for a resident when needed.

During an interview on 1/28/2025 at 10:14 a.m. with Resident 100, Resident 100 stated she had the same nasal cannula tubing for a long time. Resident 100 stated the tubing was not replaced weekly. Resident 100 stated she asked staff to give her a new nasal cannula but the staff did not. Resident 100 stated she never saw nursing staff date her nasal cannula. c.

During an observation on 1/30/2025 at 10:01 a.m., in Resident 103's room, Resident 103's nasal cannula was observed undated and touching the floor.

During a review of Resident 103's admission Record, the admission record indicated Resident 100 was originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident 103's diagnoses included kidney failure (when kidneys are unable to filter waste products from the blood) and cardiomegaly (a condition where the heart becomes enlarged, or larger than normal).

During a review of Resident 103's H&P dated 8/13/2024, the H&P indicated Resident 103 had the capacity to understand and make decisions.

During a review of Resident 103's MDS, dated [DATE], the MDS indicated Resident 103's cognitive skills for daily decision making was severely impaired.

The MDS indicated Resident 103 required supervision for oral hygiene and personal hygiene.

The MDS indicated Resident 103 required set up and clean up assistance for eating.

During a concurrent observation and interview on 1/30/2025 at 10:06 a.m. with Licensed Vocational Nurse (LVN) 7, in Resident 103's room, Resident 103's nasal cannula was observed undated with no opened date. LVN 7 stated nasal cannulas must be dated when it was newly placed on the resident.

LVN 7 stated all nasal cannulas must be dated to notify all staff how long the resident has used it.

LVN 7 stated all nasal cannulas must be dated for infection control. LVN 7 stated she did not know how often nasal cannulas must be changed. LVN 7 stated an Oxygen in Use sign must be placed outside of the resident room door for oxygen administration safety. LVN 7 stated it was important to display the sign to prevent residents, staff and visitors from smoking in that area.

During a review of the facility's Policy and Procedure (P&P) titled Oxygen Administration dated 2010, the P&P indicated an Oxygen in Use sign must be placed outside of resident room entrance door and on a designated place on or over resident's bed.

056023 01/31/2025

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

FF0700

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a

During a review of the facility's P&P tilted Proper Use of Side Rails, revised 12/2016, the P&P indicated facility would ensure the safe use of the side rails as resident mobility aid.

The P&P indicated informed consent for side rails use would be obtained from the resident after presenting potential benefits and risks.

056023 01/31/2025

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

FF0712

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

During a review of the facility's policy and procedure (P&P) titled Physician Services, revised 4/2013, the P&P indicated the resident's attending physician was to participate in the resident's assessment and care planning and oversee a relevant plan of care for the resident.

The P&P further indicated physician visits, and the frequency of visits, were to be provided in accordance with current federal regulations.

056023 01/31/2025

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

FF0726

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a

During a review of the facility's policy and procedure (P&P) tilted Job Description- Director of Staff Development and Education [DSD]), undated, the P&P indicated the DSD was responsible for planning, implementing, and evaluating the staff.

The P&P indicated the DSD would conduct competencies evaluation and maintenance.

The P&P indicated the DSD would maintain appropriate documentation of staff competency skills.

During a review of the facility's P&P titled Job Description-Director of Nursing (DON), undated, the P&P indicated the DON would coordinate clinical team and would ensure the clinical team had the clinical expertise and certification required for the resident population.

The P&P indicated the DON would hire and orient professional nursing staff and would review and evaluate the performance of nursing staff.

056023 01/31/2025

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

FF0755

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the

During a concurrent interview and record review on 1/30/2025 at 3:11 p.m. with the Infection Preventionist Nurse (IPN), Resident 115's MAR, dated 1/1/2025 - 1/30/2025 was reviewed.

The MAR indicated on multiple days, there were no licensed staff initials in the box for meropenem, to demonstrate the medication was administered.

The IPN stated Resident 115 had not received meropenem medication routinely and it would not have a therapeutic effect due to the multiple missed doses.

The IPN stated it was important for Resident 115 to receive meropenem because he had a history of urinary tract infections (UTI- an infection in the bladder/urinary tract) and sepsis (a life-threatening blood infection).

During an interview on 1/31/2025 10:10 a.m. with RN 2, RN 2 stated she had not been informed that Resident 115 had not received his meropenem medication. RN 2 stated during report, the night shift RN did not inform her Resident 115's meropenem was not administered. RN 2 stated Resident 115's missed meropenem dose should have been communicated to her. RN 2 stated not taking medication per the doctor's order decreased the effectiveness of the medication, increased the risk of infection, and increased the risk of sepsis (a life-threatening blood infection).

During a review of the facility's P&P titled Administering Medication, dated 2012, the P&P indicated medications would be administered in a safe and timely matter and as prescribed.

The P&P indicated medications must be administered in accordance with the orders, including the required time.

056023 01/31/2025

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

FF0757

Ensure each resident?s drug regimen must be free from unnecessary drugs.

During a review of Resident 71's MDS, dated [DATE], the MDS indicated Resident 71's cognitive skills for daily decision making was intact.

The MDS indicated Resident 71 required moderate assistance from staff for activities of daily living ([ADLs]- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

During a concurrent interview and record review on 1/30/2025 at 2:20 p.m., with Registered Nurse (RN 1), Resident 71's Order Summary Report, active order dated 11/22/2024, was reviewed. RN 1 stated the Order Summary Report indicated Resident 71 was to receive Eliquis 5 mg, 1 tablet by mouth two times a day. RN 1 stated the Order Summary Report indicated staff would monitor for signs and symptoms of bleeding related to anticoagulant therapy and document every shift.

During a concurrent interview and record review on 1/30/2025 at 2;30 p.m., with RN 1, Resident 71's care plan with a focus of Anticoagulant Eliquis, dated 4/4/2023, was reviewed. RN 1 stated the care plan interventions indicated staff would monitor Resident 71 for signs and symptoms of bleeding related to anticoagulant therapy such as passing blood in urine, severe bruising, prolonged nosebleeds, bleeding gums, vomiting blood and document every shift. RN 1 stated the monitoring of Resident 71's bleeding would be documented in Resident 71's Medication Administration Record (MAR).

During a concurrent interview and record review on 1/30/2025 at 2:20 p.m., with RN 1, Resident 71's MAR for the month of January 2025 was reviewed. RN 1 stated she was not able to find documented evidence Resident 71's signs and symptoms of bleeding was monitored on the MAR. RN 1 stated if it was not documented it was not done. RN 1 stated failure to monitor for bleeding for a resident receiving anticoagulant therapy could cause health complications and possibly lead to hospitalization.

During a review of the facility's policy and procedure (P&P) titled, Anticoagulation, revised 9/2012, the P&P indicated, The staff and physician will monitor for possible complications in individuals who are being anticoagulated and will manage related problems.

056023 01/31/2025

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

FF0758

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless

During a concurrent interview and record review on 1/30/2025 at 9:43 a.m., with Registered Nurse (RN) 1, Resident 9's Care Plan, dated 2/26/2021, was reviewed.

The Care Plan indicated Resident 9 had a diagnosis of schizophrenia as manifested by striking out, preventing necessary care, episodes of yelling, throwing objects.

The Care Plan indicated Resident 9 had some facial movement and had a mood disorder as manifested by angry outbursts.

The staff interventions indicated to administer haloperidol 5 mg, divalproex sodium 250 mg, and Zyprexa 2.5 mg, monitor and document anti-psychotic for tardive dyskinesia, every shift, monitor and document any side effects of anti-psychotic medication, monitor blood pressure while lying down and sitting for orthostatic hypotension, and monitor and document any side effects of anticonvulsants. RN 1 stated Resident 9 had a care plan that addressed his use of antipsychotic and anticonvulsant medications that directed the licensed nurse to monitor Resident 9 for orthostatic hypotension, tardive dyskinesia, and side effects of antipsychotic and anticonvulsant medications.

During a concurrent interview and record review, on 1/30/2025 at 9:47 a.m., with RN 1, Resident 9's Order Recap Report, dated 6/1/2024 through 1/29/2025, was reviewed.

The Order Recap Report indicated to monitor Resident 9 for tardive dyskinesia, every shift, from 5/9/2024 through 12/19/2024, monitor Resident 9's blood pressure while lying down and sitting for orthostatic hypotension, every day shift, from 5/26/2024 through 12/19/2024, monitor Resident 9 for side effects of anti-psychotic medication, every shift, from 5/9/2024 through 12/19/2024, monitor Resident 9 for side effects of anticonvulsant medication, every shift, from 10/4/2024 through 12/19/2024, and monitor Resident 9 for side effects of hypnotic medications, every shift, from 10/4/2024 through 12/19/2024. RN 1 stated Resident 9 did not have any current orders for monitoring side effects of antipsychotic, anticonvulsant, and hypnotic medications; orthostatic hypotension, nor tardive dyskinesia. RN 1 stated Resident 9 went to the hospital and was readmitted to the facility, which required Resident 9's physician's orders to be reordered. RN 1 stated Resident 9's monitoring orders were not reordered; therefore, the licensed nurses were not prompted to monitor Resident 9 for medication side effects, orthostatic hypotension, and tardive dyskinesia. RN 1 stated it was important to monitor for medication side effects, orthostatic hypotension, and tardive dyskinesia to notify Resident 9's physician of any change of condition and to receive new orders. RN 1 stated without the necessary monitoring, Resident 9 was at risk of undetected worsening of tardive dyskinesia, side effects, and hypotension, which would negatively affect Resident 9's safety and well-being.

During a review of the facility's policy and procedure (P&P) titled, Antipsychotic Medication Use, undated, the P&P indicated the nursing staff shall monitor and report any side effects and adverse consequences of antipsychotic medications to the Attending Physician

056023 01/31/2025

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

FF0761

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted

During a concurrent observation and interview on [DATE] at 11:55 a.m. of East Cart with Licensed Vocational Nurse (LVN 4), the following medications were found either expired, stored in a manner contrary to their respective manufacturer's requirements, or not labeled with an open date as required by their respective manufacturer's specifications:

One unopened insulin glargine (a medication used to treat high blood sugar) pen for Resident 112

was found stored at room temperature.

One unopened insulin glargine pen for Resident 114 was found stored at room temperature.

According to the manufacturer's product labeling, unopened insulin glargine pens should be stored in the refrigerator.

LVN 4 stated the two glargine insulin pens for Residents 112 and 114 have been stored improperly.

LVN 4 stated unopened insulin should always be stored in the refrigerator and only brought to the cart once opened and in use for the residents. LVN 4 stated it was likely that the nurses on the overnight shift who received this delivery from the pharmacy unintentionally stored the insulin in the cart instead of the refrigerator. LVN 4 stated if insulin was not stored properly, it may not work to control blood sugar. LVN 4 stated this increased the risk that Resident 112 and 114 could have had medical complications resulting from poor blood sugar control possibly leading to hospitalization.

During a review of the facility's undated policy and procedure (P&P) titled Storage of Medications, the P&P indicated The facility shall store all drugs and biologicals in a safe, secure, and orderly manner .

Medications requiring refrigeration must be stored in a refrigerator located in the drug room at the nurses' station or other secured location .

056023 01/31/2025

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

FF0803

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be

During an interview with the ADS on 1/27/2025 at 12:20 p.m., the ADS stated the pork roast for the

sated the pork pot roast should be blended in the food processor longer so it was smaller in size.

During an interview with the DS on 1/27/2025 at 1:30 p.m., the DS stated the pork pot roast should be ground and not shredded.

The DS stated the residents on a mechanical soft diet received a texture that was not consistent with the menu, which could result in some residents having a hard time eating, chewing and swallowing the food.

During an interview with the RD on 1/28/2025 at 4:00p.m., the RD stated cooks should always follow the menu and recipe.

During a review of the facility's policy and procedure (P&P) titled Mechanical Soft (ground) (revised 4/2024), the P&P indicated, Diet that requires a reduced amount of chewing.

For residents who have limited chewing ability and intact swallowing ability .

All meats (such as beef, fish, poultry and pork) should be ground or chopped.

Gravy or sauces should be added to moisten dry ground and chopped meats, poultry and fish.

Chopped: ¼- ½ pieces; Ground: 1/8 or less-consistency of ground meat.

During a review of the facility's P&P titled Puree (revised 4/2024), the P&P indicated, Food texture prepared lump-free, not firm or sticky and holds it shape on a plate.

The diet requires no biting or chewing.

Any liquids must not separate from the food and the food can fall of a spoon intact.

The food is more easily swallowed and prevents aspiration.

During a review of the Pot Roast Recipe indicated for mechanical soft texture, the recipe indicated to grind portions needed from the regular prepared recipe and serve with gravy.

056023 01/31/2025

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

FF0804

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

During the same test tray, the DS stated the pork chop was cold.

The DS stated the trays were sitting in the cart for too long before they were served and there was a temperature drop.

The DS stated the food should be higher than 100 degrees F during service, but the pureed rice and beans and vegetables were below 100 degrees F.

The DS stated the temperature of the pork chops and gravy was lower than the other food items in the kitchen and should be higher to maintain the temperature during meal service.

056023 01/31/2025

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

FF0805

Ensure each resident receives and the facility provides food prepared in a form designed to meet

During a review of Resident 82's Nutritional update, dated 7/24/2023, the nutritional update indicated Resident 82 was to receive a regular diet and a mechanical soft texture for all meals.

The nutritional update indicated to provide Resident 82 with small portion meals at dinner time to prevent further weight gain.

During a review of Resident 82's Nutritional update, dated 10/22/2024, the nutritional update indicated Resident 82 was to receive a regular diet and a mechanical soft texture for all meals.

The nutritional update did not indicate to serve small portions at dinner to Resident 82.

During a review of Resident 82's electronic medical record (EMR), dated 1/2025, unable to locate doctors' order indicating to serve small portions to Resident 82 for dinner.

During an interview on 1/29/2025 at 8:09 a.m. with Resident 82, Resident 82 stated he received small portions for dinner. Resident 82 stated he saw other residents had more food on their plate than what he had on his plate. Resident 82 stated he did not know why his portion was so small and stated that maybe it was because the facility did not have enough food. Resident 82 stated staff did not inform him why he was receiving smaller portions. Resident 82 stated he was always hungry during breakfast time because his dinner was very small.

During a concurrent interview and record review on 1/30/2025 at 9:53 a.m. with the DS, Resident 82's Doctor Orders, dated 1/2025 was reviewed.

The Doctor Orders indicated Resident 82 did not have an order for small meal portions for dinner.

The DS stated he was not informed the doctor discontinued the smaller meal portions for Resident 82.

The DS stated Resident 82 was placed on small dinner portions because the resident gained weight.

The DS stated staff should have informed him (DS) when the small portion order was discontinued.

The DS stated Resident 82 should not receive small food portions for dinner if there was no order for small dinner portions.

During a review of the facility's P&P titled Diet Orders, dated 2023, the P&P indicated diet orders as prescribed by the physician would be provided by the food and nutrition services department.

The P&P indicated nursing would send a Diet Order Communication slip to the food and nutrition services department.

The food and nutrition services director would make or adjust the diet profile and tray card as prescribed.

During a review of the facility's P&P titled Dysphagia Diets, dated 4/2024, the P&P indicated for dysphagia management, food texture must be prepared lump free, not firm or sticky and holds its shape on a plate.

The P&P indicated this diet required no biting or chewing.

The P&P indicated this type of food was more easily swallowed and prevented aspiration.

The P&P indicated puree foods should have a pudding like smooth consistency without lumps (in example, sour cream or mayonnaise thickness/moistness).

056023 01/31/2025

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

FF0806

Ensure each resident receives and the facility provides food that accommodates resident allergies,

and stated staff were to accommodate those preferences.

056023 01/31/2025

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

FF0810

Provide special eating equipment and utensils for residents who need them and appropriate

spoon by pushing the spoon against the edge of the plate.

The P&P indicated a plate guard was used

056023 01/31/2025

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

FF0812

Procure food from sources approved or considered satisfactory and store, prepare, distribute and

During a concurrent observation and interview with the ADS, on 1/27/2025, at 10:00 a.m., in the kitchen food preparation and service area, the range (stove and oven) and steamtable were observed.

The stove top had dried and burnt food debris, the side of the oven was sticky and stained of spillage.

The oven doors and handles had dried food debris stuck on them, the tiles of the wall behind the oven had stains and build up.

The steam table burner knobs had dried food debris and stains on them.

The ADS stated that there was a cleaning schedule and the cook should clean the stove, oven and steamtable every day.

The ADS stated there was a cleaning log but the stove, oven, and steamtable were not cleaned that day (1/27/2025) because the cook called in sick.

During a concurrent interview and record review with the DS, on 1/27/2025 at 1:30 p.m., the Cleaning Schedule was reviewed.

The Cleaning Schedule indicated the cleaning of the oven, range and burners were done daily.

The DS stated the cleaning of the oven was done once a week.

The DS verified that the schedule needed to be clarified.

The DS also stated that the oven, range and steamtable were dirty and dirty areas had the potential to attract pests to the kitchen.

During an interview with the Registered Dietitian (RD) on 1/28/2025 at 4:00 p.m., the RD stated she does monthly infection control audits in the kitchen and noticed that the kitchen had dried food debris and stains.

The RD stated she discusses her findings with the Dietary Supervisor and Adminstrator.

During an interview with the Administrator (ADM) on 1/29/2025 at 3:00 p.m., the ADM stated an outside cleaning company was hired to provide deep cleaning services in the kitchen and the service had been delayed.

The ADM stated the kitchen should be cleaned of dust and food debris.

During a review of the 2022 U.S.

Food and Drug Administration Food Code titled Nonfood-contact Surfaces Code 4-602.13, the document indicated, The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment of the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.

During a concurrent observation and interview with the ADS on 1/27/2025 at 10:35 a.m., in the

Resident Refrigerator located in the Ice Machine Room, observed one paper bag containing left-over food from a fast-food restaurant dated 1/16/2025.

Observed another paper bag containing food for a resident dated 12/29/2024 stored in the resident refrigerator.

There was a carton of one dozen shell eggs stored in the freezer with date of 8/19/2024.

The ADS stated dietary staff was responsible for monitoring the expiration dates of the food and discard from the refrigerator.

The ADS stated resident outside food was stored for 3 days then they were discarded.

The ADS stated residents should not eat the leftovers that exceeded the use by date because they could get sick.

During a review of the facility's P&P titled Foods Brought by Family/Visitors (revised 2/2014) the P&P indicated, The dietary staff is responsible for discarding perishable foods on or before the use by date.

056023 01/31/2025

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

FF0842

Safeguard resident-identifiable information and/or maintain medical records on each resident that are

During a review of Resident 115's Medication Administration Record (MAR), for the month of January

1/8/2025 at 2 p.m., 1/9/2025 at 2 p.m. and 10 p.m., 1/10/2025 at 2 p.m., 1/11/2025 at 6 a.m., 1/12/2025 at 6 a.m., 1/13/2025 at 2 p.m., 1/15/2025 at 10 p.m., 1/17/2025 at 6 a.m., 1/20/2025 10 p.m., 1/21/2025 at 6 a.m., 1/22/2024 at 10 p.m., 1/25/2025 at 6 a.m., 1/27/2025 at 2 a.m., 1/29/2025 at 10 p.m., and 1/30/2025 at 10 p.m.

During a review of Resident 115's electronic medical record, unable to locate nursing progress notes that indicated the reason why Resident 115 did not receive Meropenem on 1/27/2025.

During a review of Resident 115's Care Plan for antibiotic therapy for prostate abscess, dated 1/8/2025, the care plan indicated Resident 115's goal was to be free from infection.

The care plan interventions indicated to administer 1 gram of meropenem intravenously every eight hours, change the IV tubing every 24 hours, follow IV orders by checking the IV site for redness, pain at the insertion site, swelling, infiltration or phlebitis, adverse reaction to infusion.

The interventions indicated to ensure the IV device is intact and saline flush 10 milliliters (ml, unit of volume) every eight hours before and after medication administration During an interview on 1/29/2025 at 8:14 a.m. with Registered Nurse (RN) 1, RN 1 stated when a nurse did not administer a medication to a resident, the nurse must document on the MAR the reason the medication was not administered and the nurse must document the notification to the doctor. RN 1 stated blank entries on the MAR was not acceptable because it creates confusion about the medication administration and the monitoring of the IV site.

During a concurrent interview and record review on 1/29/2025 at 8:38 a.m. with RN 1, Resident 115's MAR, for the month of January 2025 was reviewed.

The MAR indicated on multiple days, there were no licensed staff initials in the box for Meropenem, to demonstrate the medication was administered.

The MAR indicated on multiple days, there were no licensed staff initials in the box for monitoring Resident 115's IV site, flushing of the IV site and changing the IV tubing to demonstrate IV monitoring was performed. RN 1 stated blank entries on the MAR meant Meropenem was not administered and the IV site monitoring was not performed. RN 1 stated all IV monitoring must be performed to keep it free from infection and to be alert if the IV was not working.

During a concurrent interview and record review on 1/29/2025 at 8:50 a.m. with RN 1, Resident 115's Nursing progress notes, dated 1/2025, were reviewed. RN 1 stated there were no progress notes indicating why Resident 115 did not receive Meropenem or that the resident's doctor was notified. RN 1 stated she did not document when she informed Resident 115's and did not document the doctors' response. RN 1 stated she was supposed to document the doctor's new orders on the nursing progress notes.

During a review of the facility's Policy and Procedure (P&P) titled Charting and Documentation dated 4/2008, the P&P indicated all observations, medications administered, services performed, etc., must be documented in the resident's clinical records.

056023 01/31/2025

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

FF0850

Hire a qualified full-time social worker in a facility with more than 120 beds.

During a review of the Social Services Director (SSD) bachelor's degree certificate, dated 11/2020, the bachelor's degree certificate indicated it was awarded for Applied management.

During an interview on 1/29/2025 at 3:40 p.m. with the SSD, the SSD stated she had been working at the facility for 5 months.

The SSD stated she had a bachelor's degree in applied administration.

The SSD stated she did not have a social worker certificate.

The SSD stated she had never worked as a social worker in a healthcare setting because she was not a social worker.

The SSD stated the facility required her to have a bachelor's degree and 1 to 2 years' of experience in social work.

The SSD stated she had experience helping people in the community with housing needs and other resources but not in a healthcare setting.

During an interview on 1/31/2025 at 11:35 a.m. with the Administrator (Admin), the Admin stated he required the SSD to have a bachelor's degree in line with job function and a minimum of 1 year experience in social work.

The Admin stated he was aware that SSD did not have a bachelor's degree in social work or in healthcare.

The Admin stated residents did not receive the support they needed because the SSD did not encompass the knowledge a social worker had.

The Admin stated it was important to employ staff with required qualifications to ensure they are able to meet resident's needs.

During a review of the facility's Job description for Social Service Supervisor, dated 2023, the job description indicated the education/vocational requirement for a social worker supervisor was an accredited bachelor's in social work and two years' experience as a social worker.

FF0880

Provide and implement an infection prevention and control program.

During an interview on 1/29/2025 at 8:14 a.m. with Registered Nurse (RN) 1, RN 1 stated IV dressings must be changed once a week or as needed for infection control. RN 1 stated nurses must date and initial the IV dressing. RN 1 stated it was important to maintain the IV dressing in a dry, clean and intact manner to prevent IV complications. RN 1 stated Resident 115 did not have any orders for an IV dressing change. RN 1 stated Resident 115's IV dressing had not been changed since it was inserted on 1/7/2025.

During a review of the facility's Policy and Procedure (P&P) titled Peripheral IV Dressing Changes, dated 2016, the P&P indicated its purpose of his procedure was to prevent catheter-related infections associated with contaminated, loosened or soiled catheter-site dressings.

The P&P indicated to change the IV dressing at least every 5 to 7 days.

The P&P indicated to label IV dressing with date, time, and initials.

056023 01/31/2025

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

FF610

Minimal harm or Many Based on interview and record review, the facility failed to safely discharge three of six sampled residents affected

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.

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

FF622

TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40994 Few a resident assessment tool) assessment Section I (active diagnoses) by failing to include a diagnosis of affected