Health Inspection - AVALON VILLA CARE CENTER

F-Tag F610

Harm Level: Minimal harm or

Residents Affected: Many Based on interview and record review, the facility failed to safely discharge three of six sampled residents

F-F610.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 99 056023 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0622 Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47286

Residents Affected - Many Based on interview and record review, the facility failed to safely discharge three of six sampled residents (Residents 117, 320, and 321) when:

1. The facility discharged Resident 117 from the facility, without his knowledge, request, or consent, on 11/9/2024.

2. The facility discharged Resident 320 from the facility, without his knowledge, request, or consent, on 10/13/2024.

3. The facility discharged Resident 321 from the facility, without his knowledge, request, or consent, on 10/7/2024.

These deficient practices placed all three residents at risk for avoidable physical and psychosocial harm due to their discharge without confirmation of their whereabouts and/or safety, and no notification provided to the residents, local law enforcement agencies, the State Agency, or the Ombudsman (a neutral third party who investigates and resolves complaints) for further follow-up. These deficient practices also placed facility residents and staff at risk when Resident 117 returned to the facility on [DATE REDACTED] brandishing a large knife.

Findings:

1. During a review of Resident 117's Admission Record, the Admission Record indicated Resident 117 was admitted on [DATE REDACTED]. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 99 056023 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0622 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. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 117's social services progress note, dated 11/8/2024 at 3:49 p.m., the progress note indicated the Social Services Director (SSD) spoke with Resident 117 about his order to leave the Residents Affected - Many facility OOP, and the time limit of four hours. The progress note indicated the SSD spoke with Resident 117 about referring him to a housing coordinator to assist with transition back into the community. The progress note did not indicate Resident 117 expressed a desire to be discharged , or intentions to not return to the facility from his four-hour OOP leave.

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 an approved OOP four-hour leave and did not return within four hours.

The progress note indicated staff attempts to contact Resident 117 were unsuccessful. The progress note indicated Resident 117 was discharged from the facility against medical advice (AMA, a situation where a patient leaves a healthcare facility or discontinues treatment without the consent or recommendation of their healthcare provider). The progress note did not indicate information related to the discharge was communicated to Resident 117.

During a review of Resident 117's physician order, dated 11/9/2024, the order indicated Resident 117 was discharged AMA due to exceeding the OOP four-hour time limit. The order indicated staff attempted to contact Resident 117 via cellular telephone and there was no response.

During a review of Resident 117's progress note, dated 11/9/24 at 7:15 a.m., the progress note indicated Resident 117 returned to the facility and went to his room. The progress note indicated Resident 117 was informed he was discharged and that his presence on the facility premises was trespassing. The progress note indicated Registered Nurse (RN) 1 contacted law enforcement, and law enforcement removed Resident 117 from the facility. The progress note indicated Resident 117 left with some of his belongings, and that he was told he could pick up his remaining belongings on 11/11/2024.

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 and was very aggressive and brandishing a large knife. The progress note indicated Resident 117 was yelling expletives (curse words). The progress note indicated law enforcement was contacted but never arrived. The progress note indicated Resident 117 collected the remainder of his belongings and left the facility premises.

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.

During an interview on 1/31/2025 at 10:16 a.m., with RN 1, RN 1 stated a discharge AMA was initiated if a resident expressed a desire to leave the facility. RN 1 stated an AMA discharge required facility staff to explain the risks and benefits of leaving the facility to the resident, and stated the resident would be encouraged to stay in the facility. RN 1 stated an AMA discharge was to be requested by the resident and was not to be initiated by facility staff. RN 1 stated Resident 117's discharge was not safe. RN 1 stated discharging Resident 117 AMA indicated the discharge was Resident 117's choice, and stated this was not confirmed with Resident 117. RN 1 stated a discharge AMA also indicated there would be no attempt to search for the resident or involve any other agencies to ensure the resident's well-being.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 99 056023 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0622 During an interview on 1/31/2025 at 11:15 a.m., with the SSD, the SSD stated an AMA discharge was initiated if a resident expressed a desire to leave the facility immediately. The SSD stated she was arranging Level of Harm - Minimal harm or discharge housing for Resident 117 prior to his discharge from the facility on 11/9/2024 and stated they had potential for actual harm planned to review housing paperwork on Monday, 11/11/2024. The SSD stated that discharging a resident without a place to go was dangerous. The SSD stated the resident could be exposed to crime and poor Residents Affected - Many weather conditions, which could negatively impact their safety and well-being.

During an interview on 1/31/2025 at 1:02 p.m., with the Medical Records Director (MRD), the MRD stated Resident 117 did not sign an AMA acknowledgment form (a document that a patient signs to acknowledge their decision to leave a healthcare facility against their doctor's advice) at the time he was discharged because he was not in the facility and was unable to be contacted by telephone.

During an interview on 1/31/2025 at 12:05 p.m., with the Director of Nursing (DON), the DON stated multiple attempts to reach Resident 117 were unsuccessful prior to the facility's decision to discharge Resident 117 AMA. The DON stated the facility did not know Resident 117's whereabouts, or if there was a reason he did not return within the four-hour timeframe, when the facility discharged him. The DON stated Resident 117's discharge was not safe.

2. During a review of Resident 320's Admission Record, the Admission Record indicated Resident 320 was admitted to the facility on [DATE REDACTED]. Resident 320's admitting diagnoses included generalized muscle weakness, abnormalities of gait (the way someone walks, runs, or jogs) and mobility, right foot drop (a condition where the foot is unable to lift off the ground due to weakness or paralysis of the muscles), discitis (an infection and/or inflammation of the space between the spinal bones), and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing).

During a review of Resident 320's H&P, dated 9/13/2024, the H&P indicated Resident 320 had the capacity to understand and make decisions.

During a review of Resident 320's admission MDS, dated [DATE REDACTED], the MDS indicated Resident 320 did not have cognitive impairments (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 320 required partial to moderate assistance from staff for mobility while in and out of bed, including to walk 10 feet. The MDS indicated Resident 320 was not assessed for his ability to transfer in and out of a vehicle, or to walk 50 feet or 150 feet, due to medical conditions and/or safety concerns.

During a review of Resident 320's discharge MDS, dated [DATE REDACTED], the MDS indicated Resident 320 was independent in making decisions regarding tasks of daily life, and his decisions were consistent and reasonable. The MDS indicated Resident 320 did not exhibit wandering behavior or rejection of care. The MDS indicated Resident 320 required partial to moderate assistance from staff for mobility, including to walk 10 feet. The MDS indicated Resident 320 was not assessed for his ability to transfer in and out of a vehicle, walk 50 feet or 150 feet, walk on uneven surfaces (outdoor or indoor), or to go up and down a step or curb, due to medical conditions and/or safety concerns.

During a review of Resident 320's case management progress note, dated 10/3/2024, the progress note indicated Resident 320 was refusing to be discharged home.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 99 056023 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0622 During a review of Resident 320's Nursing Weekly Summary assessment, dated 10/7/2024, the assessment indicated Resident 320 required a wheelchair and did not display any behavior concerns related to his Level of Harm - Minimal harm or admission at the facility. The assessment indicated Resident 320 was receiving physical therapy and potential for actual harm occupational therapy services, with slow steady progress. The assessment indicated Resident 320 required blood sugar level monitoring on all shifts. Residents Affected - Many

During a review of Resident 320's progress note, dated 10/11/2024 at 9:57 a.m., the progress note indicated Resident 320 requested to leave the facility OOP, and indicated Resident 320's physician ordered an OOP leave, not to exceed four hours.

During a review of Resident 320's progress note, dated 10/12/2024 at 2:23 p.m., the progress note indicated Resident 320 left the facility OOP at 2:00 p.m., in stable condition. The progress note did not indicate Resident 320 expressed a desire to be discharged from the facility or an intent to not return.

During a review of Resident 320's progress note, dated 10/12/2024 at 8:48 p.m., the progress note indicated Resident 320 had not yet returned to the facility. The progress note indicated the facility did not have a contact number to reach Resident 320 by phone, and did not have an alternate emergency contact to call.

The progress note did not indicate the facility had been in contact with Resident 320.

During a review of Resident 320's progress note, dated 10/12/2024 at 11:28 p.m., the progress note indicated Resident 320 had not yet returned to the facility. The progress note indicated the facility did not have a contact number to reach Resident 320 by phone, and did not have an alternate emergency contact to call. The progress note did not indicate the facility had been in contact with Resident 320.

During a review of Resident 320's physician order, dated 10/13/2024, the order indicated staff were to discharge Resident 320 AMA.

During a review of Resident 320's progress note, dated 10/13/2024 at 12:00 a.m., the progress note indicated Resident 320 was discharged AMA. The progress note did not indicate the facility had been in contact with Resident 320 since he departed the facility on 10/12/2024. The progress note did not indicate

the facility was aware of why Resident 320 had not returned.

During a concurrent interview and record review, on 1/31/2025 at 1:52 p.m., with the DON, Resident 320's progress notes dated 10/12/2024 and 10/13/2024 were reviewed. The DON stated the progress notes did not indicate Resident 320 expressed a desire to be discharged , and stated there was no documentation indicating Resident 320's safety, well-being, or disposition were identified by facility staff prior to his discharge on 10/13/2024. The DON stated Resident 320 was not explained the risks related to an AMA discharge, and stated Resident 320's discharge was not safe. The DON stated Resident 320's whereabouts remained unknown at the time of the interview.

3. During a review of Resident 321's Admission Record, the Admission Record indicated Resident 321 was admitted on [DATE REDACTED]. Resident 321's admitting diagnoses included generalized muscle weakness, abnormalities of gait and mobility, and peripheral vascular disease (a slow progressive narrowing of the blood flow to the arms and legs).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 99 056023 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0622 During a review of Resident 321's H&P, dated 9/7/2024, the H&P did not indicate if Resident 321 had the capacity to understand and make decisions. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 321's admission MDS, dated [DATE REDACTED], the MDS indicated Resident 321 did not have cognitive impairments. The MDS indicated Resident 321 could walk distances of 10 feet and 50 feet Residents Affected - Many with staff assistance prior to or following the activity. The MDS indicated Resident 321 was not assessed for his ability to transfer in and out of a vehicle or walk 150 feet due to medical conditions and/or safety concerns.

During a review of Resident 321's admission MDS, dated [DATE REDACTED], the MDS indicated Resident 321 was independent in making decisions regarding tasks of daily life, and his decisions were consistent and reasonable. The MDS indicated Resident 321 did not exhibit wandering behavior or rejection of care. The MDS indicated Resident 321 could walk distances of 10 feet and 50 feet with staff assistance prior to or following the activity. The MDS indicated Resident 321 was not assessed for his ability to transfer in and out of a vehicle, walk 150 feet, walk on uneven surfaces (outdoor or indoor), or to go up and down a step or curb, due to medical conditions and/or safety concerns.

During a review of Resident 321's physician order, dated 9/12/2024, the order indicated Resident 321 was permitted to leave the facility OOP, not to exceed four hours.

During a review of Resident 321's progress note, dated 10/5/2024 at 11:00 a.m., the progress note indicated Resident 321 left the facility OOP in an electric wheelchair. The progress note indicated Resident 321 was alert and aware he was expected to return within four hours.

During a review of Resident 321's progress note, dated 10/6/2024 at 7:33 a.m., the progress note indicated that on 10/5/2024 during the 3:00 p.m. to 11:00 p.m. shift, Resident 321 returned to the facility and then departed OOP a second time. The progress note did not indicate the exact time of Resident 321's second departure on 10/5/2024. The progress note indicated Resident 321 contacted the facility during his second OOP leave on 10/5/2024 and informed staff he would be returning to the facility on [DATE REDACTED] around 9:00 a.m.

The progress note indicated that on 10/6/2024 at 7:33 a.m., Resident 321 had not returned to the facility.

During a review of Resident 321's progress note, dated 10/6/2024 at 3:15 p.m., the progress note indicated

the resident had not yet returned to the facility. The progress note did not indicate contact was made with Resident 321.

During a review of Resident 321's social service progress note, dated 10/8/2024 at 2:32 p.m., the progress note indicated the SSD notified Resident 321's daughter that Resident 321 did not return to the facility from his OOP leave, and indicated Resident 321 was discharged AMA.

During an interview on 1/31/2025 at 1:59 p.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated Resident 321 left on 10/5/2024 during her shift. LVN 5 stated Resident 321 did not express a desire to be discharged from the facility or that he did not intend to return. LVN 5 stated that if he wanted to be discharged , staff would have explained the risks of leaving AMA and asked him to sign the AMA acknowledgement form. LVN 5 stated Resident 321 did not sign an AMA acknowledgement form. LVN 5 stated Resident 321 returned to the facility in November, a month after he was discharged AMA. LVN 5 stated Resident 321 was angry and appeared dirty as if he was living on the street. LVN 5 stated Resident 321 came to pick up his belongings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 99 056023 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0622 During a concurrent interview and record review, on 1/31/2025 at 2:08 p.m., with the DON, Resident 321's progress notes dated 10/5/2024 to 10/6/2024, and census, were reviewed. The DON stated the progress Level of Harm - Minimal harm or notes indicated Resident 321 informed the facility of his intent to return on 10/5/2024 while he was on OOP. potential for actual harm The DON stated the progress notes did not indicate Resident 321 requested to be discharged . The DON stated the progress notes did not indicate any contact was made with Resident 321 after his last contact on Residents Affected - Many 10/5/24 or prior to his discharge on 10/7/2024. The DON stated the census indicated Resident was discharged after 12:00 a.m. on 10/7/2024.

During a concurrent interview and record review, on 1/31/2025 at 12:05 p.m., with the DON, the facility policy and procedure (P&P) titled Discharging a Resident without a Physician's Approval, revised 2012, and the facility document titled Leaving Against Medical Advice, undated, were reviewed. The DON stated the P&P revised 2012 defined an AMA discharge and outlined the process for an AMA discharge. The DON stated

the P&P indicated an AMA discharge required a resident (or their responsible party) to request an immediate discharge and required the resident to sign a release of responsibility form. The DON stated the facility document titled Leaving Against Medical Advice was the facility's release of responsibility form, and stated

the form required the resident to acknowledge being informed of the risks involved in leaving the facility AMA. The DON stated the facility's process was to discharge AMA any resident who left the facility OOP, and did not return to the facility within four hours or by midnight. The DON stated law enforcement, the State Agency, and the Ombudsman were not notified of the resident's departure from the facility if discharged AMA. The DON stated that based on the facility P&P revised 2012, Resident 117, Resident 320, and Resident 321 did not meet the criteria for an AMA discharge.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 99 056023 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0622 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 Level of Harm - Minimal harm or were to assist the resident with transportation, escort the resident to transportation, prepare a discharge potential for actual harm 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. Residents Affected - Many Cross Reference F-tags

F-Tag F622

Harm Level: TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40994

Residents Affected: Few a resident assessment tool) assessment Section I (active diagnoses) by failing to include a diagnosis of

F-F622.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 99 056023 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40994 potential for actual harm Based on interview and record review, the facility failed to accurately complete the minimum data set (MDS - Residents Affected - Few a resident assessment tool) assessment Section I (active diagnoses) by failing to include a diagnosis of depression per information in the medical record for one of five residents sampled for unnecessary medications (Resident 36).

The deficient practice of failing to accurately assess active diagnoses and complete MDS Section I increased

the risk that Resident 36 may not have received care planning and treatment according to her needs possibly leading to a decline in her overall health and well-being.

Findings:

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 REDACTED] and most recently readmitted on [DATE REDACTED] 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 99 056023 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 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) Level of Harm - Minimal harm or days of the resident's admission . Information derived from the comprehensive assessment helps the staff to potential for actual harm plan care that allows the resident to reach his/her highest practicable level of functioning .

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 99 056023 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40994 potential for actual harm Based on interview and record review, the facility failed to accurately complete the Preadmission Screening Residents Affected - Few and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) level I screening by omitting a diagnosis of schizophrenia (a mental illness characterized by hearing or seeing things that are not there) for two of five residents sampled for unnecessary medications (Residents 1 and 36).

The deficient practice of failing to accurately complete the PASARR Level I screening increased the risk that Residents 1 and 36 could have failed to receive special psychiatric services related to their diagnosis of schizophrenia possibly leading to a decline in their overall health and well-being.

Findings:

During a review of Resident 1's Admission Record (a record containing diagnostic and demographic resident information), dated 1/29/2025, the admission record indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including schizophrenia (a mental illness characterized by hearing or seeing things that are not there) and major depressive disorder (MDD - a mental illness characterized by depressed mood, lack of interest in activities, poor appetite, and/or trouble sleeping).

During a review of Resident 1's Psychiatric Note (a medical progress assessment written by a psychiatric care provider) dated 1/2/2025, the psychiatric note indicated the resident had the capacity to understand and make decisions unless exacerbation of paranoid thoughts. Further review of the psychiatric note indicated Resident 1's psychiatric diagnoses included schizophrenia, unspecified.

During a review of Resident 1's Order Summary Report (a summary of all current physician orders), dated 1/29/2025 the order summary report indicated, on 7/1/2023, Resident 1's attending physician prescribed olanzapine 10 milligrams (mg - a unit of measure for mass) by mouth at bedtime for auditory hallucinations (hearing things that are not there) as evidenced by hearing voices related to schizophrenia .

During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool) assessment Section I (active diagnoses), dated 11/25/2024, the MDS indicated schizophrenia was currently an active diagnosis.

During a review of Resident 1's PASARR Level I Screening, dated 12/19/2024, the PASARR indicated the resident did not have a serious mental illness (such as schizophrenia) and was not prescribed psychotropic (medications that affect brain activities associated with mental processed and behavior) medication.

During a review of Resident 36's Admission Record, dated 1/29/2025, the admission record indicated the resident was admitted to the facility on [DATE REDACTED] and most recently readmitted on [DATE REDACTED] with diagnoses including paranoid schizophrenia.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 99 056023 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 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 Level of Harm - Minimal harm or decisions. potential for actual harm

During a review of Resident 36's Psychiatric Note dated 12/7/2024, the psychiatric note indicated the Residents Affected - Few resident's psychiatric diagnoses included paranoid schizophrenia and major depression.

During a review of Resident 36's Physician Order Summary, dated 1/29/2025, the order summary indicated,

on 12/18/2024, the resident was prescribed olanzapine 5 mg by mouth at bedtime for paranoid schizophrenia manifested by striking out at peers.

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 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 99 056023 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47679

Residents Affected - Some Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive care plan for 10 of 24 sampled residents (Residents 118, 48, 63, 60, 9, 75, 42, 71, 99, and 11), by failing to:

1. Develop a care plan to address Resident 118's elopement (the act of leaving a facility unsupervised and without prior authorization) from the facility on 10/13/2025.

2. Develop a care plan to address Resident 118, 48, 63, and 60's high risk for wandering (the act of roaming around and becoming lost or confused about their location) and elopement score.

3. Develop a care plan for Resident 9's use of temazepam (a medication to treat insomnia [difficulty falling asleep, staying asleep, or waking up too early, despite having adequate opportunity for sleep]).

4. Develop a care plan for Residents 75, 42, and 71's use of bed bars ([side rails]-a short rails on one or both sides of the bed that can be used to assist in bed mobility).

5. Ensure a fall mat (a floor pad designed to help prevent injury should a person fall) was placed at Resident 99's bedside, as indicated in Resident 99's fall risk care plan.

6. Ensure Resident 11 received a Magic Cup (a frozen dessert used for providing additional calories and protein to those experiencing involuntary weight loss) with meals, and a modified texture diet, as indicated in Resident 11's nutritional problem care plan.

These deficient practices resulted in Resident 118 eloping from the facility, a second time, on 11/24/2024, and had the potential to result in Resident 48, 63, and 60 being under monitored and supervised for wandering and elopement. These deficient practices also resulted in the mismanagement of Resident 9's care with the use of Temazepam, which may increase Resident 9's risk of adverse effects (unwanted, uncomfortable or dangerous effects that a drug may have), and had the potential to negatively affect Residents 75, 42, 71, and 11's physical well-being and had the potential to result in injury. These deficient practices also resulted in Resident 11's decreased meal intake which could lead to weight loss, malnutrition and insufficient provision of care and services.

Cross Reference

F-Tag F623

Harm Level: Minimal harm or

Residents Affected: Many Based on interview and record review, the facility failed to provide advance notice of discharge to three of six

F-F623.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 99 056023 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,

before transfer or discharge, including appeal rights. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47286

Residents Affected - Many Based on interview and record review, the facility failed to provide advance notice of discharge to three of six sampled residents (Residents 117, 320, and 321) and the Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities).

This deficient practice placed all three residents at risk for avoidable physical and psychosocial harm due to their discharge from the facility, without sufficient time for housing, transportation, and/or care arrangements to be made. The deficient practice also prevented the Ombudsman (a neutral third party who investigates and resolves complaints) from being aware of the need for follow-up related to the unsafe discharges.

Findings:

1. During a review of Resident 117's Admission Record, the Admission Record indicated Resident 117 was admitted on [DATE REDACTED]. 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 99 056023 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 During a review of Resident 117's social services progress note, dated 11/8/2024 at 3:49 p.m., the progress note indicated the Social Services Director (SSD) spoke with Resident 117 about his order to leave the Level of Harm - Minimal harm or facility OOP, and the time limit of four hours. The progress note indicated the SSD spoke with Resident 117 potential for actual harm about referring him to a housing coordinator to assist with transition back into the community. The progress note did not indicate Resident 117 expressed a desire to be discharged , or intentions to not return to the Residents Affected - Many facility from his four-hour OOP leave.

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 an approved OOP four-hour leave and did not return within four hours.

The progress note indicated staff attempts to contact Resident 117 were unsuccessful. The progress note indicated Resident 117 was discharged from the facility against medical advice (AMA, a situation where a patient leaves a healthcare facility or discontinues treatment without the consent or recommendation of their healthcare provider). The progress note did not indicate information related to the discharge was communicated to Resident 117.

During a review of Resident 117's physician order, dated 11/9/2024, the order indicated Resident 117 was discharged AMA due to exceeding the OOP four-hour time limit. The order indicated staff attempted to contact Resident 117 via cellular telephone and there was no response.

During a review of Resident 117's progress note, dated 11/9/24 at 7:15 a.m., the progress note indicated Resident 117 returned to the facility and went to his room. The progress note indicated Resident 117 was informed he was discharged and that his presence on the facility premises was trespassing. The progress note indicated Registered Nurse (RN) 1 contacted law enforcement, and law enforcement removed Resident 117 from the facility. The progress note indicated Resident 117 left with some of his belongings, and that he was told he could pick up his remaining belongings on 11/11/2024.

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 and was very aggressive and brandishing a large knife. The progress note indicated Resident 117 was yelling expletives. The progress note indicated law enforcement was contacted but never arrived. The progress note indicated Resident 117 collected the remainder of his belongings and left the facility premises.

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.

During an interview on 1/31/2025 at 10:16 a.m., with Registered Nurse (RN) 1, RN 1 stated a discharge AMA was initiated if a resident expressed a desire to leave the facility. RN 1 stated an AMA discharge required facility staff to explain the risks and benefits of leaving the facility to the resident, and stated the resident would be encouraged to stay in the facility. RN 1 stated an AMA discharge was to be requested by the resident and was not to be initiated by facility staff. RN 1 stated Resident 117's discharge was not safe. RN 1 stated discharging Resident 117 AMA indicated the discharge was Resident 117's choice, and stated this was not confirmed with Resident 117. RN 1 stated a discharge AMA also indicated there would be no attempt to search for the resident or involve any other agencies to ensure the resident's well-being.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 99 056023 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 During an interview on 1/31/2025 at 11:15 a.m., with the SSD, the SSD stated an AMA discharge was initiated if a resident expressed a desire to leave the facility immediately. The SSD stated she was arranging Level of Harm - Minimal harm or discharge housing for Resident 117 prior to his discharge from the facility on 11/9/2024 and stated they had potential for actual harm planned to review housing paperwork on Monday, 11/11/2024. The SSD stated that discharging a resident without a place to go was dangerous. The SSD stated the resident could be exposed to crime and poor Residents Affected - Many weather conditions, which could negatively impact their safety and well-being.

During an interview on 1/31/2025 at 1:02 p.m., with the Medical Records Director (MRD), the MRD stated Resident 117 did not sign an AMA acknowledgment form (a document that a patient signs to acknowledge their decision to leave a healthcare facility against their doctor's advice) at the time he was discharged because he was not in the facility and was unable to be contacted by phone.

During an interview on 1/31/2025 at 12:05 p.m., with the Director of Nursing (DON), the DON stated multiple attempts to reach Resident 117 were unsuccessful prior to the facility's decision to discharge Resident 117 AMA. The DON stated the facility did not know Resident 117's whereabouts, or if there was a reason he did not return within the four-hour timeframe, when the facility discharged him. The DON stated Resident 117's discharge was not safe.

2. During a review of Resident 320's Admission Record, the Admission Record indicated Resident 320 was admitted to the facility on [DATE REDACTED]. Resident 320's admitting diagnoses included generalized muscle weakness, abnormalities of gait (the way someone walks, runs, or jogs) and mobility, right foot drop (a condition where the foot is unable to lift off the ground due to weakness or paralysis of the muscles), discitis (an infection and/or inflammation of the space between the spinal bones), and type 2 diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing).

During a review of Resident 320's H&P, dated 9/13/2024, the H&P indicated Resident 320 had the capacity to understand and make decisions.

During a review of Resident 320's admission MDS, dated [DATE REDACTED], the MDS indicated Resident 320 did not have cognitive impairments (problems with a person's ability to think, learn, remember, use judgement, and make decisions). The MDS indicated Resident 320 required partial to moderate assistance from staff for mobility while in and out of bed, including to walk 10 feet. The MDS indicated Resident 320 was not assessed for his ability to transfer in and out of a vehicle, or to walk 50 feet or 150 feet, due to medical conditions and/or safety concerns.

During a review of Resident 320's discharge MDS, dated [DATE REDACTED], the MDS indicated Resident 320 was independent in making decisions regarding tasks of daily life, and his decisions were consistent and reasonable. The MDS indicated Resident 320 did not exhibit wandering behavior or rejection of care. The MDS indicated Resident 320 required partial to moderate assistance from staff for mobility, including to walk 10 feet. The MDS indicated Resident 320 was not assessed for his ability to transfer in and out of a vehicle, walk 50 feet or 150 feet, walk on uneven surfaces (outdoor or indoor), or to go up and down a step or curb, due to medical conditions and/or safety concerns.

During a review of Resident 320's case management progress note, dated 10/3/2024, the progress note indicated Resident 320 was refusing to be discharged home.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 99 056023 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 During a review of Resident 320's Nursing Weekly Summary assessment, dated 10/7/2024, the assessment indicated Resident 320 required a wheelchair and did not display any behavior concerns related to his Level of Harm - Minimal harm or admission at the facility. The assessment indicated Resident 320 was receiving physical therapy and potential for actual harm occupational therapy services, with slow steady progress. The assessment indicated Resident 320 required blood sugar level monitoring on all shifts. Residents Affected - Many