Avalon Villa Care Center

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

hemodialysis access site had a pressure dressing on it, and stated the dressing was from Resident 1's hemodialysis treatment on 9/17/2025. LVN 2 stated the original pressure dressing was not removed or changed. During a concurrent interview and record review, on 9/18/2025 at 2:56 PM, with LVN 2, Resident 1's Dialysis Communication Record, dated 9/17/2025, was reviewed. LVN 2 stated the record indicated Resident 1's pressure dressing was to be removed after 12:00 PM. LVN 2 stated she overlooked the instruction and should have carried out the instruction as written. LVN 2 stated the pressure dressing was to be removed to prevent infection at the site and to allow for assessment of the site for complications. LVN 2 stated removal of the pressure dressing was also important to ensure blood circulation was maintained.

During a telephone interview, on 9/19/2025 at 10:36 AM, with Social Worker (SW) 1 from Resident 1's hemodialysis center, SW 1 stated the hemodialysis technicians reported that Resident 1's pressure dressing from her treatment on 9/17/2025 was still in place upon her arrival to the dialysis center on 9/19/2025. During a concurrent interview and record review, on 9/19/2025 at 11:01 AM, with Registered Nurse (RN) 1, the facility's policy and procedure (P&P) titled Hemodialysis Access Care, revised 9/2010, was reviewed. RN 1 stated the P&P indicated nursing staff were to routinely assess for signs of infection and adequate circulation at the hemodialysis access site. RN 1 stated these assessments required direct visual observation and direct physical (touch) examination of the access site. RN 1 stated a pressure dressing would obstruct the licensed nurse's ability to perform accurate assessments of the access site. RN 1 stated the pressure dressing should be removed as instructed on the Dialysis Communication Record.

During an interview, on 9/19/2025 at 11:14 AM, with RN 1, RN 1 stated Resident 1 did not have documentation every shift of the condition of her hemodialysis access site, or the report and applicable special instructions provided following hemodialysis. 2a. During an interview on 9/19/2025 at 11:06 AM, with RN 1, RN 1 stated nursing staff were to document a progress note every shift that included any special instructions and report from the hemodialysis nurse, and the condition of the resident and their hemodialysis access site. RN 1 stated it was important to document this information every shift to ensure all staff were aware of any pertinent clinical information and to ensure that any special instructions were carried out. During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 7/21/2025. Resident 2's diagnoses included ESRD and dependence on hemodialysis. During a review of Resident 2's MDS, dated [DATE REDACTED], the MDS indicated Resident 2 had moderately impaired cognition. The MDS indicated Resident 2 required substantial to maximal assistance from staff for all mobility while in and out of bed. During an interview on 9/19/2025 at 11:16 AM, with RN 1, RN 1 stated from 9/1/2025 to 9/19/2025 there was no documentation of the condition of Resident 2's hemodialysis access site or the report provided by the hemodialysis nurse post-dialysis. 2b. During a review of Resident 3's admission Record, the admission Record indicated the facility admitted Resident 3 on 7/10/2025. Resident 3's diagnoses included ESRD and dependence on hemodialysis. During a review of Resident 3's MDS, dated [DATE REDACTED], the MDS indicated Resident 3 had moderately impaired cognition. The MDS indicated Resident 3 required substantial to maximal assistance for all mobility while in and out of bed. During an interview on 9/19/2025 at 11:18 AM, with RN 1, RN 1 stated from 9/1/2025 to 9/19/2025 there was no documentation of the condition of Resident 3's hemodialysis access site or the report provided by the hemodialysis nurse post-dialysis. During a review of the facility P&P titled Hemodialysis Access Care, revised 9/2010, the P&P indicated nursing staff were to document, every shift, the condition of the dressing and interventions if needed, and any part of report being given from the dialysis nurse post-dialysis.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/19/2025

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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 4) received a soft and bite-sized texture diet as ordered. This deficient practice placed Resident 4 at risk of choking, aspiration (accidental inhalation of foreign substances, such as food, liquids, or mucus, into the lungs), and possible infection within the lungs and/or death.Findings: During a review of Resident 4's admission Record, the admission Record indicated the facility originally admitted Resident 4

on 10/18/2021, and most recently re-admitted him on 2/25/2013. Resident 4's diagnoses included dysphagia (difficulty swallowing). During a review of Resident 4's Minimum Data Set (MDS, a resident assessment tool), dated 7/2/2025, the MDS indicated Resident 4 did not have impaired cognition (decline in

a person's mental abilities). The MDS indicated Resident 4 could eat independently. During a review of Resident 4's care plan, titled Oral/dental health problems, edentulous (having no teeth)., dated 4/4/2025,

the care plan indicated staff were to provide Resident 4 his diet as ordered. During a review of Resident 4's physician order, dated 9/4/2025, the order indicated Resident 4 was to receive a soft and bite sized texture diet. During an observation on 9/19/2025 at 12:30 PM, in the dining room, Resident 4 was observed eating lunch. Resident 4 was edentulous (having no teeth) and was not wearing upper or lower dentures. Resident 4's tray ticket (a detailed printout used in healthcare to guide food service staff in assembling trays for residents or patients) indicated Resident 4 was to have soft and bite-sized texture food on his lunch tray. On Resident 4's plate, Resident 4 had a square slice of cornbread, approximately two inches thick. The cornbread was not cut or broken into pieces and was served whole. During a concurrent observation and interview, on 9/19/2025 at 12:36 PM, with the Dietary Supervisor (DS), Resident 4's lunch tray was observed. The DS stated Resident 4's tray ticket indicated Resident 4 was to receive a tray with soft and bite-sized texture food. The DS stated the slice of cornbread did not meet the soft and bite-sized requirement. The DS stated the cornbread was a safety risk for Resident 4. During an interview on 9/19/2025 at 2:07 PM, with the Speech Therapist (ST), the ST stated it was important to serve a soft and bite-sized texture as ordered for resident safety. The ST stated serving a diet as ordered was to ensure the resident could safely chew and eat the food and helped to prevent choking and aspiration of food. The ST stated aspiration of food could lead to pneumonia (infection of the lungs) and possibly death. During a

review of the facility's policy and procedure (P&P) titled Soft and Bite Sized Diet, undated, the P&P indicated a soft and bite-sized diet was used for residents with dysphagia. The P&P indicated the food was to be no larger than 1/2 inch by 1/2 inch sized pieces. The P&P indicated any bread components were to be pureed (a very smooth, crushed or blended food), and no regular, dry bread was permitted. During a review of the facility document titled Fall Menus, dated 9/19/2025, the menu indicated that cornbread for residents

on a soft and bite-sized texture diet was to be pureed.

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