Avalon Villa Care Center

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

physician was responsible for explaining the risks and benefits of Depakote use and to answer any questions RP 1 could have. The QA Nurse stated the licensed nurse was responsible for verifying with RP 1 of their informed consent to administer Depakote to Resident 2. The QA Nurse stated by administering Depakote to Resident 2 without documentation informed consent was verified with RP 1, RP 1 may not be fully aware of the treatments given to Resident 2. During a review of the facility's Policy and Procedure (P&P) titled, Antipsychotic Medication Use, revised 7/2022, the P&P indicated, Residents and/or resident representatives will be informed of the recommendation, risks, benefits, purpose, and potential adverse consequences of antipsychotic medication use. Residents and/or representatives may refuse medications of any kind.During a review of the facility's P&P titled, Psychotropic Medication Use, revised 7/2022, the P&P indicated, Residents, families, and/or the representative are involved in the medication management process. Psychotropic medication management includes indications of use; dose (including duplicate therapy); duration; adequate monitoring for efficacy and adverse consequences; and preventing, identifying, and responding to adverse consequences. The P&P indicated, Residents and/or representatives have the right to decline treatment with psychotropic medications. The staff and physician will review the resident/representative the risks related to not taking the medication as well as appropriate alternatives.

Event ID:

Facility ID:

If continuation sheet

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

12/23/2025

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 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

interview and record review, the facility failed to conduct monitoring for one of four sampled residents' (Resident 2) who had behaviors of angry outbursts.This deficient practice had the potential to result in the inaccurate assessment of the effectiveness of Resident 2's medication regimen.Findings:During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was initially admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. Resident 2's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), schizophrenia (a mental illness that is characterized by disturbances in thought), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The admission Record indicated Resident 2 had a responsible party (RP) 1.During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool), dated 11/20/2025, the MDS indicated Resident 2's cognition (process of thinking) was intact. The MDS indicated Resident 2 had hallucinations (perceptual experiences in the absence of real external sensory stimuli). The MDS indicated Resident 2 was independent with eating, oral hygiene, toileting, upper/lower body dressing, and personal hygiene. The MDS indicated Resident 2 was taking anticonvulsant medication (used to treat seizures [a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness] and other behavioral conditions).During a review of Resident 2's History and Physical (H&P), dated 5/18/2025, the H&P indicated Resident 2 did not have the capacity to understand and make decisions.During a review of Resident 2's Orders, active on 12/24/2025, the Orders indicated to administer Depakote (an anticonvulsant medication) 500 milligrams (mg, a unit of measurement), by mouth once a day for mood disorder manifested by angry outbursts. During a review of Resident 2's Care Plan titled, Mood Disorder Manifested by Angry Outbursts, dated 6/17/2025, the Care Plan's indicated interventions were to monitor Resident 2's behavior episodes of mood disorder manifested by angry outbursts every shift and to document the frequency of the behavior.During a concurrent interview and record review on 12/23/2025 at 2:02 p.m., with Registered Nurse (RN) 2, Resident 2's Orders, dated 5/16/2025 through 12/23/2025, were reviewed. The Orders indicated from 5/16/2025 through 10/14/2025, Resident 2 was monitored for behavior episodes manifested by angry outbursts every shift. The Orders indicated to document the frequency of the behavior. RN 2 stated Resident 2's behavior monitoring was discontinued on 10/14/2025 and was never reordered. RN 2 stated the order prompted the licensed nurse to tally the frequency of behaviors every shift using the Behavior Monitoring Sheet. RN 2 stated monitoring and documenting Resident 2's behaviors allowed the healthcare team to determine the efficacy of Depakote and whether the medication dose had to be increased or decreased. RN 2 stated without proper monitoring, Resident 2 may experience more behaviors that are improperly managed. During a review of

the facility's Policy and Procedure (P&P) titled, Antipsychotic Medication Use, revised 7/2022, the P&P indicated, The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications.

Event ID:

Facility ID:

If continuation sheet

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

12/23/2025

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 0907 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

essential to allow the staff to safely move around the area to provide care. The ADM stated limited space could result in the residents feeling anxious, agitated, and/or frustrated.During a review of the facility's Policy and Procedure (P&P) titled, Quality of Life- Accommodation of Needs, dated 8/2009, the P&P indicated, The resident's individual needs and preferences shall be accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. The P&P indicated, In order to accommodate individual needs and preferences, adaptations may be made to the physical environment, including the resident's bedrooms and bathrooms, as well as the common areas in

the facility.

Event ID:

Facility ID:

If continuation sheet