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Complaint Investigation

Avalon Villa Care Center

December 23, 2025 · Los Angeles, CA · 12029 Avalon Blvd
Citations 3
CMS Rating 1/5
Beds 131
Provider ID 056023
Healthcare Facility
Avalon Villa Care Center
Los Angeles, CA  ·  View full profile →
Inspection Summary

AVALON VILLA CARE CENTER in LOS ANGELES, CA — inspection on December 23, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0552
Resident Rights Deficiencies
Potential for More Than Minimal Harm

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/23/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Avalon Villa Care Center

12029 Avalon Blvd Los Angeles, CA 90061

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

12/23/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Avalon Villa Care Center

12029 Avalon Blvd Los Angeles, CA 90061

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

Frequently Asked Questions

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.


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