Health inspection·August 19, 2025

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure routine drugs and biologicals were provided to residents by allowing an unlicensed nurse (Staff 1) to administer medications to four of six sampled residents (Residents 1, 2, 3, and 4) for over one and a half years. This deficient practice caused an increased risk in unsafe and inappropriate care of the residents, medication errors, and adverse outcomes to the residents. Findings: a. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including right ankle and foot osteomyelitis (an infection in the bone). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/2025, the MDS indicated Resident 1 had the ability to make self-understood and to understand others. The MDS indicated Resident 1 received an opioid (a drug used for pain) medication. During a review of the Medication Administration Records (MAR) dated 6/1/2025 through 8/15/2025, the MAR indicated Resident 1 received Norco 5-325 mg (a controlled substance used to relieve moderate to severe pain) on seven separate occasions administered by Staff 1. During a concurrent interview and record review on 8/18/2025 at 10:45 a.m., with Director of Staff Development (DSD), Staff 1's personnel file was reviewed. The personnel file indicated Staff 1 was hired to work in the facility as a Licensed Vocational Nurse (LVN, an entry level healthcare provider who must complete a state approved educational program and pass a licensing exam to practice) on 1/8/2024, and did not have proper documentation of a valid professional LVN license. The DSD stated Staff 1's personnel file contained a California Identification Card (ID) and Social Security (SS) card but did not contain evidence of a valid LVN license verification through the California Board of Vocational Nursing and Psychiatric Technicians (BVNPT) system. The DSD stated Staff 1's employee file contained a copy of a LVN license of an unidentified individual which did not match Staff 1's ID and SS card. The DSD stated the facility hired Staff 1 by using the unidentified individual's professional LVN license. The DSD stated by allowing unlicensed Staff 1 to function as an LVN for over a year and a half placed all residents at risk for unsafe care and potential harm. b. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE] with diagnoses including pelvis (bony structure inside hips) fracture (a break in a bone) and lumbar vertebra (bone in the lower back) fracture. During a review of Resident 2's MDS, dated [DATE], the MDS indicated Resident 2 had the ability to make self-understood and to understand others. The MDS indicated Resident 2 received an opioid medication. During a review of the Medication Administration Records (MAR) dated 6/1/2025 through 8/15/2025, the MAR indicated Resident 2 received Oxycodone (an opioid, controlled substance used to relieve severe pain, by prescription only with a high potential for addiction, abuse and misuse) 10 mg on 31 separate occasions and the medication was administered by Staff 1. During an interview on 8/18/2025 at 1:45 p.m., the Director of Nursing (DON) stated that on 8/13/2025, it was (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 056023 Printed: 05/15/2026 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 056023 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2025 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)