Health inspection·September 11, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4), was not laying in soiled diaper for over five hours.This deficient practice resulted in Resident 4 feeling pissed off with the potential to affect the resident's dignity. Findings:During a review of Resident 4's admission Record, the admission Record indicated the facility admitted the resident on 5/19/2022 with diagnoses including nondisplaced spiral fracture of shaft of left tibia (shinbone) and closed fracture (a type of leg injury where the tibia breaks in a spiral pattern due to a twisting force, and the broken ends remain aligned without moving out of place, with the skin remaining closed), chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), diabetes mellitus (a disorder characterized by difficulty in blood sugar control and poor wound healing) and schizophrenia (a mental illness that affects a persons, thoughts, feelings and behaviors).During a review of Resident 4's Minimum Data Set (MDS- a resident assessment tool), dated 8/28/2025, the MDS indicated Resident 4's cognition (process of thinking) was intact. The MDS indicated Resident 4 was not able to complete activities of daily living (ADLs) such as bathing, dressing and toileting, and required maximum (helper does more than half the effort) assistance from staff.During a concurrent observation and interview on 9/10/2025 at 11:20 p.m. with Resident 4, in Resident 4's room, Resident 4 was observed to be awake, fidgeting and visibly uncomfortable. Resident 4 stated, I am pissed off because I have been laying in a soiled diaper for more than 5 hours. Resident 4 stated she wanted to be changed.During a concurrent observation and interview on 9/10/2025 at 11:30 a.m., Certified Nurse Assistant (CNA) 1, was observed walking into Resident 4's room and stated she would let the resident's assigned CNA know that the resident needed assistance. CNA 1 did not provide care to Resident 4. During an interview on 9/10/2025 at 11:45 a.m., with Director of Nursing (DON), the DON stated, the facility policy states, 2 minutes is how long the residents wait to be changed. During an interview on 9/10/2025 at 1:25 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated she was busy with other residents and could not assist Resident 4. CNA 2 stated Resident 4 was not provided dignity and was not able to invoke her rights.During a review of the facility's policy and procedure (P&P), titled Quality of Life-Dignity, revised 8/2009, the P&P indicated, Residents shall be treated with dignity and respect at all times.During a review of the facility's policy and procedure (P&P), titled Residents Rights, revised 12/2016, the P&P indicated, Employees shall treat all residents with kindness, respect and dignity. 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 09/11/2025 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)