Licensed Vocational Nurse 2 removed ProAmatine 5 mg, Risperdal 1 mg, and Vitamin D 5000-unit tablets from their individual bubble packs on March 8 and put them all together in one plastic pouch. The nurse then crushed all three medications together and told an inspector the medications "can be crushed together good and put in applesauce for the resident."
The resident, identified as Resident 27, was admitted to Flower Villa in November 2024 with dementia, paranoid schizophrenia, anxiety disorder, brain disease, and low blood pressure. A February assessment showed the patient had severe cognitive impairment and required complete assistance from staff for eating, hygiene, toileting, dressing, and moving around.
ProAmatine treats low blood pressure with instructions to hold the dose if blood pressure rises above 130. Risperdal treats mental health conditions like schizophrenia. The resident's medical orders specified that crushable medications could be mixed with applesauce or food, but did not authorize combining different drugs before crushing.
Director of Nursing acknowledged the error when interviewed the next day. "The medications should not be crushed all together and administered to the resident," the director told inspectors. "The nurse should have known not to do that."
The facility's own policy, revised in January 2025, states that crushed medications may be combined "when appropriate" and that resident safety and medication schedules must be considered when determining administration methods.
Federal inspectors also found that another resident had not received any dental care since admission, despite having a doctor's order for dental consultation and treatment. Resident 15, who was admitted with chronic lung disease, bipolar disorder, stroke history, and paralysis of the legs, required supervision with eating and substantial help with personal care.
The Social Services Director confirmed during chart review that Resident 15 had never been seen by a dentist at the facility since admission. "They should have been seen since the dentist has been at the facility to see other residents," the director said.
The facility's dental policy requires staff to help residents obtain routine and emergency dental care.
Kitchen safety violations compounded the care problems. Inspectors photographed dirt and debris under dry storage racks in corners of the food storage room. Grease drips covered the sides of the range oven.
Multiple food containers in the refrigerator lacked required labeling. Tuna salad, salsa, shredded cheese, mayonnaise, and soy milk containers had no use-by dates marked on them. Cook 1 admitted staff "must have forgotten to put the use by date" on the containers.
The Director of Nursing told inspectors that hand sanitizer had been removed from the kitchen area, saying it was only used when staff left the kitchen.
The facility's food labeling policy requires all containers to show both the date prepared or opened and the expiration or use-by date. The sanitation policy mandates that all food service areas remain clean, sanitary, and free from litter and rubbish.
Medical record keeping also fell short of professional standards. Four residents had incomplete or inaccurate documentation in their files.
Resident 27's end-of-life care form and advance directive contained errors. Three other residents' transfer and discharge notices lacked required signatures from the residents or their representatives.
These documentation failures could affect care delivery during medical emergencies, when accurate records become critical for treatment decisions.
The inspection covered multiple areas of resident care and facility operations. All violations were classified as causing minimal harm or potential for actual harm to residents.
Flower Villa operates at 1480 S. La Cienega Boulevard in Los Angeles. The March 9 federal inspection identified systemic problems across medication administration, dental care, food safety, and medical record maintenance that put vulnerable residents at risk.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Flower Villa, Inc from 2025-03-09 including all violations, facility responses, and corrective action plans.