LOS ANGELES, CA - State health inspectors identified serious documentation errors, staffing data reporting failures, and equipment maintenance violations at Flower Villa, Inc. during a March 2025 inspection, raising concerns about the facility's ability to maintain accurate records and ensure resident safety.
Critical Documentation Errors Found in Advance Directives
During the March 9, 2025 inspection, surveyors discovered significant documentation errors in resident advance directives and life-sustaining treatment forms that could have serious implications during medical emergencies. The review of Resident 27's medical records revealed multiple concerning issues with legally critical documents.
The resident's Physician Orders for Life-Sustaining Treatment (POLST) form, dated May 26, 2022, contained a fundamental error where "Brother" was written in the relationship box that should have indicated "self" if the patient completed the form. This type of error creates confusion about who authorized these critical medical decisions. The accompanying Advance Directive form had equally troubling problems - the physician's signature lacked any date, and the document incorrectly listed the resident's surrogate decision maker's name instead of the actual resident's name.
These documentation errors are particularly concerning given Resident 27's medical profile. The individual had been admitted with multiple serious conditions including dementia, paranoid schizophrenia, anxiety disorder, encephalopathy, and hypotension. The resident's assessment indicated severe cognitive impairment and complete dependence on staff for all activities of daily living including eating, toileting, dressing, and mobility.
When advance directives contain errors or ambiguities, medical staff may face critical delays during emergencies while attempting to determine the resident's actual wishes regarding life-sustaining treatment. Such delays can mean the difference between timely intervention and irreversible harm. Accurate documentation becomes even more critical for residents with severe cognitive impairment who cannot advocate for themselves or clarify their wishes when questions arise.
Systemic Failure in Staffing Data Reporting
The inspection revealed that Flower Villa failed to submit complete and accurate Payroll Based Journal (PBJ) data to the Centers for Medicare and Medicaid Services for three of four required quarters in fiscal year 2024. This reporting requirement allows regulators and the public to assess whether facilities maintain adequate staffing levels to meet resident needs.
The facility's CASPER system review showed alarming gaps in reported nursing coverage. During the first fiscal quarter (October through December 2023), the facility reported no registered nurse coverage on 31 different dates, primarily weekends. The second quarter data showed similar gaps with no RN coverage reported for 17 dates between January and February 2024. Most concerning was the fourth quarter, where the facility reported neither RN coverage nor 24-hour LVN coverage for the entire month of July 2024.
When interviewed, the Director of Staff and Development acknowledged that "the PBJ reporting was done by their corporate office, and it appears that the data submitted was not accurate." The director confirmed the facility actually had RN coverage every day during October and November 2023, contradicting the submitted data. The facility did acknowledge lacking RN coverage on weekends during portions of December 2023 through February 2024.
Accurate staffing data reporting serves multiple critical functions beyond regulatory compliance. These reports inform potential residents and families about staffing levels when choosing a facility, guide state survey priorities, and factor into quality ratings. When facilities submit inaccurate data showing no nursing coverage for extended periods, it undermines the entire quality monitoring system and prevents proper oversight of resident care.
The CMS PBJ Policy Manual explicitly states that facilities remain responsible for accurate reporting even when using vendors or corporate offices to submit data. The facility's own policies, revised in January 2025, emphasize ensuring "accurate and timely submission" of this data. The pattern of reporting failures across multiple quarters suggests systemic problems with the facility's data management processes rather than isolated errors.
Hoyer Lift Maintenance Violations Pose Safety Risks
Inspectors identified serious safety concerns with the facility's Hoyer lift equipment, which staff use to transfer residents with mobility limitations. During the inspection, the Maintenance Director admitted that "the Hoyer Lift are not being inspected by the manufacturer annually" despite facility policies requiring such inspections.
The observed Hoyer lift showed visible signs of deterioration including rust and chipped paint, with no stickers indicating when the equipment last received manufacturer inspection. The Maintenance Director acknowledged only replacing broken parts as needed and lacking manufacturer certification to service the equipment.
Hoyer lifts bear the full weight of residents during transfers, making proper maintenance essential for preventing catastrophic failures. Without regular professional inspections, small problems like worn cables, weakened joints, or hydraulic issues may go undetected until equipment fails during use. Such failures can result in residents falling from height, suffering fractures, head injuries, or worse.
The facility's own General Maintenance Policy, revised in January 2025, clearly requires annual professional servicing by certified technicians, including comprehensive safety checks, parts replacement, and load capacity testing. The policy mandates maintaining records of these annual services. The complete absence of manufacturer inspections and reliance on uncertified maintenance staff for repairs represents a significant departure from both facility policy and industry safety standards.
Ombudsman Notification Failures
The inspection also revealed the facility failed to properly notify the Ombudsman when transferring residents to acute care hospitals. Reviews of transfer documentation for Residents 11, 19, and 30 showed no indication that required Ombudsman notifications occurred when these individuals were transferred to hospitals on various dates in 2024 and 2025.
The Director of Nursing confirmed during the inspection that "the Transfer/Discharge form should be filled out completely and sent to the Ombudsman for notification of the transfers." The Ombudsman serves as an independent advocate for nursing home residents, and notification requirements exist to ensure someone outside the facility monitors transfer patterns and can investigate if concerns arise about inappropriate discharges or transfers.
Additional Issues Identified
Beyond these major violations, inspectors documented problems with inadequate room sizes in 18 of 21 resident rooms. These rooms measured between 67 and 76.38 square feet per resident, falling short of the required 80 square feet minimum for double-occupancy rooms. While observers noted residents and staff could move freely within the rooms during the inspection, the space limitations potentially impact privacy and the ability to safely maneuver equipment during care delivery.
The facility's Documentation Policy emphasizes ensuring "all documentation is accurate, complete and reliable," yet the pattern of violations demonstrates widespread failures to meet these basic standards across multiple documentation systems and departments.
These violations occurred at Flower Villa's facility located at 1480 S. LA Cienega Boulevard in Los Angeles, affecting the 41 residents who depend on the facility for their daily care and safety needs. The inspection findings highlight concerning gaps between written policies and actual practices that require immediate correction to ensure resident safety and regulatory compliance.
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.
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