Flower Villa, Inc

F-F623

Findings:

1. During a review of Resident 27's Admission Record dated 11/13/2024 indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including: dementia (a progressive state of decline in mental abilities), Vitamin D deficiency (condition where the body does not have enough Vitamin D, paranoid schizophrenia (a mental illness that is characterized by disturbances in thought, where there is distrust and suspicion), anxiety disorder (excessive fear or worry), encephalopathy (broad term for any brain disease that alters brain function or structure), and hypotension (low blood pressure).

During a review of Resident 27's Minimum Data Set (MDS, resident assessment tool), dated 2/13/2025 indicated the resident had severe cognitive (the ability to think, learn, and remember clearly) impairment. The MDS further indicated Resident 27 was dependent on staff for eating, oral hygiene, toileting, dressing, personal hygiene, bed mobility and transferring.

During a concurrent interview and record review on 3/9/2025 at 4:22 PM with the Director of Nursing (DON) Resident 27's POLST (Physician Orders for Life-Sustaining Treatment) form dated 5/26/2022 and Advance Directive / Medical Treatment and Decisions form dated 5/26/2022 were reviewed. The POLST indicated Brother written in the Relationship (write self if patient) box of the form. The DON verified the entry and stated it should be entered self. The Advance Directive form indicated no date entered the physician's signature and an error with the resident's name. The DON verified there was not date by the physician's signature and that the resident's surrogate decisions maker's name had been entered in error instead of the resident's. The DON stated there should be a date and the resident's name entered is a mistake.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0842 2. A review of Resident 11's Admission Record dated 3/9/2025 indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including: diabetes mellitus (DM, a disorder characterized by difficulty in Level of Harm - Minimal harm or blood sugar control and poor wound healing), hypertensive (high blood pressure) heart disease, bipolar potential for actual harm disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs), and major depressive disorder (a mood disorder that causes a Residents Affected - Some persistent feeling of sadness and loss of interest).

A review of Resident 11's MDS, dated [DATE REDACTED], indicated the resident had intact cognition. The MDS further indicated Resident 11 was independent with eating, toileting, dressing, personal hygiene, bed mobility and walking.

A review of Resident 11's Notice of Proposed Transfer/Discharge form indicated the resident was transferred to General Acute Care Hospital (GACH) on 8/30/2024.

A review of Resident 19's Admission Record dated 10/18/24 indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including: diabetes mellitus (DM, a disorder characterized by difficulty in blood sugar control and poor wound healing), chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).

A review of Resident 19's MDS, dated [DATE REDACTED], indicated the resident had intact cognition. The MDS further indicated Resident 19 required supervision or touching assistance with eating, and substantial/maximal assistance (helper does more than half the effort, or lifts or holds trunk or limbs and provides half the effort) with toileting, dressing, personal hygiene, bed mobility, and transferring.

A review of Resident 19's Notice of Proposed Transfer/Discharge form indicated the resident was transferred to GACH on 3/16/2025.

A review of Resident 30's Admission Record dated 3/9/2025 indicated the resident was admitted to the facility on [DATE REDACTED] with diagnoses including: DM, COPD, schizophrenia (a mental illness that is characterized by disturbances in thought) and bipolar disorder (sometimes called manic-depressive disorder; mood swings that range from the lows of depression to elevated periods of emotional highs).

A review of Resident 30's MDS, dated [DATE REDACTED], indicated the resident had severe cognitive (the ability to think, learn, and remember clearly) impairment. The MDS further indicated Resident 30 required substantial/maximal assistance (helper does more than half the effort, or lifts or holds trunk or limbs and provides half the effort) with eating and oral hygiene and was dependent on staff for toileting, dressing, personal hygiene, bed mobility, and transferring.

A review of Resident 30's Notice of Proposed Transfer/Discharge form indicated the resident was transferred to GACH on 7/25/2024.

During a concurrent interview and record review on 3/9/2025 at 9:43 AM with Medical Records Director (MRD), the charts for Residents 11, 19 and 30 were reviewed. The MRD verified there was no indication in

the residents' charts the Ombudsman had been informed of the transfers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0842 During an interview on 3/9/2025 at 4:54 PM with the DON, the DON stated the Transfer/ Discharge form should be filled out completely and sent to the Ombudsman for notification of the transfers. Level of Harm - Minimal harm or potential for actual harm During a review of the facility policy and procedures titled Documentation Policy: Accuracy and Completeness revised January 2025 indicated Purpose . ensure all documentation is accurate, complete and Residents Affected - Some reliable.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0851 Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Level of Harm - Minimal harm or potential for actual harm 43454

Residents Affected - Some Based on interview and record review, the facility failed to ensure their Payroll Based Journal (PBJ - information of the provider's daily staffing hours for the appropriate care of the residents) complete and accurate data had been submitted to the Center for Medicare and Medicaid Services (CMS) for three of four required quarters (1st fiscal quarter: 10/2023 - 12/2023, 2nd fiscal quarter: 1/2024 - 3/31/2024, and 4th fiscal quarter: 7/2024 - 9/2024) in 2024.

This deficient practice had the potential to place 41 facility residents (bed capacity) as risk for delay in care, treatment, and services necessary to maintain physical and emotional wellbeing.

Findings:

During a review of the facility Certification and Survey Provider Enhanced Reporting system (CASPER: Shows the facility percentage and how the facility compares with other facilities in their state and in the nation) revealed there were no Registered Nurse (RN) coverage and no licensed nursing (LVN) coverage for 4th fiscal quarter, 2nd fiscal quarter and 1st fiscal quarter.

During a review of CMS' website Staffing Data PBJ Submission website (https://www.cms. gov/medicare/quality/nursing-home-improvement/staffing-data-submission) indicated the deadlines for each reporting period were:

o The 1st fiscal quarter was from 10/01/2023 through 12/31/2023, the indicated submission due date was 02/14/2024.

o The 2nd fiscal quarter was from 1/1/2024 through 3/1/2024, the indicated submission due date was 5/15/2024.

o The 4th fiscal quarter was from 7/1/2024 through 9/30/2024, the indicated submission due date was 11/14/2024.

During a review of CMS Staffing Data Report, run date 3/4/2025, the PBJ staffing data report indicated,

i. On 1st fiscal quarter, facility has no RN hours coverage for the following dates: 10/01/2023, 10/07/2023, 10/08/2023; 10/14/2023; 10/15/2023; 10/21/2023; 10/22/2023; 10/28/2023; 10/29/2023; 11/04/2023; 11/05/2023; 11/11/2023; 11/12/2023; 11/18/2023; 11/19/2023; 11/24/2023; 11/25/2023; 11/26/2023, 11/27/2023, 12/02/20230, 12/03/2023; 12/09/2023; 12/10/2023, 12/16/2023, 12/17/2023; 12/23/2023; 12/24/2023; 12/25/2023, 12/29/2023, 12/30/2023; 12/31/2023, and no LVN coverage for 24 hours/day on the following dates: 10/29/2023, 11/07/2023; 11/14/2023; 11/27/2023.

ii. On 2nd quarter, there were no RN hours coverage for the following dates: 01/06/2024; 1/7/2024; 1/13/2024; 1/14/2024; 1/20/2024; 1/21/2024, 1/27/2024; 1/28/2024, 2/3/2024; 2/4/2024, 2/5/2024; 2/10/2024; 2/12/2024; 2/17/2024; 2/18/2024; 2/24/2024; 2/25/2024

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0851 iii. On 4th quarter, there were no RN hours coverage and no LVN coverage 24 hours/day for the following dates: 7/1/2024; 7/2/2024; 7/3/2024; 7/4/2024; 7/5/2024; 7/6/2024; 7/7/2024; 7/8/2024; 7/9/2024; 7/10/2024; Level of Harm - Minimal harm or 7/11/2024; 7/12/2024; 7/13/2024; 7/14/2024; 7/15/2024; 7/16/2024; 7/17/2024; 7/18/2024; 7/19/2024; potential for actual harm 7/20/2024; 7/21/2024; 7/22/2024; 7/23/2024; 7/24/2024; 7/25/2024; 7/26/2024; 7/27/2024; 7/28/2024; 7/29/2024; 7/30/2024; 7/31/2024 Residents Affected - Some

During an interview with Director of Staff and Development (DSD) on 3/9/2025 at 2:22 PM, DSD stated, the PBJ reporting was done by their corporate office, and it appears that the data submitted was not accurate. DSD stated, on 10/2023 and 11/2023, they have RN coverage every day and there's LVN coverage for 24 hours/day on 10/2023, 11/2023 and 7/2024. DSD stated, they did not have an RN coverage on the weekends of 12/2023, 1/2024, 2/2024.

During a review of the facility policy and procedure (P&P) titled, Staffing, dated 1/31/2024, the P&P indicated Direct staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system on the schedule specified by CMS, not no less than once a quarter.

During a review of the facility P&P titled, PBJ Reporting Policy, revised on 1/2025, the P&P indicated, To ensure accurate and timely submission of Payroll-Based Journal (PBJ) data to CMS in compliance with federal regulations . All staffing hours, including direct care staff, contract employees, and administrative personnel, must be recorded accurately in the payroll system.

During a review of the CMS PBJ Policy Manual, dated 6/1/2022, indicated Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. The Policy indicated Staffing information is required to be an accurate and complete submission of a facility's staffing records. Facilities should run the staffing reports that are available in CASPER to verify the accuracy and completeness of their final submission prior to the submission deadline. CMS will conduct audits to assess a facility's compliance related to this requirement. The policy also indicated Facilities that do not meet these requirements will be considered noncompliant and subject to enforcement actions by CMS. Note: If a facility uses a vendor to submit information on behalf of the nursing home, the nursing home is still ultimately responsible for meeting all the requirements.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0908 Keep all essential equipment working safely.

Level of Harm - Minimal harm or 43454 potential for actual harm Based on observation and interview, the facility failed to ensure one of one Hoyer Lift (a mechanical device Residents Affected - Some used to lift and/or transfer a person from place to place) was properly maintained for a safe and effective operation with safety regulations.

This deficient practice has a potential to cause incidental accidents to the residents while using the equipment.

Findings:

During a concurrent observation of the facility's Hoyer Lift and interview with Maintenance Director (MTD) on 3/8/2025 at 8:52 AM, the Hoyer Lift was observed with no stickers of the date when the last manufacturer's inspection. The Hoyer Lift was also observed with rusty color and paints were chipped. MTD stated, the Hoyer Lift are not being inspected by the manufacturer annually. MTD stated, if the Hoyer Lift is broken, he replaces the broken parts if needed. MTD stated, he does not have a certification from the Manufacturer to service the Hoyer Lift.

During a review of facility policy and procedures (P&P) titled, Hoyer Lift Maintenance Policy, revised on 1/2025, the P&P indicated, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk.

During a review of facility P&P titled, General Maintenance Policy, revised on 1/2025, the P&P indicated, All Hoyer lifts shall be regularly inspected, maintained, and repaired in accordance with manufacturer guidelines and facility safety protocols. Only trained personnel are permitted to operate and perform basic maintenance

on Hoyer lifts . Annual Professional Servicing:

o A certified technician must inspect and service all Hoyer lifts at least once per year.

o The servicing will include a comprehensive safety check, parts replacement as needed, and a load capacity test.

o A record of the annual service must be kept in the facility's equipment maintenance records.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm 44253

Residents Affected - Some Based on observation, interview, and record review the facility failed to ensure 18 of 21 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 14, 15, 16, 18, 19, 21, 23 and 25) met the are footage requirements of 80 square feet (sq ft) per resident.

This deficient practice had the potential to result in inadequate space to provide safe nursing care and privacy for 31 Residents.

Findings:

A review of facility's room waiver request letter, dated 2/28/25, indicated 18 of 21 rooms do not have at least 80 sq ft per resident.

A review of the Client Accommodation Analysis, dated 2/28/2025, indicated the following:

Room # No. Total Sq ft

of Beds Sq ft per bed

1 2 144.72 72.36

2 2 144.72 72.36

3 2 144.72 72.36

4 2 147.4 73.7

5 2 147.4 73.7

6 2 144.72 72.36

7 2 152.76 76.38

9 2 144.72 72.36

10 2 147.4 73.7

11 2 144.72 72.36

14 2 134 67

18 2 144.72 72.36

19 2 144.72 72.36

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0912 21 2 144.72 72.36

Level of Harm - Potential for 23 2 144.72 72.36 minimal harm 25 2 144.72 72.36 Residents Affected - Some

A review of the The State Operations Manual (SOM - is a federal document, issued by CMS, containing survey and certification rules and guidance), revised 2/3/2023, indicated the square footage requirements for

a two-bed capacity room is at least 160 sq ft.

During multiple observations made from 3/7/2025 to 3/9/2025, both residents and staff had enough space to move about freely inside the rooms. The nursing staff had enough space to safely provide care to the residents with space for beds, side tables, dressers and resident care equipment.

A review of the facility policy and procedures titled, Resident Rooms, revised 1/2025, indicated resident bedrooms will measure at least 80 square feet per resident and multiple resident bedrooms and at least 100 square feet and single resident bedrooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 056438

F-F759

Findings:

During a review of Resident 27's Admission Record dated 11/13/2024 indicated the resident was admitted to

the facility on [DATE REDACTED] with diagnoses including: dementia (a progressive state of decline in mental abilities), Vitamin D deficiency (condition where the body does not have enough Vitamin D, paranoid schizophrenia (a mental illness that is characterized by disturbances in thought, where there is distrust and suspicion), anxiety disorder (excessive fear or worry), encephalopathy (broad term for any brain disease that alters brain function or structure), and hypotension (low blood pressure).

During a review of Resident 27's Minimum Data Set (MDS, resident assessment tool), dated 2/13/2025 indicated the resident had severe cognitive (the ability to think, learn, and remember clearly) impairment. The MDS further indicated Resident 27 was dependent on staff for eating, oral hygiene, toileting, dressing, personal hygiene, bed mobility and transferring.

During a review of Resident 27's Order Summary Report dated 3/1/2025 indicated orders for ProAmatine (medication for low blood pressure) oral tablet 5 mg give one tablet by mouth one time a day for blood pressure hold if above 130, Risperdal (medication to [NAME] mental health condition such as schizophrenia) oral tablet (Risperidone) give 1mg by mouth three times a day for paranoid schizophrenia, Vitamin D3 (supplement) oral tablet (Cholecalciferol) give 5000 unit by mouth one time a day for Vitamin D deficiency.

The same report further indicated an order of may crush all crushable meds then mix with apple sauce or food.

During an observation with concurrent interview on 3/8/2025 at 9:05 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 was observed passing medications for Resident 27. LVN 2 removed ProAmatine 5 mg tablet, Risperdal 1 mg tablet and Vitamin D 5000 - unit tablet from their bubble packs, put them all together in one plastic pouch and proceeded to crush all three medications together. LVN 2 stated the medications can be crushed together good and put in applesauce for the resident.

During an interview with the Director of Nursing (DON) on 3/9/2025 at 4:59 PM, the DON stated the medications should not be crushed all together and administered to the resident, the nurse should have known not to do that.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0760 During a review of the facility's policy and procedures titled Crushed Medications revised January 2025 indicated Medications shall be crushed in accordance with standards of practice for safety and accuracy in Level of Harm - Minimal harm or medication administration. Crushed medications may be combined and administered orally, when potential for actual harm appropriate. a. Resident's safety, needs, mediation schedule, preferences, and functional ability shall be considered when determining the most appropriate method for administering medications. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0790 Provide routine and 24-hour emergency dental care for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44252 potential for actual harm Based on observation, interview, and record review, the facility failed to provide a routine dental visit to one Residents Affected - Few of five residents (Resident 15).

This failure had the potential to affect the resident's self-esteem and quality of life.

Findings:

During a review of Resident 15's Admission Record dated 3/9/2025 indicated the resident was admitted to

the facility on [DATE REDACTED], with diagnosis including; chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), and bipolar disorder (sometimes called manic-depressive disorder, schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior), cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain) and paraplegia (loss of movement and/or sensation, to some degree, of the legs).

During a review of Resident 15's MDS dated [DATE REDACTED], indicated the resident had moderately impaired cognition. The same MDS further indicated Resident 15 required supervision or touching assistance with eating, and partial to substantial assistance with toileting, dressing, personal hygiene, bed mobility, and transferring.

During a review of Resident 15's Order Summary Report dated 3/9/2025 indicated an order of dental consult and treatment as indicated.

During a concurrent interview and record review with Social Services Director (SSD) on 3/8/2025 at 4:27 PM Resident's 15's chart was reviewed. The SSD verified and stated there was no indication Resident 15 was seen by a dentist at the facility since his admission and stated they should have been seen since the dentist has been at the facility to see other residents.

During a review of the facility policy and procedures (P&P) titled Dental Services, revised 1/2025, the P&P indicated, it is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 44252

Residents Affected - Some Based on observation, interview, and record review the facility failed to follow food safety, labeling, and kitchen sanitation policies and procedures.

These deficient practices had the potential to result in compromised food qualities, harmful bacteria growth could lead to foodborne illness in medically compromised residents living in the facility.

Findings:

During an observation on 3/7/2025 at 5:22 PM in the facility's dry food storage room, dirt and debris were noted under the dry storage racks in the corners of the room (picture taken).

During an observation on 3/7/2025 at 5:27 PM in the facility's kitchen some drips of grease were noted on

the sides of the range oven (picture taken).

During a concurrent observation and interview on 3/8/2025 at 9:20 AM with [NAME] (CK) 1 the open food containers and all food in the fridge were reviewed for labeling of open on date and use by date. Containers of tuna salad, salsa, shredded cheese, mayonnaise and soy milk were noted with no use by dates. CK confirmed the findings and stated they must have forgotten to put the use by date.

During an interview on 3/9/2025 at 5:09 PM with the Director of Nursing (DON), DON stated the hand sanitizer has been removed from the kitchen, but it was only being used when the staff would leave the kitchen.

During a review of the facility policy and procedures (P&P) titled, Sanitation Inspection, reviewed January 2025, indicated, all food service areas shall be kept clean, sanitary, free from litter, rubbish.

During a review of the facility policy and procedures (P&P) titled Food Labeling Policy, reviewed January 2025, indicated, Labeling requirement in the kitchen . date prepared or opened . expiration or use-by date.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44252

Residents Affected - Some Based on interview and record review, the facility failed ensure the medical record for four of five residents (Residents 11, 19, 27 and 30) was accurate and compete for:

1. Resident 27's Physician Orders for Life Sustaining Life (POLST- a portable medical order that communicates a patient's wishes for end-of-life care and treatment interventions, particularly during a medical emergency, and is intended for people with serious illnesses) and Advance Directive were filled out accurately,

2. Residents 11, 19 & 30's Notice of Proposed Transfer / Discharge form was signed by the residents or representative.

This failure resulted in an inaccurate and incomplete forms in the medical record and had the potential to affect the delivery of care.

Cross reference with

F-F760

Findings:

During a review of Resident 27's Admission Record dated 11/13/2024 indicated the resident was admitted to

the facility on [DATE REDACTED] with diagnoses including: dementia (a progressive state of decline in mental abilities), Vitamin D deficiency (condition where the body does not have enough Vitamin D, paranoid schizophrenia (a mental illness that is characterized by disturbances in thought, where there is distrust and suspicion), anxiety disorder (excessive fear or worry), encephalopathy (broad term for any brain disease that alters brain function or structure), and hypotension (low blood pressure).

During a review of Resident 27's Minimum Data Set (MDS, resident assessment tool), dated 2/13/2025 indicated the resident had severe cognitive (the ability to think, learn, and remember clearly) impairment. The MDS further indicated Resident 27 was dependent on staff for eating, oral hygiene, toileting, dressing, personal hygiene, bed mobility and transferring.

During a review of Resident 27's Order Summary Report, dated 3/1/2025, indicated orders for ProAmatine (medication for low blood pressure) oral tablet 5 mg give one tablet by mouth one time a day for blood pressure hold if above 130, Risperdal (medication to [NAME] mental health condition such as schizophrenia) oral tablet (Risperidone) give 1mg by mouth three times a day for paranoid schizophrenia, Vitamin D3 (supplement) oral tablet (Cholecalciferol) give 5000 unit by mouth one time a day for Vitamin D deficiency.

The same report further indicated an order of may crush all crushable meds then mix with apple sauce or food.

During an observation with concurrent interview on 3/8/2025 at 9:05 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 was observed passing medications for Resident 27. LVN 2 removed ProAmatine 5 mg tablet, Risperdal 1 mg tablet and Vitamin D 5000 - unit tablet from their bubble packs, put them all together in one plastic pouch and proceeded to crush all three medications together. LVN 2 stated the medications can be crushed together good and put in applesauce for the resident.

During an interview with the Director of Nursing (DON) on 3/9/2025 at 4:59 PM, the DON stated the medications should not be crushed all together and administered to the resident, the nurse should have known not to do that.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0759 During a review of the facility's policy and procedures titled Crushed Medications revised January 2025 indicated Medications shall be crushed in accordance with standards of practice for safety and accuracy in Level of Harm - Minimal harm or medication administration. Crushed medications may be combined and administered orally, when potential for actual harm appropriate. a. Resident's safety, needs, mediation schedule, preferences, and functional ability shall be considered when determining the most appropriate method for administering medications. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44252 potential for actual harm Based on observation, interview, and record review the facility failed administer medications without error to Residents Affected - Few one of five sampled residents (Resident 27).

This failure resulted in three medications being crushed and administered together, which had the potential to result in therapeutic failure, and unpredictable chemical and physical interactions of the medications.

Cross reference with

F-F851

Findings:

During A review of Center for Medicare and Medicaid Services (CMS) Staffing Data Report, run date 3/4/2025, the PBJ Payroll Based Journal (PBJ- information of the provider's daily staffing hours for the appropriate care of the residents) staffing data report indicated, on 1st fiscal quarter, facility has no RN hours coverage for the following dates: the facility did not have RN coverage onsite on the following days: 12/02/20230, 12/03/2023; 12/09/2023; 12/10/2023, 12/16/2023, 12/17/2023; 12/23/2023; 12/24/2023; 12/25/2023, 12/29/2023, 12/30/2023; 12/31/2023.12/02/20230, 12/03/2023; 12/09/2023; 12/10/2023, 12/16/2023, 12/17/2023; 12/23/2023; 12/24/2023; 12/25/2023, 12/29/2023, 12/30/2023; 12/31/2023.

During a review of the facility's [NAME] Staffing Nursing Record dated 12/1/2023 to 12/31/2024, indicated

During an interview with Director of Staff and Development (DSD) on 3/9/2025 at 2:22 PM, DSD stated and confirmed, there were no RN coverage for the following days: 12/02/20230, 12/03/2023; 12/09/2023; 12/10/2023, 12/16/2023, 12/17/2023; 12/23/2023; 12/24/2023; 12/25/2023, 12/29/2023, 12/30/2023; 12/31/2023.

During an interview with Director of Nursing (DON) on 3/9/2025 at 5:03 PM, DON stated, the facility did not have any RN coverage for the following days: 12/02/20230, 12/03/2023; 12/09/2023; 12/10/2023, 12/16/2023, 12/17/2023; 12/23/2023; 12/24/2023; 12/25/2023, 12/29/2023, 12/30/2023; 12/31/2023. DON stated an RN coverage is required for safety of the all the residents.

During a review of the facility policy and procedures (P&P) titled, Staffing, revised on 1/2025, the P&P indicated, Our facility provides adequate staffing to meet needed care and services of our resident population . Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met. Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0732 Post nurse staffing information every day.

Level of Harm - Minimal harm or 43454 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the actual nursing hours Residents Affected - Some worked by licensed and unlicensed nursing staffing directly responsible for resident care per shift were posted for three of three sampled days (3/7/2025, 3/8/2025 and 3/9/2025).

This deficient practice resulted in the actual staffing information not being readily accessible and available to residents and visitors and had the potential to cause inadequate staffing.

Findings:

During an observation of the facility on 3/7/2025 at 6:18 PM., observed Direct Care Services Hours Per Patient Day (DHPPD) posted on the wall with only the projected hours posted. No actual hours were posted and no calculation of unlicensed nursing staffing directly responsible for resident care in the DHPPD posting, there was no DHPPD posted for the previous day (3/6/2025).

During an observation of the facility on 3/8/2025 at 10:18 PM, observed DHPPD posted on the wall with only

the projected hours. No actual hours were posted and no calculation of unlicensed nursing staffing directly responsible for resident care in the DHPPD posting, there was no DHPPD posted for the previous day (3/7/2025).

During an observation of the facility on 3/9/2025 at 11:25 PM, observed DHPPD posted on the wall with only

the projected hours posted. No actual hours were posted and no calculation of unlicensed nursing staffing directly responsible for resident care in the DHPPD posting, there was no DHPPD posted for the previous day (3/8/2025).

During an interview with Director of Staff and Development (DSD) on 3/9/2025 at 1:51 PM, DSD stated, she works part time in the facility, and she helps out with staffing roles, but she was not the main person responsible for posting the DHPPD and calculate the hours of licensed and unlicensed nursing.

During an interview with Minimum Data Set Coordinator (MDSC) on 3/9/2025 at 2:38 PM, MDSC stated, the DHPPD posting are on the wall with only the projected hours included for licensed nursing. MDSC stated,

she is not sure if the DHPPD posting should include the actual hours and if the DHPPD posting for the previous day should also be posted. DSD further stated the calculation of the unlicensed nurses' hours are not readily available on the DHPPD posting.

During an interview with the Director of Nursing (DON) on 3/9/2025 at 5:03 PM, DON stated, the DHPPD posting are posted daily with the projection hours for that day. DON stated the actual hours are not calculated for the previous day and they do not post the actual hours from the previous day. DON stated, he was not familiar on the policy and regulations of DHPPD posting requirements.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0732 During a review of the facility policy and procedures (P&P) titled Nursing Hours Per Patient Day (NHPPD) Posting Policy revised on 1/2025, the P&P indicated, The facility shall calculate, update, and visibly post Level of Harm - Minimal harm or NHPPD information daily to maintain compliance with state and federal regulations, ensuring staff and potential for actual harm residents are informed of nursing care availability . Posting requirements: The posting shall include: date of calculation, total nursing hours, patient census, NHPPD value, staff responsible for verification. Residents Affected - Some

During a review of the facility P&P titled, Nursing Hours Per Patient Day (NHPPD) Policy, revised on 1/2025,

the P&P indicated, This policy establishes guidelines for calculating and maintaining appropriate Nursing Hours Per Patient Day (NHPPD) to ensure optimal patient care and regulatory compliance . The facility shall maintain a NHPPD calculation to ensure adequate staffing levels based on patient acuity, regulatory requirements, and industry best practices.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43454

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure to label an open date of ipratropium-albuterol inhalation solution (used to prevent and treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness) inhalation solution for one of five residents (Resident 13) that can expire once opened with an open date according to manufacturer guidelines.

This deficient practice had the potential to compromise the therapeutic effectiveness of the stored medications and unintended complications related to the management of medications.

Findings:

During a review of Resident 13's Admission Record indicated Resident 19 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including hypertensive heart disease (includes a number of complications of high blood pressure that affect the heart), chronic kidney disease (CKD-a longstanding disease of the kidneys leading to renal failure) and chronic obstructive pulmonary disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe).

During a review of the Minimum Data Set (MDS - resident assessment tool) dated 2/7/2025, indicated Resident 13's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact. The MDS indicated Resident 13 was independent for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).

During a review of Resident 193s Order Summary Report (OSR), dated 2/18/2025, the OSR indicated, physician ordered, ipratropium-Albuterol solution 0.5-2.5 milligram (mg)/3 millimeter (ml - unit of measurement) - 1 vial inhale orally two times a day for COPD via nebulizer.

During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1 on 3/8/2025 at 3:27 p. m., Medication Cart 1 was observed. Observed Resident 13's ipratropium-albuterol medication with an opened foil pouch and the unit-dose vials were visible, there were no labels of date when it was first opened. LVN 1 stated, the medication should be labeled when it was first opened. Resident 13's ipratropium-albuterol medication label indicated, expires: seven days if open.

During an interview with Director of Nursing (DON) on 3/9/2025 at 4:51 PM, DON stated, inhalation medications foil pouches should be dated once opened and follow the manufacturer and pharmacy's recommendations.

During a review of Nephron Pharmaceutical (manufacturer) guidelines for Ipratropium Bromide and Albuterol Sulfate Inhalation Solution, indicated, once the foil pouch is opened, the individual vials should be used within one week and discarded.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0755 During a review of the facility policy and procedures (P&P) titled, Nebulizer Therapy, revised on 1/2025, the P&P indicated, It is the policy of this facility for nebulizer treatments, once ordered, to be administered by Level of Harm - Minimal harm or nursing staff as directed using proper technique and standard precautions. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 27 056438 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056438 B. Wing 03/09/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035

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)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44252 potential for actual harm Based on observation, interview, and record review the facility failed to maintain a medication error rate Residents Affected - Few below 5% (percent-unit of measurement).

This failure resulted in three medication errors observed for one of three sampled residents (Resident 27). There was a total of 28 medication opportunities out of which three were observed given incorrectly, which resulted in a medication error rate of 10.71%.

Cross reference with